TIME health

How Lessons From the AIDS Crisis Can Help Us Beat Ebola

Health officials counsel guests on the p
Health officials counsel guests on the prevention of HIV/AIDS transmission at the Argungu fishing festival in Kebbi State, northwestern Nigeria on March 13, 2008. Hundreds of fishermen from different parts of Nigeria and neighbouring West African countries have started arriving in Argungu fishing Town to participate in the fishing festival. AFP PHOTO / PIUS UTOMI EKPEI (Photo credit should read PIUS UTOMI EKPEI/AFP/Getty Images) PIUS UTOMI EKPEI—AFP/Getty Images

Ruth Katz is the director of the Health, Medicine and Society program at the Aspen Institute, a nonpartisan educational and policy studies institute based in Washington, D.C.

For too long, the history of infectious diseases has been that of ignoring a threat until it nears disaster

Without urgent action, Ebola could become “the world’s next AIDS,” said Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention (CDC). HIV/AIDS has killed some 36 million people since the epidemic began, and another 35 million are living with the virus. Is history really about to repeat itself?

It doesn’t have to, if we have the wisdom to learn from past experiences. The tools we need immediately are swift international action, strong leadership, respect for science and broad-based compassion. But once we contain Ebola – and we will – we need new resource commitments and global health strategies to bring the next deadly epidemic under control much more quickly.

We’ve already done some things right. President Obama traveled to CDC headquarters in Atlanta, a rare presidential action, to detail an aggressive offensive against Ebola that includes sending troops and supplies to build health care facilities in Africa. Contrast that with the response to AIDS under President Reagan, who did not mention the epidemic publicly until 1987, six years after people started dying from it. This time around, we’re seeing leadership at the top.

Health officials have also put out a unified message about how Ebola can be transmitted – only through direct contact with bodily fluids. That, too, stands in welcome contrast with HIV, where irresponsible rumors quickly took hold and people worried about sharing toilets seats and touching doorknobs. The importance of educating health care workers and keeping them safe represents a commonality between Ebola and HIV, and must be among our highest priorities. Following the science is the only way we’re going to stop this thing.

Another lesson from HIV is that adequate resources can transform disease outcomes. The President’s Emergency Plan for AIDS Relief (PEPFAR), a $15 billion, five-year commitment under President George W. Bush saved millions of lives around the world. But by contrast, even though the CDC is attacking Ebola with the largest global response in its history, the effort doesn’t come close to having the budget necessary to do all the field work needed to really beat back Ebola. Bipartisan funding support is crucial to enable public health officials to act aggressively.

One lesson that has not been well learned is that we stigmatize people at our own peril. During the AIDS epidemic, we saw an American teenager, Ryan White, expelled from school after he contracted HIV through a blood transfusion. In Dallas, where the first known Ebola victim in the U.S. has died, we hear reports that people of African origin have been turned away from restaurants and parents are pulling their children out of school. Cries to ban flights from Ebola-affected countries — an ineffective strategy reminiscent of the 22-year ban on the entry of HIV-positive people into the U.S. — are growing louder.

Experience tells us that when we are driven by fear, we tend to push infected people underground, further from the reach of the health-care system and perhaps closer to harming others. There was a time when many people assumed every gay man could spread AIDS; now some are suspicious that anyone from West Africa could harbor a deadly virus. Acting on ignorance is the best way to disrupt an optimal public health response.

We should look to other infectious diseases for lessons as well. After severe acute respiratory syndrome (SARS) surfaced in China in 2002 and spread to more than 30 countries in just a few months, an aggressive, well-coordinated global response averted a potential catastrophe. We saw how much could be done when political and cultural differences were set aside in favor of cooperation. SARS also spurred the World Health Organization (WHO) to update its International Health Regulations for the first time in 35 years, and prompted many countries to strengthen their surveillance and response infrastructure, including establishing new national public health agencies.

But glaring gaps remain in the health care and public health systems of many nations, despite years of warnings from almost anyone who has taken a careful look at them. With a population of 4 million, Liberia has only 250 doctors left in the country. That’s more than just Liberia’s problem, because if we can’t contain the Ebola epidemic there, we’re at much higher risk here. And within our own borders, we have a public health system that the Institute of Medicine termed “neglected” back in 2002. That assessment was largely unchanged a decade later when the IOM said that “public health is not funded commensurate with its mission” in the U.S.

The international community dragged its feet far too long on Ebola, and as a result, the virus still has the upper hand, outpacing the steps finally being taken to defeat it. Sierra Leone has just 304 beds for Ebola patients and needs almost 1,500 right now; by next week, it will need more. When it comes to control and prevention, speed is paramount. With the epidemic doubling every three weeks, the actions we take today will have a much greater impact than if we take those actions a month from now.

