SEATTLE — The
Ebola epidemic in West Africa has killed more than 10,000 people. If anything
good can come from this continuing tragedy, it is that Ebola can awaken the
world to a sobering fact: We are simply not prepared to deal with a global
Of all the things that could kill more than 10 million people around the world
in the coming years, by far the most likely is an epidemic. But it almost
certainly won’t be Ebola. As awful as it is, Ebola spreads only through physical
contact, and by the time patients can infect other people, they are already
showing symptoms of the disease, which makes them relatively easy to identify.
Other diseases — flu, for example — spread through the air, and people can be
infectious before they feel sick, which means that one person can infect many
strangers just by going to a public place. We’ve seen it happen before, with
horrific results: In 1918, the Spanish flu killed more than 30 million people.
Imagine what it could do in today’s highly mobile world.
Much of the public discussion about the world’s response to Ebola has focused on
whether the World Health Organization, the Centers for Disease Control and
Prevention and other groups could have responded more effectively. These are
worthwhile questions, but they miss the larger point. The problem isn’t so much
that the system didn’t work well enough. The problem is that we hardly have a
system at all.
To begin with, most poor countries, where a natural epidemic is most likely to
start, have no systematic disease surveillance in place. Even once the Ebola
crisis was recognized last year, there were no resources to effectively map
where cases occurred, or to use people’s travel patterns to predict where the
disease might go next.
Then, once it became clear that a serious emergency was underway, trained
personnel should have flooded the affected countries within days. Instead it
took months. Doctors Without Borders deserves a lot of credit for mobilizing
volunteers faster than any government did. But we should not count on nonprofit
groups to mount a global response.
Even if we signed up lots of experts and volunteers right away, it’s not clear
how we would deploy them quickly into the affected area, or how we would
transport patients. Few organizations are capable of moving thousands of people,
some of them infected, to different locations on the globe with a week’s notice.
The Ebola epidemic might have been a lot worse if the United States, Britain and
other governments had not used military resources to fly people and equipment
into and out of affected areas. But we should not assume that the next epidemic
will limit itself to countries that welcome Western troops.
Data is another crucial problem. During the Ebola epidemic, the database that
tracks cases has not always been accurate. This is partly because the situation
is so chaotic, but also because much of the case reporting has been done on
paper and then sent to a central location for data entry.
Then there’s our failure to invest in effective medical tools like diagnostic
tests, drugs and vaccines. On average it has taken an estimated one to three
days for Ebola test results to come back — an eternity when you need to
quarantine people until you know whether they’re infected. Drugs that might help
stop Ebola were not tested in patients until after the epidemic had peaked,
partly because the world has no clear process for expediting drug approvals.
Compare all this to the preparation that nations put into defense. Armies have
systems for recruiting, training and equipping soldiers. NATO has a mobile unit
that is ready to deploy quickly. Although the system isn’t perfect, NATO members
do joint exercises where they work out logistics like how troops will get food
and what language they will use to communicate.
Few if any of these approaches exist for an epidemic response. The world does
not fund any organization (not even the W.H.O.) to coordinate all the activities
needed to stop an epidemic. In short, in a battle against a severe epidemic, we
would be taking a knife to a bazooka fight.
I believe that
we can solve this problem, just as we’ve solved many others — with ingenuity and
We need a global warning and response system for outbreaks. It would start with
strengthening poor countries’ health systems. For example, when you build a
clinic to deliver primary health care, you’re also creating part of the
infrastructure for fighting epidemics. Trained health care workers not only
deliver vaccines; they can also monitor disease patterns, serving as part of the
early warning systems that will alert the world to potential outbreaks. Some of
the personnel who were in Nigeria to fight polio were redeployed to work on
Ebola — and that country was able to contain the disease very quickly.
We also need to invest in disease surveillance. We need a case database that is
instantly accessible to the relevant organizations, with rules requiring
countries to share their information. We need lists of trained personnel, from
local leaders to global experts, prepared to deal with an epidemic immediately.
We need trained military resources ready to respond, and a list of supplies to
be stockpiled or commandeered in an emergency.
