Hollow Words and an Exponential Horror

At last, a sense of serious urgency imbues the world’s response to the Ebola crisis. On Sept. 18, by the largest vote in U.N. history, the Security Council adopted a unanimous resolution, co-sponsored by 130 countries, that declared Ebola a security threat to all nations.

On Sept. 20, the General Assembly gave Secretary-General Ban Ki-moon authority to command an international response to the virus out of a newly created United Nations Mission for Ebola Emergency Response (UNMEER), located in New York. And, on Sept. 25, U.S. President Barack Obama addressed the General Assembly, calling on all nations to step up to the challenge with unprecedented haste, unprecedented commitment, and unprecedented coordination.

"Stopping Ebola is a priority for the United States," Obama said in his address to the U.N. "We’ll do our part. We will continue to lead, but this has to be a priority for everybody else. We cannot do this alone. … To my fellow leaders from Liberia, Sierra Leone and Guinea, to the people of West Africa, to the heroic health workers who are on the ground as we speak, in some cases, putting themselves at risk — I want you to know that you are not alone. We’re working urgently to get you the help you need. And we will not stop, we will not relent until we halt this epidemic once and for all."

The tap is turned, and water is starting to flow. But the questions in this newly announced war on Ebola are now are twofold: Will personnel and resources reach West Africa rapidly enough to dam the viral flow, and will the nations of the world learn from this disaster to build institutions and long-term targets that prevent pandemics in the future?

According to Médecins Sans Frontières (Doctors Without Borders, or MSF) international president Joanne Liu, few of the promised personnel and resources have yet reached Liberia, Sierra Leone, and Guinea. Following Obama’s speech to the U.N., she, in graphic detail, told the American network NPR how her organization’s Ebola clinics were so overwhelmed that each morning staff were removing the dead from their hospital beds, taking a count, and then admitting that number of ailing from the queues of Ebola-sufferers lying outside hospital doors. Far from getting ahead of the virus, she insisted, the world’s response is still racing to simply catch up.

The World Health Organization (WHO) continues to release daily tolls of confirmed cases and deaths, but the WHO notes with each of its releases that the numbers are, at best, snapshots of what might have been the prevalence of Ebola a few days earlier. As WHO Director-General Margaret Chan told the Security Council, the numbers are "vast underestimates." Nevertheless, the most recent WHO forecast reckons that by Nov. 2, 2014, the three countries will cumulatively have 20,000 Ebola cases.

But I believe the cumulative total is close to, or has already eclipsed, 20,000.

In its official case count for reports received as of Sept. 24, the WHO says a total of 6,242 cases with 2,909 deaths have been officially counted. For weeks I have suggested that the reporting has been off by a factor of three, meaning far more Ebola-sufferers were never identified, as they ailed and died outside the overwhelmed health-care system on the ground in the three countries. Based on that reckoning, the current cumulative instances would be triple the official number of 6,242, making it 18,726 cases. I suggested on radio broadcasts that the epidemic case count could top 400,000 by Christmas if the global community failed to respond rapidly and effectively enough in September.

On Sept. 23, the U.S. Centers for Disease Control and Prevention (CDC) published its best estimates of the epidemic’s scale and its likely future course, based on the agency’s reckoning that reporting is off by a factor of 2.5. (That would put the cumulative current count at 15,605 cases.) If the global response fails to get to the ground with effect in a timely fashion, the CDC insisted, even a less severe caseload forecast would put the number of infected — both survivors and dead — at 500,000 by January 2015. In a worst-case calculation, the CDC forecasts 1.4 million cases in the same time period.

My reckoning of 400,000 by Christmas was more conservative, as it turns out, because I was imagining numbers for all three countries. In contrast, the CDC’s startling projections are for just two: Liberia and Sierra Leone. The worst-case estimation of 1.4 million would equal 14 percent of the two countries’ combined populations.

Those numbers may still be conservative, as there is growing evidence that Sierra Leone has grossly undercounted its epidemic and may actually have a larger crisis than neighboring Liberia. Quarantines now encompass the majority of Sierra Leone’s villages and much of its capital, Freetown.

Mortality estimates for this epidemic have run a wild empirical course. On the one hand, based on the 1976 original outbreak in Yambuku, Zaire, it is commonly reported in both scientific literature and popular media that Ebola mortality can be "as high as 90 percent," but that has never occurred in the post-1976 epidemics. On the other hand, many skeptics in both medical and popular press circles say that the death tolls in the current outbreak are well below that 90 percent — and that, in fact, the numbers are closer to 50 percent, indicating there may have been some early sensationalism in the descriptions of Ebola’s lethality in the current outbreak.