When we finally subdue this epidemic, we also need to shed our complacency towards the infectious diseases that plague us still, and the new ones likely to arrive with little warning. In a globalized world, they remain an immense threat. Almost 50,000 new HIV infections occur in the United States every year, as do 2 million worldwide. Influenza kills thousands of people annually, and more virulent strains can be much more dire. Yet we shrug most of this off, rarely paying attention until blaring headlines announce an impending cataclysm.

To get ahead of the curve, we need a renewed commitment to research and action, and enough resources to put more public health boots on the ground, both at home and abroad. Greater support for the Global Health Security Agenda, designed to close gaps in the world’s ability to quell infectious disease, should be a priority. The agenda, launched earlier this year, is a partnership involving the U.S. government, WHO, other international agencies and some 30 partner countries.

For too long, the history of infectious diseases has been that of ignoring a threat until it nears disaster, and then stepping in to prevent it from getting even worse. We can’t afford to keep repeating that pattern, and squandering blood and treasure in the process.

Ebola is a humanitarian crisis, but it does not belong to West Africa alone. We are all in this together.

 

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Ruth Katz is the director of the Health, Medicine and Society program at the Aspen Institute, a nonpartisan educational and policy studies institute based in Washington, DC. She served from 2009 to 2013 as Chief Public Health Counsel with the Committee on Energy and Commerce in the U.S. House of Representatives. Ms. Katz was the lead Democratic committee staff on the public health components of the health reform initiative passed by the House of Representatives in November 2009. Prior to her work with the Committee, Ms. Katz was the Walter G. Ross Professor of Health Policy of the School of Public Health and Health Services at The George Washington University. She served as the dean of the school from 2003 to 2008. This article also appears in the Aspen Journal of ideas.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME ebola

Ebola Health Care Workers Face Hard Choices

A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment center on Oct. 5, 2014 in Paynesville, Liberia.
A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment center on Oct. 5, 2014, in Paynesville, Liberia John Moore—Getty Images

The risks to doctors and nurses are never far from their minds

For Laura Duggan, going to Sierra Leone to care for patients with Ebola wasn’t so much a choice as a moral responsibility. “This is one of the biggest public-health emergencies of our time,” Duggan, a 34-year-old Irish nurse, told TIME as she prepares to leave London. “I’m trained to do this and there’s a great need. I couldn’t sit here and not go.”

Duggan had done her research, and knew the challenges: fatigue, long hot days spent working in sweltering biohazard suits, and the emotional toll of watching more than half her patients die no matter how heroic her efforts. But as for catching the disease itself, she wasn’t worried. Ebola is only spread through contact with infected bodily fluids. Duggan was confident that as long as she followed basic self-protection protocols, she would stay safe. But then, on Oct. 6, a nursing assistant in Madrid contracted Ebola from a priest who had recently returned from Sierra Leone. A week later, an American nurse treating a Liberian man in Dallas who died of Ebola also tested positive for the virus. Duggan’s partner, a Spaniard, pointed out that the Spanish nurse had been following the same rules, and still got sick. “He was getting a little nervous and saying, ‘Well, if she followed procedure and you’re saying you’ll follow procedure, then what happened? Why has she become infected?’” Duggan recalled. “That was my first little wobble and I kind of just went, Oh God.”

Despite pledges of support and widespread international concern, the Ebola epidemic in the West African nations of Liberia, Sierra Leone and Guinea is rapidly outpacing all efforts to contain it. As of Oct. 10, the number of cases had topped 8,399, with 4,033 deaths. With local populations of doctors and health care professionals cut down by disease and fear, and with those that remain overwhelmed, it is essential that their ranks be filled with international volunteers who can treat the ill and help prevent Ebola’s spread. But finding qualified doctors and nurses willing to face the risks, as well as repercussions back home, is “a challenge,” says Eric Talbert, the USA executive director for Emergency, an international medical organization that is setting up a 100-bed Ebola treatment center in Sierra Leone. “There is a significant fear factor. They are putting their lives on the line for people they have not met. It’s a courageous ask.”

(PHOTOS: See How A Photographer Is Covering Ebola’s Deadly Spread)

Never has the need been so great, and it looked like it might be exacerbated Monday when health care workers in Liberia signaled they would strike to protest conditions and pay — although many workers ended up defying the call to strike).

Calling the Ebola outbreak in West Africa a “tragedy not seen in modern times,” at the annual meeting of the International Monetary Fund and the World Bank on Oct. 9, Sierra Leone’s President Ernest Bai Koroma said, via video link, that his country would need 750 doctors and 3,000 nurses to treat the anticipated caseload.

