Lessons From an Outbreak: How Ebola Shaped 2014
Experts weigh in on what to take away from the devastation of the disease.
This was the year of the biggest Ebola outbreak of all time. It started in Guinea at the tail end of 2013, and the World Health Organization was made aware of it in March 2014, by which time Guinea had 86 cases, and there were suspected cases in neighboring Liberia and Sierra Leone. The virus spread steadily, claiming more and more lives until the WHO declared the outbreak a “public-health emergency of international concern" on August 8.
People in affected communities were understandably fearful; some were distrustful of health workers and resisted going to treatment centers, where it may have seemed they were only going to die. There is, after all, no cure for Ebola. Experimental treatments helped some, but not enough. Health workers, harried and overworked trying to keep people alive, may not have had the time to assuage patients' fears. And those who tried to care for their loved ones themselves often got infected, too. The virus forces people into isolation, spread as it is through contact with bodily fluids, and to hug a sick family member is to put oneself at risk.
While some in the Western media criticized West Africans' fear of health workers and resistance to public-health measures, the United States got a small taste of Ebola panic when Thomas Eric Duncan became the first case diagnosed in the country in September, followed by three other cases this fall. Duncan was the only patient to die in the U.S., and the panic died down quietly.
In West Africa, though, the outbreak is far from over, and it looks like Ebola will belong not just to 2014, but 2015 as well. There have been more than 6,000 deaths in the region so far, according to the Centers for Disease Control and Prevention. The latest WHO report says that transmission rates are stable in Guinea, decreasing in Liberia, but still "intense" in Sierra Leone.
With that in mind, I asked several experts—healthcare workers, journalists, and officials—what they've taken away from watching the Ebola outbreak unfold this year, and what lessons we, as a society, should learn to better deal with this outbreak, and future ones. Their responses have been edited and condensed for clarity.
Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health
The Ebola crisis serves as a stark personal reminder of something I have witnessed multiple times in my decades working in the field of infectious diseases. When a new infectious disease risk arises, a segment of the general public frequently perceives the risk to be much larger than it actually is, certainly out of proportion to what the scientific information would indicate. Because it is human nature to fear the unknown, this response is understandable. Time and time again, we have seen that the best solution to this misperception is crisp, clear communication about what is known and unknown about how the disease is transmitted and spread, who is most at risk, and how individuals who may be at risk can best protect themselves from infection.
The Ebola outbreak has cast a bright light on how disparities in healthcare infrastructure can profoundly affect the vulnerability of certain populations to the spread of certain infectious diseases. A sound healthcare infrastructure that can readily identify people with Ebola infection, isolate them, protect healthcare workers from becoming infected, and do tracing of contacts of infected people who might then spread the virus is critical to prevent widespread outbreaks. If the West African countries stricken by the current Ebola outbreak had a reasonable healthcare infrastructure, the outbreak would not have gotten out of control. The developed world should act in partnership with poorer countries to eliminate this disparity.
Ashoka Mukpo, a freelance journalist and Ebola survivor
It's wrong to assume that large institutions and governments are the only agents that can address problems in the developing world. Heroic efforts by Doctors Without Borders, the World Health Organization, and other healthcare workers that ran Ebola treatment units were invaluable, but it appears that many deaths in Liberia were prevented by Liberians themselves. Once people started to see their neighbors dying, awareness of the disease increased and people shifted behavior patterns that put them at risk for Ebola. It makes one wonder what could have been possible if Liberian community leaders were given a bigger role in the fight during the first phase of the outbreak.
Incidentally, I also learned that it's wise to use twice as much chlorine spray as you think is necessary while covering an Ebola outbreak.
Poverty isn't a problem that only affects the people who shoulder its burdens. If we trace a line back to the beginning of the Ebola crisis, it's clear that the feeling of isolation and neglect that people in West Africa live with had much to do with why the disease spread so fast. Few people were willing to believe the warnings of a world that they saw as, at best, unconcerned with and, at worst, actively exploitative towards them. If this strain of Ebola had been more contagious, we could be looking at a global plague right now. We need to do a better job of ensuring that people in places like West Africa see the outside world as partners so that during moments like last summer there's shared trust and genuine communication across cultural lines. That starts by actively seeking out the views of community members and civil-society actors in countries like Liberia before problems such as Ebola come up, and then trying to respond to their concerns.
