We Could Have Stopped

This
Public health officials knew Ebola was coming. They know how
to defeat it. But theyre blowing it anyway.

BY
LAURIE GARRETT -SEPTEMBER 5, 2014

World, you still just don't get it. The Ebola epidemic that is
raging across West Africa, killing more than half its victims, will not be
conquered with principles of global solidarity and earnest appeals. It will not
be stopped with dribbling funds, dozens of volunteer health workers, and
barriers across national borders. And the current laboratory-confirmed
tolls (3,944 cases, with 2,097 deaths) will soon rise exponentially.
To understand the scale of response the world must mount in order to stop
Ebola's march across Africa (and perhaps other continents), the world

community needs to immediately consider the humanitarian efforts

following the 2004 tsunami and its devastation of Aceh, Indonesia. The U.S.
and Singaporean militaries launched their largest rescue missions in
history: The United States alone put 12,600 military personnel to a rescue
and recovery mission, including the deployment of nearly the entire Pacific
fleet, 48 helicopters, and every Navy hospital ship in the region. The World
Bank estimated that some $5 billion in direct aid was poured into the
countries hard hit by the tsunami, and millions more were raised from
private donors all over the world. And when the dust settled and
reconstruction commenced, the affected countries still cried out for more.
In contrast, the soaring Ebola epidemic garnered only a negligible
international response from its recognition in March until early July. The
outbreak originated in the tropical rain forest of Guinea in December 2013,
but local health authorities did not recognize the new disease in humans in
the country until four months later. They can be forgiven a slow reaction, as
Ebola has never previously appeared in the West African region. Shortly
after the World Health Organization (WHO) officially declared an outbreak of
the same strain of Ebola that first appeared in Zaire in 1976, outside
humanitarian responders appeared on the scene to assist Guinea; they
were the organizations that dominated the treatment and prevention efforts
throughout the spring and into the summer, as Ebola spread to Liberia and
Sierra Leone. During that time the outbreaks were largely rural, confined to
easily isolated communities, and could have been stopped with
inexpensive, low-technology approaches.
But the world largely ignored the unfolding epidemic, even as the sole
major international responder, Doctors Without Borders (also known by its
French acronym, MSF), pleaded for help and warned repeatedly that the
virus was spreading out of control. The WHO was all but AWOL, its miniscule

epidemic-response department slashed to smithereens by three years of

budget cuts, monitoring the epidemic's relentless growth but taking little
real action.
Even as the leading physicians in charge of Liberia and Sierra Leone's Ebola
responses succumbed to the virus, global action remained elusive.
The neglectful status of the WHO was, horribly, by design. Its governing
body, the World Health Assembly (WHA), in which nearly every nation on
Earth is a voting member, has declined to increase country WHO dues for
more than a quarter-century. Worse, following the 2008 financial crisis,
most of the extrabudgetary special support that the WHO relied upon -funds from rich countries that more than doubled the agency's financing -disappeared as once-wealthy governments turned away from philanthropy
while saving their fiscal skins. The WHO saw its revenues fall by more than
$1 billion, and inflation-adjusted dues from member countries plummeted
to pre-1990 levels. As Europe's financial crisis worsened in 2010,
speculators sold their euros in favor of Swiss francs, driving the value of
that currency up 32 percent. Since the WHO receives its revenues in U.S.
dollars, but makes its Swiss payroll and other payments in francs, the
agency was forced to lay off 20 percent of its staff. And in 2011, the WHA
began pressuring the Geneva-based WHO to decrease its infectious
diseases work in favor of a radical increase in attention to
noncommunicable ailments such as cancer and heart disease. The coup de
grce came with the 2012 WHA meeting, in which the nations of the world
voted to chop the WHO's crisis and epidemic funding by 50 percent,
bottoming out this year at a mere $114 million.
As I wrote last month, the world simply didn't get it. And it still doesn't. The
WHO doesn't have a giant SWAT team of disease-fighting soldiers ready to
swoop into a beleaguered area on an agency-owned transport jet, armed