As the numbers climb in West Africa, so too does the chance that more cases will be exported abroad, raising the likelihood that doctors and nurses around the world will find themselves faced with Ebola. “There is no doubt that we will see more cases of health workers getting sick” in West Africa, and those volunteers will have to go home for treatment, says Heather Etienne, a registered nurse from Texas who is on her way to Sierra Leone to work in an Emergency Ebola treatment center. So far, 416 health workers have been infected with Ebola in West Africa, and 233 have died, a sobering outcome. “You have to be comfortable with some amount of risk before doing something like this. You don’t have to be at peace with the idea of your death, but you shouldn’t be too uncomfortable with the concept either,” Etienne says.

(PHOTOS: Inside the Ebola Crisis: The Images That Moved Them Most)

Having the wrong people could be just as bad as — if not worse than — not having enough, Talbert says. Ideally, volunteers would be willing to commit to a length of time that would make their training and airfare expenses worthwhile. They should have experience in the region, says Talbert, “so they know what they are getting into,” and experience working with highly infectious diseases, “because making mistakes can be lethal.” And because the risk of burnout is so high, there needs to be enough workers to fill a continuously rotating roster. Health care workers in Ebola treatment centers work under extreme duress, sweltering under layers of protective plastic to take care of patients who have a high chance of dying. “It takes a physical and emotional toll. Nobody can do that for too long,” Talbert says.

Umar Ahmad, a 29-year-old junior doctor at the Royal London Hospital in Whitechapel, who recently completed a three-month program at the London School of Hygiene and Tropical Medicine, is ready to take up the challenge, but he is finding it hard to take a few months away from a full time job. “There are plenty of doctors that would volunteer, but the issue is, what it actually means is that you take a financial hit, a career hit,” Ahmad says. “For lots of people, they’ve got responsibilities and they can’t justify it.”

For Etienne, the nurse from Texas, getting time off wasn’t an issue. Even though many of her colleagues told her she was “insane” for going to Sierra Leone, her superiors were supportive. Her main concern is about what happens when she comes back. As a nurse, she well understands the fear and stigma brought on by Ebola. Upon her return she intends to observe an informal self-quarantine, staying away from her hospital for 21 days, the incubation period for Ebola. “Given how jittery everyone is these days, they don’t really need me at the patient desk, only to have someone say, ‘Oh, you just got back from Sierra Leone. Get me out of here!’” she says.

Clare Parsons, a 28-year-old doctor who is leaving for a one-month stint with the King’s Sierra Leone Partnership, an initiative of King’s Centre for Global Health in London, shares those concerns. Even if she displays none of the symptoms of Ebola, she is planning to lay low at home for a few weeks, just in case. “Obviously I don’t want to go gallivanting around London and be known as the person that spread [Ebola] all over the London Underground,” she says.

Duggan, the Irish nurse, finally decided to go through with her mission despite her concerns, and left on Oct. 13 to work with Doctors Without Borders for six weeks. She is still afraid, she said, but she keeps reminding herself to go back to the facts and follow the procedures. In the end, she said, nursing, wherever it is, “is my job, and something that I’ve been trained to do.” Experience in other international aid missions has taught her that international health workers can sometimes be a breed apart. “You have a very high concentration of people who are willing to make a sacrifice and put themselves at risk for the need of others,” she said.

If Ebola is to be defeated, she, and several thousand more like her, will have to join their ranks.

Read next: CDC Chief Urges U.S. Hospitals to ‘Think Ebola’

TIME ebola

This Is How Ebola Patients Are Equipping Their Homes

A Doctors Without Borders, worker displays a family and home disinfection kit which MSF distributed on Oct. 4, 2014 in New Kru Town, Liberia.
A Doctors Without Borders, worker displays a family and home disinfection kit which MSF distributed on Oct. 4, 2014 in New Kru Town, Liberia. John Moore—Getty Images

"It’s dangerous, but there are not many other options”

When his wife grew sick with Ebola, Alex T. Kamanda didn’t have the option of sending her to one of Monrovia’s Ebola Treatment Centers. They were all full. But he knew how contagious the disease could be, and how risky it was to come in contact with her bodily fluids. So he did the best he could to protect himself while caring for her, wrapping his hands in plastic garbage bags until members of his church were able to bring him supplies. He mixed chlorine powder with water to make a disinfecting solution for his skin and a stronger version to clean up her vomit and diarrhea. It was a solution that almost certainly saved his life.

Caring for Ebola patients at home is a practice that is becoming more common in a region with not enough Ebola Treatment Units (ETUs), supplies or personnel to treat the sick—a stop-gap solution that is now being standardized in Liberia. But it’s not without controversy.