Dr. Darin Portnoy, a physician with Doctors Without Borders, who recently completed a four-week assignment at a treatment center in Monrovia, Liberia
On the terrible side, the human impulse to help a loved one who’s ill is one of the things that’s really been at the heart of spreading the epidemic. It seems so deeply unfair but it explains why the disease is really ripping through societies in each of these countries. And saying goodbye to someone who dies, going to a funeral ceremony, is also a way disease is often passed on. Both those totally human normal reactions in society are things that would be done by any of us and that’s what’s really making the disease still so difficult to control.
But there is a good side. In the treatment center, as a doc, you also see people who are getting over Ebola, they’re in the pre-recovery stage, they’re able to get up and feed themselves, get water, walk outside the tent where they’re staying. We saw this over and over, where someone would be terribly ill [and a recovering patient would stay with them]. In an Ebola treatment unit you can’t have family in there with you; you’re dependent on our staff for everything that you need. To have another patient provide some assistance means an enormous amount. It’s one of those selfless, beautiful human gestures that I did see over and over. In the midst of this horrible disease, you have people who have no connection at all, not family, didn’t know each other, helping each other out.
As a doctor, you want to have every tool you possibly can to treat a complex disease like Ebola. There’ve been close to 30 years since this disease has been discovered, and even after all that time I still don’t have the very best tools I need to take care of patients. There’s not a vaccine yet available. There aren't specific treatments. You’d think after all that time there’d be some more attention and effort to develop these tools. It really takes something that’s affecting a large number of people to get the world’s attention.
Dr. Nicole Cooper, a Liberian-American physician training at Miami's Jackson Memorial Hospital
My biggest lesson has been compassion and the courage to have it in the face of grave danger. This has been exemplified by the physicians and even more widely by the family members caring for patients. Countless doctors, mothers, fathers, brothers, and children in villages, cities, hospital wards, and isolation centers refused to abandon their charges and loved ones and sacrificed their own lives so that the victims of this epidemic would not die alone and unattended to. As committed as I was to serving Liberia and building its healthcare system before this crisis, I am even more determined now.
The larger lesson that I feel we should take away from this is the importance of functional systems. Each sector of society is intrinsically linked to the success of the other. The effective functioning of the Liberian healthcare system depends on the equally effective functioning of the road networks, electricity supply, food supply, and many other non-medical factors. As members of any society, it's important to look outside of our individual selves and be invested in and actively working towards improving these infrastructural pillars in order to secure ourselves against devastating challenges like Ebola.
Pete Muller, a photojournalist who covered Ebola in Sierra Leone
Above all else, the Ebola outbreak has impressed on me the profound need for healthcare enhancements in many developing African countries. The healthcare systems in countries like Sierra Leone and Liberia were already among the weakest in the world before Ebola arrived. We talk often of systems being overwhelmed; well, in the case of Sierra Leone and Liberia—where most institutions were devastated by long civil wars— it would take less than an expansive Ebola outbreak to overwhelm the system. Despite the challenging circumstances and limited resources, it’s been extraordinary to watch doctors, nurses, and an army of support staff rise to meet this crisis head-on. At the outset, many provided care to patients without suitable protective equipment. In those stages, healthcare workers became infected and died in droves. While self-preservation would urge many to abandon posts, we saw even more joining the ranks.
People who contracted Ebola and were evacuated to Western countries had extraordinary survival rates. With few exceptions, nearly all Westerners who contracted the disease were able to survive. Experts say that Ebola outbreaks—all of which have occurred in African countries—have historically had fatality rates between 70 and 90 percent. As of October 2014, the survival rate of Ebola patients in the United States was 80 percent. Given this profound disparity, one must conclude that Ebola is a largely survivable disease if it occurs in a place where suitable care is available.
