AHEAD IN 2015: VIRUSES, EPIDEMICS AND UNITED NATIONS HAGGLING—PART ONE: The Ebola Epidemic in West Africa
Since this is the dawn of a new year let us begin with the good news: Liberia has brought its epidemic way down from the hideous highs of late September to a manageable number of cases. The U.S. Centers for Disease Control (CDC) worst-case scenario forecast—1.4 million Ebola cases in Liberia, Sierra Leone, and Guinea, with more than nine hundred thousand deaths—was not realized, as the forecast was predicated on the assumption that no global mobilization of assistance would materialize in 2014.
But none of the three hard-hit countries has managed to reach Ebola eradication targets set by their leaders. President Ellen Johnson Sirleaf of Liberia forecast elimination of new cases in her country by Christmas—a target that clearly has been missed. President Ernest Bai Koroma of Sierra Leone predicted in October that his nation would be “containing the Ebola virus” by Christmas. Instead, group Christmas celebrations were banned nationwide amid an out-of-control epidemic, and many communities were on mandatory lockdown. Guinea’s President Alpha Condé, once optimistic that his government could contain the virus, now personally micromanages the national effort. Moreover, the late August World Health Organization (WHO) forecast for the size and horror of the epidemic was almost exactly correct: twenty thousand cases by mid-November with 50 percent mortality. By December 28, the cumulative case load officially topped twenty thousand with 7,842 deaths reported, according to the WHO. Given the cumulative death numbers do not include Liberia (see WHO chart below), it is safe to assume that the mortality toll has, as predicted, exceeded 50 percent. Assuming underreporting and delays in confirming and conveying data to the WHO, it seems the Geneva-based agency’s forecast was accurate, though off by about three weeks.
The Ebola epidemic, which was missed entirely when it began in December 2013 in a remote Guinean village, turned out to be the 2004 tsunami–like challenge of 2014, forcing a massive collaborative effort across UN agencies, humanitarian groups, the African Union, and donor governments, especially of the United States and United Kingdom. Global-scale mobilization was only realized ten months after the onset of Ebola and it has yet to reach its targets for financial and human resources; there is a very real threat that the virus will linger in the region throughout 2015, if not longer. The prospect of endemic Ebola is grave, as even isolated human cases will deter investors and travelers, keep commercial airlines away from the region, and push the economies into deeper recessions.
When the epidemic was first recognized in March, I began calling attention to the situation, urging government officials and our Council on Foreign Relations (CFR) global health followers to take seriously the first West African outbreak in known history. The toll rose steadily in Guinea in late March, feeding local concerns. On March 25 the WHO held its first press conference on the situation, reporting eighty-six confirmed cases. The following day the government of Guinea declared that its Ebola crisis was contained, even as rumors swirled of its spread across the borders into Liberia and Sierra Leone and the first infected individuals began heading to the capital cities. As cases of the disease reached the three capitals by May, urbanizing Ebola for the first time in history, I joined a then-small chorus of anxious voices, urging the world to take the plights of Guineans, Liberians, and Sierra Leoneans seriously. In late June the overwhelmed Doctors Without Borders / Médecins Sans Frontières (MSF) pleaded with the world for help: “The epidemic is out of control,” said Dr. Bart Janssens, MSF director of operations.
The three capital cities—Monrovia, Liberia (population 1.1 million); Freetown, Sierra Leone (roughly 950,000); and Conakry, Guinea (2.2 million)—share four features relevant to the evolving epidemic. Each is the largest population center in its country, all are sea ports and trade hubs, each is serviced by an international airport, and the average resident of these three cities lives on less than two U.S. dollars per day. Exacerbating the poverty are extraordinary birth rates in all three metropolises of 4.1 to 6.0 children per woman, spawning a demographic youth bulge that historically has provided child soldiers for warring factions in the long years of civil war (1990–2004).
