Ebola preparedness starts with dispelling fear

Many of the media articles concerning the ebola crisis open or close with a death count or a list of symptoms caused by the virus. But can this epidemic be boiled down to the spread of a lethal disease? Or does this simplification reveal our ignorance and feed our fear?

A quote from Howard Lovecraft’s short story The Crawling Chaos echoes the fear surrounding ebola: “Slowly but inexorably crawling upon my consciousness and rising above every other impression came a dizzying fear of the unknown, a fear all the greater because I could not analyse it…not [of] death, but some nameless, unheard-of thing inexpressibly more ghastly and abhorrent.”

In an attempt to dispel any fear of the unknown surrounding ebola, EuroScientist has analysed many facets of the current outbreak based on the opinion of a broad range of experts. Above all, we look at whether European countries are sufficiently prepared to make adequate policy decisions that will help end this outbreak and prevent future ones.

Just how severe is this outbreak?

The ebola virus is different from some pathogens affecting society today. “The severity of a disease is a combination of its frequency and its effect on the body,” says Antonie Flahault, a biostatistician and doctor at the University of Geneva in Switzerland and the University of Paris V in France. “With influenza, you have low mortality, but high frequency. Ebola is the other way around.” This means a relatively small proportion of the population catches the ebola virus, but those who do, often die.

Compared to AIDS or the Spanish flu epidemic of 1918, ebola will probably be a rather small outbreak in terms of number of deaths, says Flahault. Yet “the fear associated with ebola is much higher than the fear associated with the flu,” he says. Like AIDS in the 1980s, a large part of this fear stems from a fear of the unknown, adds Mahlet Zimeta, a philosopher in the Department of Science and Technology Studies at University College London in the UK.

The characteristics of the latest ebola outbreak are unusual. “There are elements of archaism and modernity in this current epidemic,” says Patrick Zylberman, a historian of epidemics at the School for Advanced Studies in Public Health (EHESP) in Rennes, France and the Centre Virchow-Villermé in Paris, France and Berlin, Germany. “Ebola can be compared with ancient epidemics because there are currently no major therapeutic or preventative measures against the virus.” However, “the very modern element of this epidemic is how it was caused by and is affecting globalised society,” he adds.

Flahault elaborates: “We knew ebola as a disease with outbreaks limited to small, rural areas, but West African countries are becoming more densely populated and globalised.” Among the growing populations there has also been political strife. “In Sierra Leone and Liberia, civil wars have led to reduced trust in authorities and this wasn’t the case for previous outbreaks,” he adds. In sum, we were not prepared to think of ebola in a modern, urban, globalised environment, which partly led to the World Health Organisation’s (WHO) delayed response, says Zylberman.

Problems with health policy

If policy makers had paid more attention to research from the social sciences, they may have foreseen the social causes of this outbreak and responded sooner, says Flahault. A more interdisciplinary approach could also help to keep conflicts of interests in check. Such conflicts of interest have, for example, been witnessed in cases of extreme forecasting by biostatisticians, who “select the worst-case-scenario model and sell it to politicians to obtain more funding,” he adds.

The Center for Disease Control (CDC) in the United States, for instance, projected in September 2014 that in January 2015 there will be 1.4 million cases of ebola in West Africa. The WHO also predicted in October 2014 that there will be tens of thousands of cases per week by December 2014. Flahault says both extreme forecasts may be seen as attempts to mobilise the international community and funding for ebola, an end that is not justified by its means.

When actual cases do not match predicted cases frequently, it leads to a ‘boy who cried wolf’ relationship between scientists and governments, and, consequently, governments and the public. This, in turn, leads to the creation of unnecessary fear in European and North American residents.

And such unnecessary fear only makes the jobs of policy makers more difficult. “As a policy maker you’re forced to address public concern, even if addressing their fears might not be in the public’s best, long-term interests,” says Zimeta. “Fear has been a driving force in the political responses today,” agrees Nguyen Vinh-Kim, an anthropologist and physician at the University of Amsterdam in the Netherlands. “Screening people at airports, for example, is an ineffective way of combating the disease, but it pacifies public anxiety.”