The United States has pledged to send up to 400,000 so-called “home treatment kits” to Ebola-stricken households in Liberia; some 9,000 have already been distributed, according to USAID. Each kit contains gloves, masks, disposable gowns and plastic aprons, along with chlorine powder, buckets, spray bottles and plastic bags to safely dispose of infected items.

This is not the gold standard infection control, but overcrowding in Liberia’s Ebola treatment centers leaves little choice. Government health officials and NGOs have already started door-to-door training so that affected families know how to use the equipment properly.

“’Perfect’ cannot be the enemy of ‘good’ in this case,” says Stephan Monroe, the deputy director of the Centers for Disease Control and Prevention’s (CDC) National Center for Emerging Zoonotic and Infectious Diseases. “Perfect is having patients in isolation centers with health care workers treating them, but we cannot build them fast enough.”

Treatment at home carries risks. Even fully trained and equipped health-care workers in isolation wards are getting sick. And there are concerns that providing the protection kits may encourage families to keep their loved ones at home, under the assumption that it is safe.

According to Amanda McClelland, the senior officer coordinating the Ebola response for the International Red Cross, the organization is starting to attempt safe home-based care training in Monrovia, and other groups are trying a variation of it in other locations. “We are really in this gray phase. We have to do extraordinary measures to do the best we can until the isolation centers have met the demand in the next few weeks,” says McClelland. “There’s a lot of pressure on us and other organizations to undertake things like home-based care. Which is shifting the risk from health workers to families. It’s dangerous, but there are not many other options.”

The Red Cross will have volunteers in every affected community, and if they get a suspected case they will try to transfer the patient to a treatment center, but if they can’t, they will help the family isolate the patient in the home, even if it is just a mattress tucked behind a makeshift drape. They will also train a family member to care for the patient as safely as they can until admission into a treatment center can be arranged. “It is quite a reasonably controversial idea. It’s really the measures of last resort that we are in at the moment,” says McClelland.

The missionary group Samaritan’s Purse announced on October 7 that it has also launched home-based intervention training in the most remote areas of Liberia by instructing caregivers in infection control and giving families home care kits. The Samaritan Purse kits, in addition to the basic protective gear, also include medicine to treat Ebola’s side effects, like pain, dehydration and diarrhea. So far they’ve been equipping families in an area along the River Gee in southern Liberia where cases have been on the rise, but there are no Ebola treatment centers nearby.

On Oct. 3, USAID administrator Dr. Raj Shah said in a press conference that USAID is offering support in the distribution of hygiene and protective equipment kits “so families can protect their patients in their families.” USAID, along with UNICEF and the World Health Organization, has already distributed 9,000 of those kits. According to Shah, another 10,000 are on their way, and are being distributed throughout Liberia.

According to U.S. ambassador to Liberia, Deborah Malac, home care is a short-term solution. “Until you have some place to take someone to receive further treatment, you need to protect yourself and family members as much as possible,” she says. “So [the kits are for use] in the home, but not for long term care, [and only] if there is no other alternative.” That kind of temporary solution to a vexing public health problem is also likely to be well received on the ground. The ETUs are simply taking too long, says Kenneth Martu, a community organizer in Westpoint, one of the hardest hit areas of Monrovia. “You call for an ambulance, and they say there are no beds available [in the treatment centers]. So home care is one of the best approaches in the fight against Ebola. It’s what we can do in the absence of beds. We need to prevent Ebola’s spread.”

With reporting by Aryn Baker / Monrovia

TIME ebola

Halting Flights to Ebola Regions Could Threaten Relief Efforts, Experts Warn

Cuban doctors and health workers unload boxes of medicines and medical material from a plane upon their arrival at Freetown's airport to help the fight against Ebola in Sierra Leone, on Oct. 2, 2014.
Cuban doctors and health workers unload boxes of medicines and medical material from a plane upon their arrival at Freetown's airport to help the fight against Ebola in Sierra Leone, on Oct. 2, 2014. Florian Plaucheur—AFP/Getty Images

Officials and aid agencies say the fight against Ebola is being hampered by the shortage of transportation to the epicenter of the disease in West Africa

You can book to travel on British Airways (BA) from London Heathrow to Roberts International airport in Monrovia, but the direct flight will take nine hours—and at least 25 weeks—to arrive in the Liberian capital.

In August BA suspended flights to Liberia and Sierra Leone, citing public health concerns amid the spread of ebola in the region. Now, the U.K. carrier has announced its decision to maintain that suspension through the end of March 2015. BA isn’t alone; there are now so few airlines flying into the area that key workers are being forced onto wait lists and lengthy journeys with multiple stopovers. Right now, European travelers hoping to get to Monrovia or Sierra Leone’s capital Freetown must squeeze on to services operated by Brussels Airlines and Royal Air Maroc, or thumb a ride on a military jet.