Before Ebola struck, these three countries had among the weakest healthcare systems in the entire world. Life expectancy at birth in 2012 was sixty-two for Liberia, fifty-eight in Guinea, and a mere forty-six for Sierra Leone. Under-five-year-old mortality rates were hideous, with 75 of every 1,000 children born in Liberia dying before their fifth birthdays; in Guinea 101 of every 1,000 died and in Sierra Leone it was a dreadful 182 of every 1,000. It is a reflection of the tremendous poverty of these nations that such dismal vital statistics were the pre-Ebola norms despite considerable percentage of gross domestic product (GDP) government expenditures on health: 6 percent of GDP in Guinea in 2011, 15.6 percent of GDP in Liberia, and 16.3 percent in Sierra Leone. But a high percentage of nothing yields nothing. In these impoverished nations those seemingly lofty commitments translated into per capita health expenditures of a mere thirty-two dollars per year in Guinea; sixty-five dollars in Liberia, and ninety-six dollars in Sierra Leone.
Counting physicians, nurses, and midwives, Liberia had three health professionals per ten thousand people, Sierra Leone’s rate was two per ten thousand, and Guinea hit the bottom at one per ten thousand. Between the onset of the Ebola crisis in January 2014 and December 21, 2014, an estimated 666 healthcare workers had contracted Ebola, all but seventeen of them from Guinea, Sierra Leone, or Liberia, and 366 had perished. In total, the three countries had about 3,690 doctors, nurses, and midwives before Ebola, and roughly 3,324 today. Long after Ebola has (hopefully) disappeared, these countries will be struggling to provide basic health services with their greatly diminished workforces and endeavoring to train replacements for those they have lost.
Many events in August raised alarms in the region and caused 10 Downing Street and the White House to take note of the catastrophic epidemic unfolding far away, but no event seemed to shake up the policy world as much as MSF’s September 2 declaration: “World leaders are failing to address the worst ever Ebola epidemic, and states with biological-disaster response capacity, including civilian and military medical capability, must immediately dispatch assets and personnel to West Africa.”
Born out of the bloody Nigeria/Biafra conflict of 1967–69, MSF has always distanced itself from military forces of all kinds, choosing neutrality and recently opting to abandon missions, such as in Somalia, rather than resort to hiring military protection or forming alliances with armed forces. The Nobel Peace Prize-winning group’s call for help from the U.S. military was, therefore, astonishing, and a clear indication of the gravity of the Ebola situation. Eight days after the MSF declaration was released I participated in a special Ebola meeting of the Joint Chiefs of Staff called by General Martin Dempsey, and have subsequently reviewed 101st Airborne activities in Liberia and participated in two more Joint Chiefs’ meetings and a Red Team review of Defense Department’s Ebola actions. Overall, the U.S. military’s involvement in the epidemic is serious. It contributed to the downturn of Liberia’s outbreak and offered a real-world test of the Obama administration’s “whole-of-government” approach to intervention, bringing multiple civilian and military agencies together under a single command structure. In Liberia, the 101st Airborne answers to a command that is led by disaster-response experts from the U.S. Agency for International Development (USAID).
Though U.S. agencies (particularly USAID and the CDC) are assisting in Guinea and Sierra Leone, the Obama administration is taking a back seat in those countries to France and United Kingdom, respectively, and the United Nations Mission for Ebola Emergency Response (UNMEER).
It may be possible to eradicate Ebola from Liberia in early 2015, but the almost entirely undefended borders that the country shares with Guinea and Sierra Leone will become increasingly porous as weary rural Liberians inevitably resurrect trade and travel with their neighbors. As I observed on the Liberia-Sierra Leone border, trade in produce, animals, small machinery, and home products was essential to the local economy, and border closure has brought deep impoverishment. In the hard-hit Jene-Wonde area of Liberia, the economic effects of Ebola have been so severe that the currency economy has been replaced by barter and most people live on what they can grow or harvest from local forests.
In my meetings with President Ellen Johnson Sirleaf and her top advisors, it was clear that the Liberians know they will never be free from fear of Ebola until the virus is eliminated from the entire region.
Sadly, neither Sierra Leone nor Guinea appear to be poised to eradicate the virus from their countries this winter, spring, or perhaps even in 2015. As this WHO chart (updated daily in the agency’s Ebola Situation Reports) shows, Sierra Leone’s epidemic has never plateaued or dipped—it has simply grown steadily since May. (The apparent downward trend in recent weeks is a reflection of lag times in case and death reporting, not an actual decline in epidemic incidence or prevalence.) There are many reasons for Sierra Leone’s tragic course, but at the top of the are cultural practices in bereavement and funeral rites, government corruption, and its extreme public sector weaknesses pre-Ebola.