How can this chain of extreme predictions to unnecessary fear to faulty policies be ended? One option is to stop extreme modelling in its tracks by limiting predictions to no more than one month in the future, says Flahault. He argues predictions made beyond one month are not responsible, especially for unpredictable, emerging diseases like ebola.

Solution one: develop a vaccine

All agree the level of preparedness is not as good as it should be. For example, one vital solution to the ebola epidemic can and should come from science: a vaccine. “Experimental vaccines with high success rates in animal models have been around for ten or more years,” says Hans-Dieter Klenk, a virologist at Philipps University in Marburg, Germany. While vaccines for ebola are now in clinical trials, “if they had been developed for human use before the outbreak, this would have made a major difference,” Klenk points out.

But Zylberman emphasises that a vaccine without the health policy to implement its use proactively is pointless. “This epidemic has shown us that people in the government were suffering from complacency and complacency is an incurable disease.” Policy makers have to “establish the fire brigade before the fire breaks out,” agrees Klenk.

A vaccine also increases the potential for more international volunteers, adds Zylberman. “It’s hard to convince skilled doctors and nurses to go to West Africa because they are afraid they will be in the same situation as the people they are trying to help.” But if volunteers were vaccinated prior to departure this fear would be eliminated.

Solution two: public education for all

Another key aspect of ebola preparedness comes from public education, experts believe. “A major source of transmission is burial customs,” says Klenk. “If someone dies, the mourners have very close contact with the dead – they kiss and touch them. The local population needs to better understand the threat of the ebola virus.”

Education should be a key preventative measure not only for the African public, but also for the public in the Western world. “Many suggest public education concerning ebola in African countries will help prevent future outbreaks and I agree,” says Zimeta. “But a better educated public in North America and Europe would also make the policy makers’ jobs easier.”

Why? “Pressure on European policy makers by the European public is now – ‘stop this from coming to us’ – but this ‘them vs us’ mentality exacerbates the health and economic inequality that will make another epidemic likely in the future,” adds Zimeta.

Solution three: infrastructural support

Western countries can also help end this outbreak and prevent a future one by contributing infrastructural support in African countries. “In Liberia, at the beginning of the outbreak, there were only 50 doctors for six million people,” says Zylberman. “The public health and hospital services in these areas are very poor and could not cope with this outbreak and this was a major problem,” agrees Klenk. Along these lines, a large reason why ebola most likely will not spread in European and North American countries is excellent access to health care.

Neglected infrastructures also fuel another cause of the epidemic: poor hygiene. “The plague was a devastating epidemic, but that changed when the hygienic conditions improved,” adds Klenk. “Improving the hygienic conditions in these countries will be an important aspect of preventing future ebola outbreaks.”

Solution four: scientific equality

Even though Europe might have scientific resources at home, an effective response to the ebola epidemic would require adequate laboratory capabilities to be established in Africa too. “Ebola is hitting southern countries, but the means to react to this epidemic and others are in the north,” says Zylberman. Indeed, the vast majority of biosafety level 4 (BSL4) laboratories are located in Europe, North America and Australia. Yet the majority of the diseases they study, including ebola, do not exist in these areas.

According to Zylberman, part of the French government’s efforts in Conakry, Guinea, involves revamping an old Louis Pasteur Institute, which has been closed for 40 years, with the aim of studying viruses. By establishing more of these labs in Africa, international development will become more of a partnership and less of a hierarchy, says Zimeta.

A quote from the writer and activist Susan Sontag’s book In the Kingdom of the Sick gets at the heart of the false polarity pervading reactions to this epidemic, says Zimeta: “‘Everyone who is born holds dual citizenship, in the kingdom of the well and the kingdom of the sick. Although we all only prefer to use the good passport, sooner or later each of us is obliged, for a spell, to identify ourselves as citizens from that other place.'”

If all of us – policy makers, scientists, doctors and members of the public in Africa, Europe and North America – acknowledge we have dual citizenship to the same health community, we should recognise we have a shared future, says Zimeta. And this means that while all of us, including European policy makers, may be instigators of the problem, each of us is also a component of the solution.

Featured image credit: CC BY 2.0 by Niaid

Vanessa Schipani
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