Nobody would dispute the wisdom of taking the threat of Ebola very, very seriously, but aid agencies warn that a shortage of transportation to and from west Africa, far from containing Ebola, instead risks undermining efforts to quell the epidemic.

At an Oct. 8 Washington press conference with U.K. Foreign Secretary Philip Hammond, U.S. Secretary of State John Kerry called for the international community to “step up” efforts against Ebola and stressed the importance of keeping air routes open. It is a point Justin Forsyth, CEO of the U.K.-based charity Save the Children, also emphasizes.

“The main way to defeat the spread of Ebola not just in the region but globally is to get it under control in Sierra Leone and Liberia and Guinea and the best way of getting it under control is to make sure that we can get health workers into the region because they’re not going to have enough capability in these countries themselves,” says Forsyth, whose charity is working with the British military to establish a treatment center in Sierra Leone, as well as setting up care centers in Liberia and training thousands of health workers. “They’re going to need a lot of people coming in, and not all of it by military [flights].”

There have been fresh calls to isolate the disease by further isolating west Africa, after Liberian Thomas Eric Duncan died on Oct. 8 in Dallas, and Spain awaits news of Teresa Romero Ramos, the first person to contract Ebola outside west Africa in this outbreak. Louisiana Gov. Bobby Jindal had already advocated banning all flights from the region. “We need to protect our people,” he said last week.

On the surface it makes sense. Ebola may not be airborne, but authorities’ assurances that sitting on a plane with an infected person shouldn’t pose a big risk ring increasingly hollow, as Spanish health authorities try to figure out how Ramos caught the disease. She wore protective clothing and followed hospital protocols, though she has said she may have touched her face with a contaminated glove.

Yet in the view of many experts, following the impulse to isolationism is already making countries beyond Africa more vulnerable, not less. Christopher Stokes, director of Médecins Sans Frontières (Doctors Without Borders) in Brussels, told the Guardian “Airlines have shut down many flights and the unintended consequence has been to slow and hamper the relief effort, paradoxically increasing the risk of this epidemic spreading across countries in west Africa first, then potentially elsewhere. We have to stop Ebola at source and this means we have to be able to go there.”

Save the Children’s Forsyth agrees. He recognizes the concerns of airline staff, though, and says “It’s a big decision by anybody to go to work in one of these countries at the moment. We’ve got lots of people stepping forward to do it but it’s not an easy decision.”

The only option, Forsyth believes, is for governments to take the lead. “We need the airline industry to come together. This is where governments have a big role to play, to bring airlines together,” he says. “The other way to do it is to set up an air bridge paid for by governments or the military.”

TIME ebola

Ebola Cases Surpass 8,000

WHO stresses cases are being underreported in Liberia

Over 8,000 people in Liberia, Guinea and Sierra Leone have been infected with Ebola, according to new data from the World Health Organization (WHO).

The numbers show there were 2,799 new cases in the last 21 days. Of the 8,011 people infected, 3,857 people have died. “The situation in Guinea, Liberia, and Sierra Leone continues to deteriorate, with widespread and persistent transmission of [Ebola],” says the WHO in a statement.

The WHO cites problems gathering data in Liberia, and says it should be emphasized that “the reported fall in the number of new cases in Liberia over the past three weeks is unlikely to be genuine. Rather, it reflects a deterioration in the ability of overwhelmed responders to record accurate epidemiological data.”

This happened before in Guinea, when it appeared cases had slowed, but in reality cases went unreported or were hidden. The WHO says there is likely a lot of underreporting in Liberia, as fears and distrust of government grow, and that official estimates are likely lower than Liberia’s actual number of cases.

“There is no evidence that the [Ebola] epidemic in West Africa is being brought under control,” the WHO says. “Though there is evidence of a decline in incidence in the districts of Lofa in Liberia, and Kailahun and Kenema in Sierra Leone.”

TIME ebola

Ebola Vaccines Are Being Expedited

Professor Adrian Hill, Director of the Jenner Institute, and Chief Investigator of the trials, holds a phial containing the Ebola vaccine at the Oxford Vaccine Group Centre for Clinical Vaccinology and Tropical Medicine (CCVTM) in Oxford, southern England on Sept. 17, 2014.
Professor Adrian Hill, director of the Jenner Institute and chief investigator of the trials, holds a vial containing the Ebola vaccine at the Oxford Vaccine Group Centre for Clinical Vaccinology and Tropical Medicine in Oxford, southern England, on Sept. 17, 2014 Steve Parsons—Reuters

"Nothing can be allowed to delay this work"

International experts want a fully tested and licensed Ebola vaccine scaled up for mass use in the near future, according to a recent World Health Organization (WHO) meeting.