Finally, we need to invest far more in research on drugs, vaccines and
diagnostic tests, and make it possible to accelerate the approval of new
approaches in times of crisis.
The United Nations should empower and fund a global institution to coordinate
these efforts. The United Nations and the W.H.O. are studying the lessons of
this epidemic; their evaluations would be a good starting point for a
conversation about how to strengthen the W.H.O. and what pieces of the system it
I have not seen a rigorous projection for what a system like this would cost.
But we know the cost of failing to act. According to the World Bank, a worldwide
flu epidemic would reduce global wealth by $3 trillion, not to mention the
immeasurable misery caused by millions of deaths. Preventing such a catastrophe
is well worth the world’s time and attention.
Recent days have brought two alarming developments in the
struggle to contain Ebola. The campaign against the epidemic in West Africa, the
only sure way to prevent the spread of the virus to the United States and other
countries, fell even further behind. And the discovery that a nurse treating an
Ebola patient in Dallas had herself become infected despite wearing protective
gear raised questions about the readiness of American hospitals to deal with
Reassuring statements by health officials that virtually any hospital with an
isolation unit could treat such patients now look rashly optimistic.
That said, the risk that the Ebola virus might cause outbreaks in this country
remains small. By far the greater danger lies in the very real possibility that
the virus will continue to spiral out of control in Guinea, Liberia and Sierra
Leone and spread from there to other parts of Africa or other continents,
opening a wider range of pathways for infected people to reach the United
Many countries and international organizations, led by the United States, have
pledged money, equipment and manpower to fight the epidemic in West Africa. But
the aid has been slow to reach the front lines, leaving health care workers with
too few treatment beds to accommodate the sick.
In Sierra Leone, on Friday, health officials — facing just such a shortage of
beds — adopted a new policy of having families treat patients in their homes by
distributing painkillers, rehydrating solutions and gloves to hundreds of
Ebola-afflicted households. But if a nurse in Dallas, clothed in protective
garments, could not escape infection, it is hard to believe that less
well-equipped households in Sierra Leone will be able to escape contamination
from an Ebola patient in their midst.
The pace of international aid needs to be stepped up dramatically. This is not a
task that can be left to such nongovernmental organizations as Doctors Without
Borders, which has heroically provided much, if not most, of the care in the
stricken countries. The United States has taken the lead in providing aid to
Liberia, a country with long ties to the United States.
The Army has started deploying thousands of troops to the area to help build new
treatment centers, perform laboratory tests and train health care workers in how
to treat patients, but most of that help has yet to arrive. It was thus
disheartening to hear Maj. Gen. Darryl Williams, the commander of the United
States Army Africa, dismiss criticism that American aid had been “too little,
too late” with the excuse that the Pentagon was simply filling a “small gap”
left by other health organizations.
The United States’ obligation is greater than that; President Obama needs
personally to ramp up the urgency of the American response and the level and
speed of the resources provided.
Perhaps the Dallas case will add urgency to those efforts to control the
epidemic abroad. The case is not cause for domestic panic, but it is cause for
greater vigilance among health care workers. Even without knowing fully what
happened with the nurse, the Centers for Disease Control and Prevention is
exploring ways to make it easier to don protective gear, wear it while treating
a patient and take it off afterward without infecting oneself.
The task of treating Ebola patients can clearly be carried out by experienced
personnel. Five Ebola patients were flown back to the United States from West
Africa and have been treated safely at specially designated hospitals in Atlanta
and Omaha. But the Dallas hospital made mistakes in handling this case from the
start, and the infected nurse was reportedly a young graduate of a nursing
program with little experience in infectious diseases. It seems possible that
additional health care workers who cared for the patient will come down sick as
The C.D.C. is urging all hospitals, no matter how small, to take travel
histories to identify any patients who have been in West Africa within the past
21 days, and immediately place those with Ebola-like symptoms in isolation. The
C.D.C. plans to increase its training efforts for hospital personnel, a vital
need given that a survey of nurses found a vast majority had received no
instructions from their hospitals on how to deal with Ebola. Smaller hospitals
will probably have to transfer any Ebola patients to more specialized centers
But all of these efforts, however useful, pale against this country’s much
larger responsibility to help defeat the disease at its source.