A decade ago, scientists would have laughed at the idea of Ebola as a public health emergency of international concern. Today, they are shocked at the glaring gaps the deadly virus has exposed in the global response to the current outbreak.
Ebola, a rare tropical disease, has killed almost as many people in 6 months as in the previous 40 years. Experimental vaccines and treatments are available, but months away from use by the estimated 30,000 people who could have benefited from them, according to Nature magazine.
“I would have laughed if you had said Ebola would be a global public health emergency,” said David Heymann, who was working with the CDC team when the deadly virus was first recorded close to the River Ebola in Democratic Republic of Congo, then Zaire. “Ebola outbreaks can be stopped with a robust response.”
Since 1976, 25 Ebola outbreaks have occurred throughout Africa. Most of them were contained within the locality of patient zero – the first person to be infected when the virus jumped to humans from animals, as it does periodically.
That changed in March when the deadly Zaire strain was confirmed in Gueckedou, a small town in southern Guinea. Since then, it has killed over 1,350 people across West Africa, spanning hundreds of kilometers from Guinea to Nigeria.
"There is a whole series of issues in terms of recognition by health workers, a system in which to report, then the need to take the data and act on it, and there have been weaknesses in Guinea in all three of those areas,” said Heymann, adding that fear and cultural practices are also part of the challenge.
A similar situation prevailed in Sierra Leone and Liberia, but decades of civil war and corruption resulting in weak health systems meant their governments couldn’t face the threat alone. Criticism has emerged of the World Health Organization (WHO), the United Nations’ lead agency in fighting disease.
Heymann, who is currently at the London School of Hygiene and Tropical Medicine, said he was disappointed with the WHO response to the Ebola outbreak. West African nations and aid organizations have been less restrained in their criticism.
“Boiling frog effect”
Brice de la Vigne, Head of Operations for medical charity Medecins sans Frontieres (MSF), told Thomson Reuters Foundation the slow pace at which the WHO reacted to the rapidly escalating Ebola epidemic in West Africa was like boiling a frog.
“Even though we were screaming at them to gear up and scale up, the WHO did not realize they needed to change their approach to being fully in emergency mode, and not just in support mode,” said de la Vigne.
“It’s the boiling frog effect. If you put a frog in cold water and start to heat it, she will not jump out of the pan, she will adapt to the temperature and she will not realize that she is boiling to death. WHO is the same,” said de la Vigne.
In April, MSF said the current outbreak was unprecedented in its geographical scale and needed urgent international action, prompting a very public spat played out on Twitter, where the WHO accused the medical charity of causing panic.
On August 8, WHO declared Ebola a public health emergency of international concern. Fifty people were sent to help with contact tracing, disease surveillance, laboratory work, logistics, information-sharing and social mobilization -- but no doctors, nurses or equipment.
"We need water and sanitation technicians, logisticians, cars, generators, tents, supplies, nurses and doctors, nurses especially. We need the whole apparatus to be able to deploy activities in the field in a difficult landscape like jungle and slums," said de la Vigne.
Francis Kasolo, Head of Ebola disease control for the WHO sub-regional office, said there was a division of labor matched to the skills of different organizations.
“Case management is predominantly government and MSF, who are doing a heroic and impressive job. WHO works in other areas, such as logistics, surveillance, laboratories. Red Cross focuses on safe burials and social mobilization,” said Kasolo.
MSF leads the field in the response to Ebola outbreaks, but despite its great work in treatment of Ebola patients, its overwhelming presence as well as an over-reliance on its expertise may have contributed indirectly to the spread of the disease.
"We didn’t try to get involved earlier because there was a point a couple of months ago when it seemed like MSF is dealing with it and they have it under control,” said Ben Phillips from the International Medical Corps (IMC).
There is no miracle cure for Ebola, but early detection and palliative care, a relatively uncomplicated service that can be provided by nurses compared to emergency surgery in the conflicts in the Central African Republic, can dramatically improve survival rates, experts say.
Four other respected medical charities could have helped mobilize resources if given training: the International Red Cross and Red Crescent movement, the International Federation of the Red Cross, Merlin, now part of Save the Children, and the International Medical Corps (IMC).
In July MSF, which has an annual budget of over $1.5 billion, more than a third of the WHO 2012-13 budget of $ 4 billion, said it was overstretched in its response to the Ebola outbreak, partly because of simultaneous crises in CAR, Syria and Sudan.
De la Vigne said MSF was the only organization in the world that had the capacity to run treatment and isolation centers, and that it was due to conduct training for other international medical aid agencies in Brussels next week, including IMC.
Asked why MSF had not been faster in giving training earlier on in the epidemic, when it did have the resources, de la Vigne said: “This is the first time we are facing an epidemic of this type and size and (it is) typically very difficult to do forecasts in this kind of environment.”
“After we have gone through this learning curve, we’ll be able to make a difference and contribute to this Ebola outbreak, and we would certainly be in a very good position to help respond to the more typical isolated, smaller Ebola outbreaks,” said Phillips of IMC.