WHO organized a panel of more than 70 experts, from scientists to medical ethicists, to reach consensus over the status of Ebola vaccines currently being tested. WHO released news from the meeting on Wednesday, the day after the U.S. confirmed its first patient with Ebola. According to the WHO statement, the mission is to “accomplish, within a matter of months, work that normally takes from two to four years, without compromising international standards for safety and efficacy.”

Two vaccines have great potential and are ready for safety testing. The first vaccine is developed by the U.S. National Institute of Allergy and Infectious Diseases (NIAID) and GlaxoSmithKline. That vaccine is currently undergoing a human-safety trial at the National Institutes of Health (NIH) campus in Bethesda, Md., as well as at the University of Oxford. The second vaccine is under development by the Public Health Agency of Canada in Winnepeg. That vaccine will start a human-safety trial in early October. Canada has already donated 800 vials of their vaccine to WHO, the organization says. Once more data is available on what dosing should be used, WHO says these vials could translate to around 1,500 to 2,000 doses of the vaccine.

The goal of the safety trials is to confirm that the vaccines are safe enough to move on to a larger human trial. Dr. Anthony Fauci, director of NIAID and the lead on the NIH vaccine, tells TIME the safety trial is so far “uneventful,” which is a good thing. “There really [are] no red flags so it seems to be going along quite well,” he says. The vaccine had already been tested in monkeys and showed very promising results.

WHO and other organizations have been expediting the testing and approval processes for these drugs since early summer, but the NIH’s vaccine has been under development since 2003. At the time, it did not have the pharmaceutical funding to move forward. “[In 2003] there was very little interest for the obvious reasons that there was no disease around,” says Fauci. “Recently, we now have a much more vigorous interest from pharmaceutical companies.”

WHO hopes that in October and November, the vaccines will make it through their safety trials and into next-stage human testing. Between January and February 2015, the goal is to have next-phase human trials approved and initiated in countries affected with Ebola. People at a higher risk for the disease, like health care workers, are a priority.

The meeting did not highlight ZMapp, the drug given to two American patients who were evacuated from Liberia to Emory University in Atlanta. Mapp Biopharmaceutical, the company that produces ZMapp, is a small team that says its resources are now exhausted. Their drug is grown in tobacco plants and requires waiting for a crop in order to produce more of it.

One of the ways trials could be quickened is if the researchers take a “wedge” approach, which means that a wedge or slice of the study population is selected for a first step in the trial, and what is learned in that step is then used on the next slice of the participants. While trials are ongoing, there are still significant technical obstacles that need to be addressed once a vaccine is ready for mass use: how vaccines will be distributed, for instance, and how low-resource health systems can ensure that vaccines are stored below –100 degrees.

In the WHO meeting, the phrase “Nothing can be allowed to delay this work” was repeated multiple times, and since Ebola has now infected more than 7,000 people and even made it to the U.S., the race to develop an effective vaccine is becoming all the more frantic.

TIME ebola

The 5 Biggest Mistakes in the Ebola Outbreak

Members of a burial team wearing protective suits bury an Ebola victim in Freetown, Sierra Leone.
Members of a burial team wearing protective suits bury an Ebola victim at King Tom Cemetery, which is bitterly resented by residents of the adjoining slum, called Kolleh Town, in Freetown, Sierra Leone, Sept. 21, 2014. Samuel Aranda—The New York Times/Redux

Experts weigh in on how the outbreak got this out of control

The U.S. Centers for Disease Control and Prevention (CDC) recently projected that if trends continue unimpeded, cases of Ebola could pass the million mark by January. While that’s an unlikely scenario, many are still wondering: How on earth did it get this bad? We canvassed experts for some clues.

1. The response was far too slow
There was a period in April when it appeared that the Ebola outbreak had subsided, prompting a collective sigh of relief. Guinea’s Ministry of Health even said that country’s caseload appeared to be under control. But the outbreak didn’t subside. Instead, it barreled through interconnected towns and villages in more-populated areas of Guinea, Liberia and Sierra Leone. And after the outbreak’s perceived lull, however, came one of the largest flare-ups. Some scientists say that during that time, their warnings were ignored.

One such scientist is Robert Garry, a Tulane University virologist who had visited a hospital in Sierra Leone caring for some of his colleagues, including Dr. Sheik Humarr Khan — one of the first doctors to die of the disease in Sierra Leone. Garry then warned various groups, including the State Department, that the outbreak was highly concerning. No one, he says, really listened to him. “Their response was cordial, but nothing really happened,” says Garry. “I was really concerned about the lack of attention. I caught a lot of flack for saying I didn’t think the numbers [of reported cases and deaths caused by Ebola] were accurate. Some of us realized this was not going to be controlled.”

