The first Ebola death in the United States makes clear that global health challenges in the 21st century can no longer be considered local problems. While the United States government just moved to require airport screening for fevers for passengers travelling from West Africa this is unlikely to be an effective strategy. Given the extended incubation period of the virus, even travelers who might have Ebola are likely to be asymptomatic. As the Director of the Centers for Disease Control and Prevention (CDC) Thomas Frieden explained, “The plain truth is we can’t make the risk zero until the outbreak is controlled in West Africa.” The only effective strategy for the United States and other countries to defend against Ebola is to invest in the global public goods needed to defeat Ebola in Liberia, Sierra Leone, and Guinea.
The Ebola catastrophe did not have to happen but instead was a result of multiple failures when it comes to disease surveillance, vaccine innovation, and the emergency public health response. It reveals that we need different strategies to prevent the next outbreak and to deal with the exponential growth of the current pandemic. As I have found in my research, effective global health responses require distinct approaches to solving collective action failures—the same type of failures that are at the root of the current crisis. Without these failures, the world would already have an Ebola vaccine, the initial outbreak would not have festered for three months without anyone figuring out what was happening, and a serious global response would not have been delayed by as much as nine months as the epidemic spun out of control.
The first failure that gave rise to the current Ebola crisis is the failure of adequate disease surveillance. It looks like the first victim of this outbreak was a 2-year-old boy in a remote Guinean village. His mysterious death in December 2013 was followed by similar deaths within that region and across the country before experts from Doctors Without Borders identified the culprit as Ebola. If Guinea’s extremely weak health system had a more robust system of surveillance this disease could have been stopped in its tracks before it ever reached Liberia or Sierra Leone. This weakest-link challenge resulting from limited disease surveillance capacity within Guinea reveals that without strengthening health systems in many of the poorest countries in the world, global health responses will continue to be behind the curve.
Even after Ebola was identified, another six months passed before any country with the resources to adequately respond to the pandemic stepped up to the plate in a major way. In September, President Obama committed the United States to building Ebola treatment units and training health care workers. Despite this important effort, the global response still faces a shortfall of over $300 million even as the cost of the epidemic continues to grow dramatically. Only three countries have committed more than $20 million and most countries have contributed nothing at all. This problem of aggregate effort is central to the challenge of financing a sufficient emergency public health response in the affected countries to contain the virus.
Perhaps the most dramatic failure is the fact that nearly 40 years after the discovery of the Ebola virus there is still no effective vaccine. Leading scientists suggest that the technical challenges to creating a vaccine are relatively modest and two potentially promising vaccine candidates already exist. Yet the lack of a sufficient financial incentive for drug manufacturers meant that neither vaccine candidate was pushed forward to human trials until very recently. In the face of this dramatic market failure, a “single-best effort” investment by the United States in vaccine innovation can make a dramatic difference for the entire world.
Despite the many failures which contributed to the current catastrophe, there are some important signs that Ebola can be defeated. The spread of Ebola to Nigeria was quickly contained in Africa’s most populous country thanks to a rapid response that included strict quarantines for suspected cases, the temporary closing of schools, and screening for thousands of others. The survival of courageous health workers from the United States and elsewhere suggests there may be promise in new treatments that the United States is now investing in bringing to human trials. The possibility of blood transfusions from those who have survived may be the most effective treatment at present. The development of a rapid diagnostic to detect Ebola, which is within reach, could dramatically simplify the process of identifying those suffering from the virus and implementing appropriate public health responses.
The reality remains, however, that none of this will be possible without a dramatically ramped up global response. Liberia alone needs hundreds of additional foreign medical staff just to treat those now infected. More than 8,000 people have been infected so far and without extraordinary efforts, the CDC estimates that this number could grow to as many as 1.4 million by January. Thousands of others are now dying from untreated malaria or other illnesses as a consequence of a pandemic that is devastating the economies of the region and causing significant food insecurity. In the short term, a global aggregate effort to finance an emergency response and provide trained health care workers is essential to prevent Ebola from reaching many more countries. In the long-term, only by strengthening the health care systems and disease surveillance capacity in West Africa and other low-income regions and by investing in innovation to catalyze effective vaccines for potentially devastating viruses such as Ebola can the United States and the rest of the world be protected.