with lifesaving drugs and vaccines. In reality, the WHO begs airlines for
tickets in coach, pleads with drug companies and protective gear
manufacturers for free handouts, and has only the expertise on hand that
governments are prepared to payroll and donate, such as scientists from
the U.S. Centers for Disease Control and Prevention (CDC).
And now the epidemic is skyrocketing -- nearly half of the cumulative case
burden of Ebola in the three countries has occurred in just the last 21
days, according to the WHO. This week CDC Director Tom Friedenreturned
from Liberia visibly stunned, flabbergasted by what he had witnessed,
warning that "There is a window of opportunity to tamp this down, but that
window is closing."
Disease fighters reckon the contagious potential of an outbreak in terms of
its RO, or reproduction number. (RO = 1 means that each infected person is
statistically likely to infect one more person, so the epidemic will neither
grow, nor shrink in size. RO = 0 signifies that the disease cannot be passed
from person to person. Any RO above 1 connotes an expanding epidemic.)
Christian Althaus of the University of Bern in Switzerland just released a
grim new calculation of the RO for this epidemic that finds that when the
outbreak began in Guinea, it was RO = 1.5, so each person infected one
and a half other people, for a moderate rate of epidemic growth. But by
early July, the RO in Sierra Leone was a hideous 2.53, so the epidemic was
more than doubling in size with each round of transmission. Today in
Liberia, the virus is spreading so rapidly that no RO has been computed.
Back in the spring, however, when matters were conceivably controllable,
Liberia's then-small rural outbreak was 1.59.
The Federation of American Scientists operates a disease notification
system called Pro-MED, which on Friday noted that the spread of the
epidemic is suddenly accelerating. From March to July 17, the first 1,000

cases accumulated over four and a half months. The toll reached 2,000
after just one month, on Aug. 13, and then jumped to 3,000 just 13 days
later, on Aug. 26. If this trend continues the epidemic could well reach
WHO's projected 20,000 cases by October. In extensive conversations with
MSF and U.N.-associated responders in the countries it is clear that the
WHO's official case reports, which solely reflect lab-confirmed patients that
have sought care in medical facilities, under-represents the true toll by at
least half, as families are keeping their sick at home and shunning health
facilities.
There are two factors contributing to the rate of spread: the genetic
capacities of the virus itself and the behaviors of human beings that put
them in contact with one another, thereby passing the virus. Though there
is strong evidence that the Ebola virus is mutating and evolving right now
as it passes through large numbers of people, none of the roughly 300
mutations detected to date have given the virus capacities that change its
inherent infectiousness. So any change in the RO is due to people taking
terrible risks, or lacking equipment and knowledge to protect themselves.
Moreover, there are increasing reasons to fear that tracking and quarantine
in Nigeria to prevent further spread there has also failed. The problem was
initially confined to a small number of people in late July who accompanied
and treated Liberian traveler Patrick Sawyer before he died of Ebola in
Lagos. But one quarantined individual escaped to Port Harcourt, while
another continued to treat patients and until he succumbed to the disease,
possibly infecting more than 60 people. And there are reports of isolated
cases of the disease in the capital, Abuja. Senegal's capital, Dakar, is
handling a case involving a traveler from Guinea. The epidemic threat is
surely widening.

This week the WHO finally came out of its somnambulant state and
infuriating claims of being just a "normative agency," as Director-General
Margaret Chan has repeatedly put it. The WHO's Chan and Keiji Fukuda,
who oversees the agency's responses to outbreaks, held a blitzkrieg of
meetings in Washington this week hoping to raise hundreds of millions of
dollars and instill confidence in United Nations leadership. With them was
David Nabarro from the United Nations' Secretary-General's Office, who was
recently appointed to coordinate Ebola responses across the entire U.N.
system. They touted the WHO's "road map," a 12-point set of principles and
needs for Ebola response that was released in August. When the road map
was originally released, the WHO said its implementation might stop Ebola
in nine months' time, at a cost of $490 million and some additional 20,000
human cases. But days later, at their Sept. 3 Washington press conference,
Nabarro put the cost at "at least $600 million" and said that "it may cost
even more," and "scale-up needs to be on the order of three to four times
what is currently in place."
The take-home message of the road map boils down to this: Stopping Ebola
is going to require a great deal of money, thousands more skilled health
workers and logistics experts, massive communications efforts, huge food
and nutrition support for the people of West Africa, and "coordination,
coordination, coordination."
"Coordination," as Nabarro said, "saves lives."
All that coordinating will presumably be executed from an "Ebola Crisis
Center" created on Sept. 5, and located in the U.N.'s New York
headquarters. But here is what WHO and U.N. leaders have not said or
explained to date.

First, where is the bank account to which donors, both public and private,
can make out their checks? Surely the logical location is the World Bank,
but months after the epidemic commenced there is still no account to which
a corporation like Goodyear (which has huge rubber operations in Liberia)
or Rio Tinto (mining in Guinea) or Titanium Resources Group (Sierra Leone)
can donate millions. If a list of celebrities wishes to mount a "We Are the
World" campaign, or social media fundraising begins in earnest, there is still
no centralized, accountable, transparent repository for the funds.
Second, nearly all commercial airlines and air delivery companies have
stopped flights to and from the three Ebola-stricken nations, and many have
halted services across all of West Africa. As a result, personnel and supplies
cannot get into the area, and exhausted health volunteers desperate for a
break cannot get out. Nabarro flew to Liberia last week -- or tried to. The
airlines refused to fly, and he reached Monrovia through a circuitous set of
connecting flights.
Happily, the government of Ghana has agreed to make Kotoka International
Airport in Accra an air bridge for Ebola responses, allowing large aircraft
from all over the world to land at Kotoka, and smaller planes to shuttle
personnel and supplies in and out of areas of need in the region. The WHO
will assure that screening is in place at all of the region's airports to ensure
that no ailing individuals fly to Ghana.
While this is a long-overdue beginning, the air bridge -- if it is to come close
to meeting the needs in the Ebola-stricken areas -- will require military-scale
logistics and support. Having landing rights is only step one: Knowing where
to warehouse goods, tracking their fate, loading secondary aircraft with
proper destinations, and ensuring absence of theft are massively complex