Actual reported deaths to date run at about 55 percent of reported cases. That would put the mortality rate below the prior 20 Ebola epidemics. Odd, given the 2014 epidemic is caused by the same viral strain as plagued Yambuku, Zaire, in the original 1976 epidemic. Odder still, the officially reported fatality rate in Liberia is about 50 percent, but next door in Sierra Leone government reports put the identical strain down to a mere 30 percent mortality rate.

But the numbers are deceptive as most of the dead are never counted — they are buried without government notice in private family locations with discreet ceremonies or no funerals at all. Moreover, in all of the past 20 Ebola outbreaks, fatality reporting has lagged far behind case counts. Researchers from the London School of Hygiene & Tropical Medicine recently scrutinized the current and past epidemics, concluding that the true fatality in today’s epidemic is 70 percent. The London team reached that conclusion based largely on computations of the time lags between deaths and their official reporting in the 20 prior Ebola outbreaks. Combined with the worst-case dire CDC forecast, this could mean that by February, Ebola will have slaughtered 980,000 Liberians and Sierra Leoneans — a number so apocalyptic as to defy our imaginations.

We have dueling narratives emerging in the Ebola fight. On one side, the forecast horrors and MSF’s reports from the ground present a dire, nightmarish story. On the other, mobilizations around the world of finances and resources suggest a world prepared to fight the virus into retreat.The first horrible narrative is accurate, assuming the second one fails to materialize in rapid, coordinated fashion. Tiny Cuba will send 461 doctors and nurses into the epidemic, but huge nations — Russia, China, India, Brazil, many of those in Europe — have made little more than symbolic gestures to date amounting to one mobile clinic, small sums of financing, and modest shipments of medical supplies.

"Partners and friends, based on understandable fear, have ostracized us; shipping and airline services have sanctioned us; and the world has taken some time to fully appreciate and adequately respond to the enormity of our tragedy," President Ellen Johnson Sirleaf told the U.N. in a speech delivered via video from her Liberian office. Despite U.S. military efforts to build an air bridge from Senegal to the beleaguered countries, the flow of supplies and personnel is still stifled by a nearly total shutdown of commercial flights and shipments to the region.

"Ebola is not only a disease of Sierra Leone and its neighbors; it is a disease of the world," Sierra Leone’s president, Ernest Bai Koroma, said in a speech delivered via teleconference to the U.N. General Assembly on Sept. 25. He continued:

Globalization, increasing urbanization, and denser networks of people rapidly moving between rural and urban areas and across borders is fuel for greater transmission of formerly isolated viral diseases. None of us recognized that this mix of trends could emerge with such force in West Africa. Our international partners were slow to recognize the threat for what it was, and when the recognition did come, it came with a flurry of fear that led to banning of travel to and from Sierra Leone and our region.

Underscoring the need for historic speed in the delivery of global assistance, Koroma warned further:

Ebola is a disease where even an hour too late leads to exponential transmissions. That is why faster response, of a kind similar to responses to natural disasters like hurricanes and earthquakes, is required. This calls for faster deployment of resources at the global, national, and health-center level. Any break in this chain of fast response would result in more deaths in our country and greater possibilities of the virus mutating and spreading into other countries and continents.

The competing narratives of the Ebola response — exponential growth in cases versus the arrival of a global rescue mission — can be charted graphically.

These data from the WHO, in orange, are estimates of publicly available data on weekly incidence of confirmed, probable, and suspected cases of Ebola; the original data are available in the New England Journal of Medicine. The adjusted caseload, in red, is an independent calculation based on these estimates and adjusting for the CDC’s reckoning of a 2.5-fold factor of underreporting.

To see a larger version of this chart, click here.

A second chart of personnel and supplies delivered to the countries and of financial commitments illustrates a pace for the response to date. If we look at these numbers side by side, it becomes starkly clear that the world’s response effort is crawling compared with the exponential growth in viral spread.

There is another false narrative lurking in the background of this horrible epidemic: that the world was prepared and that only mere tweaks in health systems would be adequate to prevent Ebola from spilling over into other nations.

I recently spoke with a group of journalists from all over the world invited by the U.S. State Department to meet with American officials. A frightened man from Djibouti asked whether health systems in the Horn of Africa would stand up better to Ebola than the very weak infrastructures of Liberia, Sierra Leone, and Guinea. A woman from Zimbabwe asked the same for her more prosperous region of southern Africa. I warned them that wherever syringes are reused due to scarcities or wherever doctors are so rare that each serves more than 10,000 patients per year, surgery is performed without proper hygienic protection for medical staff, nurses lack supplies of disinfectants and latex gloves, and clean water does not flow from hospital taps — in places like this, Ebola can thrive.