I was also struck by how the Ebola crisis highlights the financial desperation of many ordinary people. I met several men who were volunteering as gravediggers in the main cemetery in Freetown, Sierra Leone. They hoped that their volunteer efforts might eventually earn them a paid spot in the grave-digging teams. “This job pays 500,000 Sierra Leone Leones (approximately $100 USD) per week,” a volunteer told me. “There are so few jobs here, I just hope I can get on this team.” These kinds of jobs, while dangerous, offer regular pay that often exceeds the alternatives. I recall members of a body collection team explaining that their supervisor issued an advisory: If they didn’t like the job or their treatment, they could all quit. He had plenty of others who were eager to take their places, they said.
On a human level, I think we must reassess our stores of compassion. I felt very disheartened watching the discourse on Ebola in the United States—a conversation that seemed defined by fear and, to a large extent, xenophobia. Too many Americans allowed overblown, misinformed, and politically generated fears to eclipse their compassion for those who were truly suffering. To me, it seemed that two stories evolved, the story of a devastating Ebola outbreak in West Africa and another, almost disconnected story, about American fear and misunderstanding about the West African outbreak. Our respective worlds are interconnected and when it comes to infectious diseases, we must learn how to address inevitable outbreaks more constructively and with greater compassion.
Dr. Tim Lahey, an infectious disease specialist and associate professor of medicine at Dartmouth College
I have had to grapple with whether I care enough about the people who live in West Africa to lend my time and effort to fight Ebola in some capacity. How much will I donate? How else can I contribute? Would I be willing to get on a plane, travel to Sierra Leone, and treat feverish Ebola patients from inside a hot plastic suit? I have had to confront the fact that I care, and I will help, but I am not as courageous as the clinicians on the front lines. I hope my small contributions help those heroes win the war.
The possibility that Ebola could show up in the subways and bowling alleys of rich countries like ours was a vivid reminder of what it is like to live in the developing world. Here in the U.S., we expect some safety from contagion. People who live in low-to-middle income countries cannot realistically expect the same things today. Perhaps Ebola has brought the rich world closer to this quotidian reality, and in the process helped us engage more with the world’s need.
Crystal Johnson, a nurse at Emory University Hospital in Atlanta, who treated Ebola patients Kent Brantly and Nancy Writebol
The Ebola crisis has opened my eyes to the significance of healthcare infrastructures and how fortunate we are to be in a country that has a developed health system. However, if we do not help those that are less fortunate it can affect all of us.
Although we have a developed and well-established health system, we are not immune to health crises [in the U.S.]. We still need to make improvements on our preparedness for crises such as this Ebola outbreak; we need to find ways to aid those countries that are less fortunate by improving their healthcare system; and we need to continue to collaborate with each other, government agencies, and other disciplines to develop the best approach to managing and preventing crises such as this one.
Raphael Frankfurter, the executive director of Wellbody Alliance, an NGO in Sierra Leone
I do wonder what I thought would happen back in May and June, as the outbreak began with just a few people in an ultra-remote region of Kailahun District in Sierra Leone. Seeing the scale of the devastation first-hand now has certainly undone my initial instinctual sense of what such an outbreak could evolve into. Of course it makes intellectual sense that with a sluggish, ineffective international response things would spiral out of control, but it’s almost mind-boggling to see the extent of the devastation and the constant stream of ambulances in Freetown and now elsewhere.
I am deeply moved and impressed by the Sierra Leonean doctors and nurses who keep coming every day to work in clinics and treatment units, despite the obvious risks and the fact that nobody’s really stepped up yet to guarantee their prompt and high-quality treatment if they contract the disease. It’s a truly heroic dedication.
I think we’ve learned about the importance and urgency of building trust in places like Sierra Leone, between rural communities and the healthcare system. Not in a superficial, rhetorical way—but finding ways of investing in and building deep, dependable relationships between communities and clinics where patients will feel like their illnesses and felt needs (medical, relational, and emotional) will be attended to. This outbreak would not have happened if the initial small cluster of patients who avoided health workers and clinics had felt that they could trust the healthcare system to treat them humanely and with dignity. There are ways to institutionalize and re-prioritize these people-centered, humane aspects of healthcare in Sierra Leone rather than continuing to efface them under the pretext of the urgency of outbreaks.