On September 30, 2014, the CDC announced the first Ebola case diagnosed in the United States. CDC’s director has no doubt that the case will be contained. We hope he is right, but either way this is a pivotal moment for the CDC, the US and the healthcare community.
In the early 90’s I was privileged to be part of the Harvard School of Public Health’s New and Resurgent Disease working group. This group was the first of its kind to begin to explore why we were seeing what seemed to be both new, and resurgent disease outbreaks, epidemics and pandemics, both in the US and globally. I was there as the water guy – interested in new strains of waterborne diseases and the surge in toxic algal blooms along our coasts. The tragic HIV/AIDS pandemic was in full swing, with no effective treatment at the time (there is still no cure, and control through antiretroviral therapy did not begin until the late 1990s) – a disease that continues today as one of our top five infectious disease killers in the developing world, together with lower respiratory tract infections, TB, Malaria and diarrheal diseases.
At the time of our working group, HIV/AIDS had killed millions of people worldwide and hundreds of thousands in the US, but there seemed to be a plethora of others emerging/resurging – the massive outbreak of cryptosporidiosis in Milwaukee in 1993, caused by an organism that was barely recognized as a human pathogen before the emergence of HIV/AIDs. Epidemic cholera returned to South America after more than a hundred year absence and a new strain of epidemic cholera had emerged in India.
From the mid 70s through the 80s we had seen Lyme disease, Legionellosis, hantavirus pulmonary syndrome, Ebola, Marburg and Ehrlichiosis emerge as newly recognized diseases, and a resurgence of dengue, plague, yellow fever, diphtheria – and perhaps most worrying of all, rapidly increasing numbers of drug resistant cases of TB, malaria and others – the direct consequence of our treatment and animal husbandry practices (a subject for another blog) – practices that together with hygiene and immunization programs had led many to feel that death from infectious disease would soon be a “thing of the past.” We wrote in the “Ecologist,” “Suddenly, the euphoric proclamations of freedom from infection seem, at best, premature; at worst, dangerously hubristic.” (Levins R, et al. The Emergence and spread of new diseases. The Ecologist 1995; 25:21-26.)
One member of our working group, the acclaimed author Laurie Garrett, then a writer for Newsday, spent a year’s fellowship with us researching her new book, “The Coming Plague: newly emerging diseases in a world out of balance.” Published in 1994 by Farrar, Straus and Giroux, her book presents one of the most compelling and readable accounts of the phenomena of new and resurgent diseases, including a chapter dedicated to the first outbreak of Ebola. This should be required reading for all!
Not long after Laurie’s book was published, Ebola inspired the film industry to produce the film “Outbreak” (1995), about an Ebola like virus that emerges in Zaire and then spreads to a small town in the US. Of course, the CDC and military are able to eventually control the outbreak, a message that I fear creates complacency amongst those of us in this country who are currently untouched by Ebola in Africa today.
Speaking about Ebola, and in response to the undeniable fact that we are only a plane ride away from Africa, Anthony Fauci, the director of the US National Institute of Allergy and Infectious Diseases, considers it extremely unlikely that an outbreak could occur because of our healthcare system and isolation procedures. He is probably right, but his logic only applies if we can recognize an infected individual, and that individual seeks care. Many viruses are transmitted by the aerosol route, e.g., pandemic flu – placing passengers in a confined environment such as an airplane at risk of infection through proximity to an infected individual. Current thinking is that the known strains of the Ebola virus are primarily transmitted through direct contact with bodily fluids.
In fact, the CDC’s Quarantine and Isolation website provides Ebola Guidance for Airlines which state: “The risk of spreading Ebola to passengers or crew on an aircraft is low because Ebola spreads by direct contact with infected body fluids. Ebola does NOT spread through the air like flu.” Sound science behind this statement is hard to find. In fact you can find some information on the web that seems to contradict this assumption.
Am I trying to be an alarmist? Actually, I’m trying to make the argument that we in the US do not have all the answers, and that there is no guarantee that our healthcare and isolation systems will effectively deal with the next potential pandemic. We have to fight these diseases where they originate, and do everything we can to prevent an outbreak becoming an epidemic and then a pandemic. It is also ethically indefensible to allow a killer-disease to decimate rural villages when we have convinced ourselves that we have both the technical expertise, and the resources to mitigate these threats in our own country. Ebola is now global – yes, it is still in Africa but it has now emerged in the Democratic Republic of the Congo, Guinea, Liberia, Nigeria, Senegal and Sierra Leone – previous countries included Zaire, Sudan, Gabon and Uganda. In Liberia, clinics in its capital city, Monrovia – with a population of over 1,000,000 – are currently overwhelmed. Sierra Leone’s capital, Freetown, may soon face the same challenges.
With more then 3000 killed in this current outbreak to date (and this number may be considerably higher), we can no longer think of Ebola as causing sporadic outbreaks in geographically isolated areas. This is no longer a “cry for help” from a poor African country. We needed to act internationally on a major scale at the beginning of the outbreak – now we have to throw all our resources at mitigating the African epidemic – because it will continue to spread. Instead we have governments blaming the world health organization (WHO) for a slow response, and the WHO blaming governments.
How many reports have you seen that end their title with “a call for action”? I’ve written them myself in relation to waterborne disease – but does action ever happen? The last decade has seen significant threats from the specter of infectious disease pandemics – SARS, H5N1 and others – and arguably we should now be capable of an effective global response. But it didn’t happen, there is no excuse, but I’m afraid we’ll hear many from all quarters, continued finger-pointing and limited action. This is happening in Africa and it’s complicated by war, poverty, corruption, issues of sovereignty, malnutrition and a plethora of different disease states.
Yes, that’s exactly why diseases like Ebola often emerge in African countries, or in countries that lack the resources to provide the necessary response. We in the health professions need to keep these global crises at the forefront of debate – the public and our politicians cannot be allowed to lose interest, the stakes are too high. The current Ebola outbreak clearly demonstrates that we lack the commitment to human society to prevent this kind of catastrophe until its almost too late – or perhaps it already is. If this turns into a pandemic, all of us are responsible for our complacency, the least we can do is hold our politicians accountable for a strong US response.