activities -- just ask FedEx. Given the positive relations between Washington
and Accra, it seems logical that the U.S. Air Force should supply transport
flights and personnel, as well as warehousing and logistics support at
Kotoka. To get a sense of the scale of the necessary Kotoka
operations, Fukuda has calculated that for every 80 patients in care in
Liberia, for example, 200 to 250 health and logistics personnel are required.
And MSF has shown that fatigue and stress prompt errors in personal
protective behavior that risk Ebola infection. To fight this, all of MSF's
foreign volunteers are flown out to neighboring countries every few weeks
for R&R, while others are rotated in as replacements. Simple math based on
the number of cases currently estimated and the joint Fukuda/MSF calculus
shows that more than 11,000 health care workers are needed now, with
exigencies destined to soar with expansion of the epidemic. No matter
where these people come from, most will need to use the Kotoka air bridge.
But also not stated in the road map or WHO/U.N. briefings is who will pilot
and crew the planes in that air bridge? Chan said that her team has been
meeting with airline executives, trying to convince them that the safety of
their personnel can be assured. But it seems unlikely that hundreds of
commercial pilots, cargo handlers, and flight crew will volunteer to fly in
and out of Liberia, Sierra Leone, Guinea, and even, if conditions worsen,
Nigeria. Military pilots and crew, in contrast, often volunteer for dangerous
missions.
Supplies of everything from basic food for the people of Monrovia's slums to
advanced medical equipment are desperately needed, and demand for
everything will grow in tandem with the size of the epidemic. If the Ebola
RO in Liberia = 3.0 right now -- and it might -- then the expansion rate of

personnel and supplies needs to grow threefold simply to keep pace, or

fourfold to get ahead of the virus. The logistics and warehousing scale of
need is mind-boggling -- akin to FEMA mobilizations to tornado-stricken
communities or the recent movement of supplies to the Philippines
following Typhoon Haiyan in 2013. But WHO and U.N. leaders have nothing
to say about staging grounds, warehousing, and accountability for the
movement (versus theft and black-marketing) of supplies.
Some countries abutting the epidemic have refused to serve as staging
grounds, even for warehousing of crates of gloves and surgical
gowns. Though the names of these governments are whispered off the
record, WHO and U.N. officials have said nothing on the record about this
obvious breakdown in global solidarity. Will nations that refuse even to allow
humanitarian planes to land on their real estate pay any political price?
Similarly, some countries in the region have refused to allow exhausted
health workers and international volunteers entry for vital R&R respites.
One of the logical places for this -- a country that is famous for its luxury
hotels and dining -- now privately tells the U.N. that MSF and other groups
will only be allowed to "rest" at the airport, and may not stay in the nation's
hotels or facilities. Will countries pay any price at all for such approbations?
Unless the offenders are publicly named, it seems doubtful any price will be
paid for such ungenerous national behavior.
The WHO and U.N. leaders decline to speak on the record about any use of
outside military personnel in support of domestic operations inside
impacted countries, though MSF recently issued a call for military support,
specifically from the United States. (As I write, no official response to the
request has been released by the U.S. Department of Defense, but its
Canadian counterpart appears to have declined to provide military support.)

There are a number of reasons the presence of foreign military personnel

on African soil should be carefully considered. On the one hand, local police
and military forces are stressed to the limit, many having been attacked by
mobs of angry citizens. Just as health workers merit R&R, so too do the
exhausted proponents of law and order. Foreign soldiers and police may be
helpful. The U.S. military has the most sophisticated mobile response
capacity and experience in the world, having been in combat on more than
two fronts since 2001. MSF can see the benefits of putting those medical
boots on the ground. Washington officials say off the record that options for
U.S. military assistance are under consideration, and may be announced in
a few days.
But beyond bringing in military personnel to handle the logistics and air
bridge support, the presence of uniformed foreign military personnel risks
feeding conspiracy theories that already surround this epidemic.The classic
canard of every modern epidemic -- that the germ was madeor distributed
by the CIA -- is already circulating in these countries. The existing "uniform"
of hoods, gloves, goggles, and protection suits has already sparked anger
and suspicion. A visible foreign military presence could not only fuel further
suspicion, but fan Islamist claims in Nigeria that infidels are contaminating
vaccines. Any non-indigenous military use must be carefully considered,
weighing the tremendous professional skills and experience combat medics
could bring to the epidemic fight against potential blowback from
conspiracy-mongers and Islamists.
In addition to failing to address basic logistics, warehousing, financing, and
military issues, U.N. and WHO leaders have not been willing to discuss what
happens to their road map if Ebola spreads in Nigeria or Senegal, the two
richest and most cosmopolitan nations in West Africa.