In a recent paper published in the New England Journal of Medicine, Peter Piot, director of the London School of Hygiene and Tropical Medicine and one of the original researchers to discover Ebola in 1976, writes: “Ebola has reached the point where it could establish itself as an endemic infection because of a highly inadequate and late global response … It was not until five months and 1,000 deaths later that a public health emergency was declared, and it was nearly another two months before a humanitarian response began to be put in place.”

2. A lack of cultural sensitivity
Patricia Omidian, a medical anthropologist, was sought by the World Health Organization (WHO) to spend time in Liberia to help Ebola response workers better understand the communities they were serving. “I think the biggest mistake that occurred very early was that primary health care was ignored and communities were not included in their own health issues,” she says. “Programs were rolled out and people were told what not to do. No effort was made to ensure engagement and increase trust.”

Omidian’s work included explaining some of the cultural practices among Liberians, including burial rituals that involve a lot of physical contact, putting mourners at risk of contracting the virus. “This disease attacks the best of [Liberians'] culture — that of touching and caring and kindness,” says Omidian.

3. We don’t have deployable medical teams
The CDC, WHO and U.N. have important jobs when it comes to containment practices like tracking down people who may have come in contact with infected patients, and using technology to predict disease spread. However, none of those groups actually treat patients, or have doctors and nurses they can deploy. This is something that Dr. Jack Chow, professor of global health at Carnegie Mellon University and a former WHO assistant director general, says needs to change.

“The Obama mission to Liberia, which is relying on the military at the last minute, shows that the U.S. and other industrial countries haven’t built up comparable deployable medical units on the civilian side, and need to do so to prepare against future ‘flashdemics’ — high-velocity, high-lethality outbreaks,” says Chow. “In addition to building an international epidemic response force, we need to conceptualize ‘global health defense’ to include bolstering the health systems of the poorest countries.”

4. A lack of approved drugs and cures
The scarcity of drugs and vaccines is not due to a lack of innovation. Drugs have been in development for years, but since pharmaceutical companies have had no financial incentive to fund them, researchers have hit walls. “People like me and others who have worked for years in vaccines and countermeasures are frustrated,” Thomas Geisbert, a professor of microbiology and immunology at the University of Texas Medical Branch in Galveston, said in an earlier TIME article. The supply of ZMapp, the drug that was given to a few health care workers, is exhausted. It comes from a small pharmaceutical company with nine employees, and the drug grows in a tobacco plant — requiring scientists to wait for a new crop to grow just for a new batch. Thankfully, clinical trials for other drugs have kicked off.

5. Treating Ebola as a “West Africa” problem
“It’s crucial countries not be lumped together,” says Nigerian Minister of Economy and Minister of Finance Ngozi Okonjo-Iweala. “The media writes about Africa and West Africa, but there needs to be differentiation. This will end up hurting the economies of countries that have no problems. Ghana never had any cases, Burkina Faso never had any cases.” Okonjo-Iweala was also the former managing director of the World Bank, and has seen how stigma damages economies.

“We should stick to the specific countries so as not to cause massive economic damage,” says Okonjo-Iweala. “We have worked very hard to get the private sector to invest in Africa for the continent to grow based on the fact that we are a continent with a lot of vigor and good rates of return on investment. If you scare away investors by lumping the continent into one big mass, what good does it do? It will take another decade to recover.”

Nigeria has had 19 cases, seven deaths and everyone else survived. As of Tuesday, the 21 days of incubation expired for people who treated the infected, so currently no one is being monitored. “We’ve worked hard as a continent to overcome this kind of stigma of disease,” says Okonjo-Iweala.

TIME ebola

CDC: Cases of Ebola Could Double Every 20 Days

Members of a burial team wearing protective suits bury an Ebola victim in Freetown, Sierra Leone.
Members of a burial team wearing protective suits bury an Ebola victim at King Tom Cemetery, which is bitterly resented by residents of the adjoining slum, called Kolleh Town, in Freetown, Sierra Leone, Sept. 21, 2014. Samuel Aranda—The New York Times/Redux

A new CDC report predicts the enormous cost of delayed response to Ebola

If Ebola conditions continue without a scaled-up effort, the CDC estimates that cases of Ebola in West Africa will double every 20 days — and in an absolute worst-case scenario without any intervention, numbers could reach 1.4 million by Jan. 20.

Using a new Ebola Response prediction tool, the CDC has published results that show that if current trends continue unimpeded, Liberia and Sierra Leone will have approximately 8,000 total Ebola cases, or 21,000 if the tool accounts for underreporting, by Sept. 20. Liberia will account for about 6,000 of those cases.

