On Saturday, May 9, Liberia joyously---cautiously---announced itself free from Ebola. It had been 42 days since the last known case. And though neighboring Guinea and Sierra Leone are still fighting, it seems like the sun is finally setting on the latest outbreak. But the disease will be back. Or if not Ebola, it will be MERS, polio, leishmaniasis, measles, or some other infectious killer.
Liberia was among the hardest hit---4,716 out of the total 11,022 dead are Liberian. But outbreaks don't have to be this bad. They don't have to spread as far or kill as many. The lessons are right there, encoded in what happened with Ebola---if people can read them.
Disaster relief comes from rich, peaceful places, and it goes to places that are poor and conflict-ravaged. Understanding the dynamics of both are key to getting the next relief effort right. Experts in the developed world understood that some kind of disease was likely to emerge from war-torn West Africa, yet somehow wealthier countries still responded slowly, as if surprised. And when help did arrive, it encountered resistance from the locals. On-the-ground workers had to learn to balance their urgency with respect and personal care.
Ebola is what experts call a Neglected Tropical Disease. “Though the tropical part is a misnomer,” says Peter Hotez, dean of the National School of Tropical Medicine at Baylor College in Houston. NTD's, as they are known, tend to emerge in poor, war-torn areas that often happen to be in the tropics. The world has seen outbreaks like Ebola before. From the 1970s to the 1990s, African Sleeping Sickness took over half a million lives in the war-ravaged Democratic Republic of Congo. The same thing happened after the Sudanese civil war, with kala azar---a type of leishmaniasis. The biggest factors? A breakdown in social services, preventative medicine, and public trust. Nigeria was the first to quell its Ebola outbreak, says Hotez, because the country had a stable medical infrastructure in place. Nigeria has seen some turbulence in recent years, but nothing like the conflicts in Sierra Leone, Guinea, and Liberia.
If poverty and war are the horsemen that always precede pestilence, then aid groups should start working on plans for outbreaks in the Middle East and North Africa. The signs are already there. Leishmaniasis is showing up in Islamic State-held Syria. Coronavirus is cropping up in Yemen. Refugees across the region have shown an alarming number of cases of both polio and measles. And unlike Ebola---which can only be spread by direct contact---many of these diseases can transmit through the air. "The point is, in the Middle East the world might not get so lucky, if you call Ebola getting lucky," says Hotez.
Hotez says the world needs a new disaster-relief business model. His beef? It took way too long to develop an Ebola vaccine. The problem is, even in global emergencies, governments still rely on big, profit-driven pharmaceutical companies to bring treatments onto market. "The only reason that GlaxoSmithKline and Okairos got involved at the 11th hour, when Ebola was unfolding as an emergent tragedy, was there were financial incentives put into place," he says. And Bill Gates' idea for a global disease fund---paid into by all the world's governments---isn't good enough, because it still relies on big pharmas.
The solution, says Hotez is non-profit vaccine development centers, such as the Developing Vaccine Groups and Product Development Partnerships that developed in the late 1990s as an alternative to develop treatments for Neglected Tropical Diseases. (Hotez is president of a PDP called the Sabin Vaccine Institute). For evidence, he points to the Ebola vaccine that US scientists developed over a decade ago, but never tested further than monkey trials because they had no financial incentive. The people most likely to get Ebola are the ones least likely to be able to afford a vaccine against it.
Unfortunately, they're also the ones least likely to assist in their own aid. Imagine you live in a small village where people have been getting sick. One day white jeeps show up, put on rubber suits, vinyl gloves, and plastic face guards and ask you to hand over your sick friends and relatives. "What we are doing creates a lot of fear", says Ellen Watson-Stryker, a health promotion specialist with Médecins Sans Frontières (Doctors Without Borders). "You want to take time to build trust, but at the same time you are racing the clock against a spreading disease."
The first rule is to give people the opportunity---the power---to make their own decisions. "I think the solution is to really maintain the humanity of the situation, understand that you’re dealing with a rational human being who has the right to make a decision," Watson-Stryker says. When the Guinean and Liberian government started rolling troops in, for example, was the wrong tack, even if the military’s intentions---to stem spread of disease---were right.
Overall, the best way to prevent a disease outbreak is to maintain a working health care system. But in a conflict, those health care systems break down. And it’s not just that there are no vaccine programs during a conflict. Social support webs get fall apart. Children stop going to school, which wrinkles the path forward for a generation of home grown health care workers. "Maybe the solution is to not have conflict," Watson-Stryker says, with a rueful laugh.
Ebola isn’t over. The disease might never leave, becoming endemic---with its own season---like the flu in North America. And even as Liberia is celebrating its win over this disease, other diseases are on the rise. They always are.