Back in October 1999, I attended a meeting at the Paris headquarters of MSF-France, aimed at finding ways to improve poor countries’ access to basic medicines and supplies. Also at the meeting was Ariel Pablos-Méndez, a physician who is now the head of global health efforts for the U.S. Agency for International Development (USAID). The meeting was disturbed by an uproar, as shouting and screaming could be heard from below. An MSF physician raced up the stairs shouting, "We won the Nobel Peace Prize!" and pandemonium ensued. As Pablos-Méndez recalled last week at a health event coinciding with the U.N. General Assembly opening, we all danced late into the night in celebration.

Today MSF has no time to think about that Nobel Prize, as its volunteers are deployed to a staggering array of crises around the world, including the Ebola epidemics in West Africa and, separately, the Democratic Republic of the Congo.

Pablos-Méndez last week recalled the MSF jubilation of 1999 and a commitment born from it to achieve universal health coverage (UHC) for every human being on Earth. Ten years after that day of MSF joy, we co-authored, along with Bangladeshi global-health superstar Mushtaque Chowdhury, the first call for UHC, published in the Lancet. We imagined that the U.N. might one day embrace UHC and aim to bolster countries’ abilities to treat and protect their populations from diseases, including such horrors as Ebola. It now appears likely that UHC will, indeed, be among the U.N.’s Sustainable Development Goals — targets for global achievement by 2030.

But a more recent, sobering connection to noble health targets and MSF came to me this summer when Sophie Delaunay, executive director of MSF in the United States, asked me, "Where are all those Americans that were trained in bioterrorism and epidemics? We need them." USAID told Delaunay there were no such cadres of disease-fighting Americans ready to step into the breach. Similar questions have been raised regarding Ebola drugs, cures, and vaccines — where are they?

Following the 9/11 attacks and the subsequent anthrax mailings to prominent media and political leaders, George W. Bush’s administration ordered billions of dollars’ worth of preparedness efforts. As I described in my 2011 book, I Heard the Sirens Scream, the Bush administration and Congress created programs such as Project BioShield that were meant to find cures and vaccines for special pathogens, including Ebola. And through the CDC, billions of dollars were funneled to local health departments across all 50 states and the territories of the United States to create bioterrorism and pandemic preparedness teams. Every local health department and hospital in the United States has, since 2002, undergone repeated drills in which local responders — police, fire departments, hazmat teams, physicians, public health workers, nurses — simulate their scripted actions in response to an outbreak of one of the CDC’s designated special pathogens (including Ebola). Massive time and money have been spent in towns and cities, often at the expense of other essential public health services. As I wrote, many local health departments felt compelled to fire cancer prevention workers or HIV educators, replacing their budget lines with bioterrorism responders in order to obtain federal funding during the Bush presidency. The Defense Department ran similar training exercises within all branches of the armed forces. And inside the CDC, many of the ranks of science were replaced with terrorism preparedness expertise, chiefly drawn from law enforcement and the military.

Where is all that expertise now? Where are the miracle drugs, vaccines, hazmat experts, and medevac teams?

They don’t exist. Hundreds of billions of dollars and many years later — they don’t exist.

BioShield failed because lab-bench invention of drugs and vaccines could not be translated into clinical trials and commercial development without adequate profit potential for biotech and pharmaceutical industries — options nobody could guarantee given the rarity with which such diseases as tularemia, anthrax, and Ebola present.

The military’s sense of priority in its biopreparedness efforts focused on safe rescue of its personnel from a bioterrorism or outbreak situation. As described in 2005 by officers in the Special Medical Augmentation Response Team-Aeromedical Isolation — also called the SMART-AIT — which trained U.S. and allied military cadres, "It’s a get-in, get-out situation because a lot of people could be put at risk if they come in contact with the viruses that cause those fevers."

In all the civilian and military training, the focus was similarly on containment and rapid response — not on months of patient care executed by exhausted doctors and nurses working inside 120-degree spacesuits, facing a virus that has 70 percent odds of killing them should a slip-up leave them exposed to Ebola.

Americans believe in technology. Some have imagined that computers, sifting through worldwide Facebook, Twitter, and news reports, could spot outbreaks before health officials might, offering early-warning systems that would obviate concern for pandemics. The enthusiasm over the now nonexistent experimental drug ZMapp captured American belief in miracle cures and biotech savvy. Almost daily I receive claims from companies and individuals of phone apps that can track Ebola cases, hidden cures, drugs sitting on shelves that might stop Ebola.

If the world wants the epidemic to end without claiming 980,000 lives by the end of January and without spreading beyond its current boundaries, the narratives guiding the response must embrace reality.

The reality is as Obama put it at the U.N. last week: This is an all-hands-on-deck moment for mobilization of the basics. Sure, keep searching for drugs and vaccines. Keep struggling to build UHC and better health systems. But right now the Ebola world needs doctors, nurses, paved roads, electricity, oil, medical supplies, cots, protective gear, hydration kits, food, helicopters, airplanes, logistics expertise, mass communications education, soap, disinfectants, and, most of all, cause for hope.

And it needs all these things, yesterday.