The numbers are frighteningly high, but it should be noted that it’s a prediction of a hypothetical situation in which absolutely no intervention were to happen. That won’t be the case if many countries and the UN keep their promises. The model also shows that a big response could turn the outbreak around. In another hypothetical situation, the outbreak could ease up and eventually end if 70% of people with Ebola are placed in medical care facilities, Ebola treatment units, or somewhere where transmission could be contained.

“The model shows that a surge now can break the back of the epidemic,” said Dr. Tom Frieden, director of the CDC, in a press conference. “The importance of implementing effective programs rapidly cant be over-emphasized. The cautionary finding of the modeling is the enormous cost of delay.”

During the press conference, Dr. Frieden said the outbreak is very fluid and changing, but that he does not think West Africa will meet their worst case scenario predictions. “If you get enough people effectively isolated, the epidemic can be stopped…Even in dire scenarios, if we move fast enough we can turn it around. I do not think the most dire circumstances will come to pass,” he said.

The CDC report comes out on the same day the World Health Organization released their reports on the outbreaks at six months in all affected countries, and it appears that cases in Nigeria and Senegal have stabilized “for the moment.” Last week, President Obama announced a deployment of 3,000 U.S. military personnel and over $500 million in defense spending to go to West Africa, and the UN announced a new task force called the U.N. Mission for Ebola Emergency Response. The hope is that an exponentially increased response will prevent these possible scenarios.

TIME ebola

There Could Be 20,000 Ebola Cases by November if More Isn’t Done Now

Ebola Lessons
Nurses train to use Ebola protective gear with World Health Organization, WHO, workers, in Freetown, Sierra Leone on Sept. 18, 2014. Michael Duff—AP

Public-health experts warn that the epidemic could turn from “a disaster into a catastrophe”

A new study by the World Health Organization released on Tuesday warned of 20,000 Ebola cases worldwide in just over a month’s time if authorities failed to ramp up efforts to combat the growing epidemic.

“We estimate that, at the current rate of increase, assuming no changes in control efforts, the cumulative number of confirmed and probable cases by November 2 will be 5,740 in Guinea, 9,890 in Liberia, and 5,000 in Sierra Leone, exceeding 20,000 cases in total,” read the report published in the New England Journal of Medicine this week.

The Ebola virus is spread primarily through exposure to body fluids of symptomatic patients. Transmission of the virus is prevented through early diagnosis, contact tracing, patient isolation and infection control along with the safe burial of those killed by Ebola.

However, the virus has primarily hit impoverished West African communities, where many of these protocols are difficult or impossible to enforce.

“If we don’t stop the epidemic very soon, this is going to turn from a disaster into a catastrophe,” Christopher Dye, a co-author of the study and director of strategy at the WHO, told reporters in Geneva. “The fear is that Ebola will become more or less a permanent feature of the human population.”

The publication of the new report comes as Sierra Leone concluded an ambitious lockdown of the country for three days by effectively asking its 6 million residents to stay at home while approximately 30,000 volunteers and health officials canvassed the country to distribute soap and instructions on how to prevent contraction of the virus.

There are currently 5,833 recorded cases of Ebola across six African nations. The disease has killed at least 2,833 people.

TIME ebola

Ebola ‘Pretty Much Contained’ in Senegal and Nigeria

Christopher Dye, Director of Strategy of the World Health Organization speaks to the media about Ebola Virus Disease in West Africa, during a press conference, at the European headquarters of the United Nations in Geneva on Sept. 22, 2-14.
Christopher Dye, Director of Strategy of the World Health Organization speaks to the media about Ebola Virus Disease in West Africa, during a press conference, at the European headquarters of the United Nations in Geneva on Sept. 22, 2-14. Salvatore Di Nolfi—EPA

Good news for containment of an outbreak that has killed more than 2,800 people

The outbreaks of Ebola in Senegal and Nigeria have been “pretty much contained,” the World Health Organization said Monday.

There have been no new confirmed cases of Ebola in Senegal since the first case was reported Aug. 29, and the last case of Ebola reported in Nigeria was Sept. 8, the WHO’s regional office for Africa said in a statement. The news comes on the same day the WHO released details from the second meeting of the International Health Regulations Emergency Committee on Ebola. One of the top conclusions from the group was that travel and trade should continue in West Africa:

“Flight cancellations and other travel restrictions continue to isolate affected countries resulting in detrimental economic consequences, and hinder relief and response efforts risking further international spread,” the committee said.

The Committee reiterated WHO stances on making sure health care workers are protected from possible infections and ensuring people who are quarantined still have access to food and water.

There are currently 5,833 cases of Ebola in Sierra Leone, Liberia, Guinea, Senegal, Nigeria and the Democratic Republic of the Congo (though the DRC outbreak is thought to be unrelated to the others). Among those cases, 2,833 people have died.

 

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