The WHO's Chan has been at great pains in her media blitz this week to say
that the U.N. and WHO are not in charge -- the respective governments are
in command of the Ebola crisis. But Sierra Leone and Liberia are among the
poorest countries in the world, with weak governments that constantly
struggle to overcome public distrust sown by years of brutal civil wars.
Unanswered is the obvious question: What does the world community do if
a weak government fails to act, or makes wrong choices? If Ebola spreads
to other countries this conundrum will arise again, and the global
community will be left with its own question: "Who's in charge?"
The weak, deficient road map might actually be strengthened if it received
formal backing from the U.N. Security Council, with passage of specific
resolutions calling for creation of centralized banking for Ebola responses,
penalties for countries that decline to appropriately engage in the effort, at
least $1 billion in immediate support, mobilization of food for the region to
stave off imminent famine, and the like. The silence of the Security Council
is stark, as the usual reasons for division and veto, especially on the part of
Russia and China, do not apply in this case. If Ebola escapes its current
confines, the risk of contagion is shared across the planet.
Having chronicled the 1976 Ebola outbreak in Yambuku, Zaire, and having
been in the 1995 Kikwit epidemic, I have puzzled for long hours over the
litany of failures in this current epidemic. This week I spoke with Barbara
Kerstiens, who in 1995 was a young MSF physician assigned to lead just two
other foreign MSF volunteers to handle the Ebola epidemic in Kikwit. I was
filled with admiration watching them transform the General Hospital from a
hellhole of festering disease lacking water, electricity, hygiene, or any
modicum of patient comfort into a clean, electrified facility with fresh water

and decent supplies. I asked Kerstiens, who now lives in Brussels, what
made it work back in Kikwit, and discovered she had been pondering that
question for weeks.
"We were all confronted with something we did not know much about,
and/but were willing to take the risk, for many different reasons," Kerstiens
wrote in an email. All of us, including this then-journalist, found ourselves in
a situation for which there was no precedent, and, "We found ourselves
doing different things from what we were 'briefed on' and we
had/obtained the 'go-ahead' to improvise from our respective
headquarters." The two MSF volunteers arrived with their instructions from
European headquarters, as did the CDC scientists instructed from Atlanta,
the WHO folks with Geneva orders in hand, and Professor Tamfun Muyembe,
who took commands from Zaire's dictator Mobutu Sese Seko. But once on
the ground in the huge, yet remote town of Kikwit, everybody agreed to
toss the dictates from their headquarters and reconsider the best uses of
their skills and supplies.
Kerstiens credits Muyembe with warm and welcoming leadership. By nature
gregarious and gracious, Muyembe was long-practiced in the school of
charm, having worked miracles for years in getting around Mobutu and his
corrupt government. A professor of infectious diseases at the University of
Kinshasa, Muyembe was comfortable with the languages of science and
medicine, and fluent in English, French, and at least two African languages.
At his side, acting as co-leader, was David Heymann, who as a young CDC
worker and then on assignment for the WHO had worked in Africa for many
years. Heymann spoke French fluently, and handled African French dialects
adroitly. Muyembe and Heymann liked and respected one another, their

leadership was clear to all, and they saw themselves as "stewards" rather
than perhaps "commanders" of the response, Kerstiens says.
Together with the courageous Kikwit Red Cross and students from a local
medical school, the Ebola team "developed a clear plan of action," Kerstiens
recalls. They were able to convey credibility and "create the atmosphere in
the town of Kikwit of look guys, this is scary, but we have a grip -- follow our
guidance."
As in Kikwit, Kerstiens says, the Ebola responses in Liberia, Sierra Leone,
Guinea, and possibly Nigeria each need a "national force/brigade that tells
people, 'this is what you do and what you do not,' and that does
surveillance -- this brigade has to have the trust of the people."
The trust of the people: Attaining that is clearly the primary challenge these
desperate governments face. And as time marches on, with Ebola spreading
in toll and geography, the World Health Organization and the entire U.N.
system will find themselves struggling to maintain trust among the people
of this world and their governments.
DOMINIQUE FAGET/AFP/Getty Images