Guinea’s epidemic course resembles a roller coaster, with wave after wave of surges, then downturns, in Ebola cases. Since the epidemic started in Guinea a year ago, the Conakry government has scrambled to put out brush fires that have ignited in one locale after another, each threatening to burst into a national firestorm. It remains a great epidemiological puzzle why the full Ebola national inferno has never materialized, although eradication has also proven impossible.
Comparing the trajectories of the three epidemics reveals stark contrasts. Given that the biology and virology are identical in all three places, only politics, governance, and cultural practices can explain the differences.
The following is my Ebola forecast for 2015:
- The virus will not be eradicated from the region based on current tactics. Full implementation of strategies to limit group exposure to ailing, contagious individuals and cadavers, coupled with continued improvements in hospital hygiene, will bring incidence down, but are insufficient to eradicate Ebola from the region.
- Donor financial support and mobilization of external health volunteers has yet to reach levels targeted by the UN and Obama administration in September, as shown in the chart below. With the passage of time donor attention will turn to other world crises and fundraising will become more difficult.
- With only one commercial airline (Brussels Air) willing to service the countries, and travel directly between the nations limited to United Nations Humanitarian Assistance flights, Liberia, Sierra Leone, and Guinea are nearly as isolated from the rest of the world as North Korea. The combined economic effect of this isolation and domestic market disruption caused by the epidemic and its control measures are driving the three economies into downward tailspins. The longer Ebola lingers in the region, the deeper economic and food desperation will become. Development advances made in these nations since the civil wars are now being erased. Many major businesses fled with Ebola’s arrival and have yet to return and costs of operations for those that have remained throughout the epidemic (Firestone, UniRoyal) have risen.
- An entire generation of children has lost months of schooling and teachers have gone unpaid. Thousands of children have essentially given up on educations, turning to street peddling and subsistence farming activities to help their hard-hit families. Once the schools do reopen the governments will be hard-pressed to recapture former students and make up for the loss of valuable education time. Moreover, most of the children of these countries have personally witnessed Ebola losses and thousands have been orphaned. They will bring their psychic wounds to the classrooms.
- Complete eradication of Ebola from Liberia, Sierra Leone, and Guinea—and with it, restoration of global business investment and trade—can only be accomplished with development and mass-scale use of one or both of the following promised, but still unavailable, tools.
- First, a rapid point-of-contact diagnostic test is desperately needed in order to distinguish Ebola-infected individuals from those that may have headaches, fevers, nausea and/or diarrhea due to other endemic local diseases (malaria, cholera, Lassa fever, food poisoning, salmonella, HIV). Though at least nineteen companies or research institutions have claimed that such an innovation was “in the pipeline,” nothing has yet materialized. Laboratory diagnostics have improved, both in speed and accuracy, but they cannot fill the void. What is desperately needed is a quick pinprick blood test that gives results in a matter of minutes and can be safely administered at very low cost without undo sensitivity to heat and humidity. Such a test could be administered to all fever patients, travelers, trauma-injury sufferers, and cadavers to quickly and accurately determine which are contagious.
- Second, a vaccine is essential. With each passing month of ongoing infection in the region it becomes more difficult to imagine a strategy for eradication that can succeed in the absence of mass immunization.
For further details on the Ebola crisis, you may want to watch, read, or listen to the following:
- Ebola epidemic continues
25 November 2014, WBEZ WorldView
- Liberia and Guinea meet key targets in Ebola fight as Sierra Leone lags
1 December 2014, PBS NewsHour
- Ebola Update: Assessment from Africa
9 December 2014, Council on Foreign Relations Event
Richard Besser, ABC News, is joined by three panelists at the Council on Foreign Relations for a discussion about Ebola. The panelists are Nancy A. Aossey, International Medical Corps; Laurie Garrett; and David Nabarro, Special Envoy on Ebola, United Nations.
- Ebola: Story of an Outbreak
eBook by Laurie Garrett. Also available as an audiobook.
- Sierra Leone's Epidemic Is Spiraling Out of Control
10 December 2014, ForeignPolicy.com
- Facing Death Without Spreading Disease
11 December 2014, ForeignPolicy.com
- Pushing Ebola to the Brink of Gone in Liberia
24 December 2014, ForeignPolicy.com
- The Monster in the Sea
29 December 2014, ForeignPolicy.com
- A Conversation with Martin Dempsey at Carnegie Council
6 November 2014, Carnegie Council