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The Ebola Outbreak Exposed Holes in the Global Response System

The Ebola Outbreak Exposed Holes in the Global Response System
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Dr. William Schaffner, MD, the immediate past president of the National Foundation of Infectious Diseases, talked to TRUE about how the Internet and the expanding capacity to collect and analyze data globally has transformed the ability to combat epidemics. Yet, as the recent Ebola outbreak in West Africa demonstrated, the most important element in an effective response is still early and honest communications.

TRUE: Looking at the recent Ebola outbreak in West Africa, how well do you feel we communicate, as governments, public health agencies, the media, and other sources of information, during the spread of a potentially dangerous infectious disease?

Dr. Schaffner: This question makes me sigh a little bit. On one hand, I do think we communicate much better than we used to, yet as the current Ebola outbreak so clearly illustrates, not nearly as well as we need to. With Ebola, the problem began because the three most affected countries have very modest public health infrastructures. They lacked the capacity for surveillance of the disease, for defining it and counting it, and as a consequence, their communications with the outside world and with the World Health Organization were not at all good. It was really Médecins Sans Frontières — you know, Doctors Without Borders — that alerted the world to the severity of what was going on.

Sadly, the problem didn’t stop there. We subsequently learned there was yet an additional problem. If the sending of information was not so good, the receiving of information was also less than optimal. Because of the Ebola outbreak, many of us in the public health community learned for the first time that the epidemic response mechanism of the World Health Organization had been substantially diminished by budgetary cuts. When I read the article in The New York Times [outlining the WHO cutbacks], I will tell you honestly I was shocked. It was over breakfast and I told my wife, “I can’t believe what I’m reading here.”

Obviously, some people knew and perhaps didn’t recognize the implications of what had been dismantled. But in an instance where the world was waiting to take cues from the WHO on how to respond, there was a seriously diminished capacity, talented people who knew exactly how to handle this had been let go. We look to the WHO to be the conductors of the world’s public health orchestra. Epidemic response is clearly an essential part of that mission and function. We look to them to jawbone countries to do the right thing in terms of sharing information on outbreaks. And in a world that has become so small — thanks to our mobility — we need to be able to mount a timely and appropriate response [to infectious disease], and that means rebuilding the WHO.

Post_Schaffner_660x400TRUE: Does the recent case of Ebola in Texas indicate we have holes in our coordination to prevent the spread of the disease? Is it possible for countries to screen people coming in from infected areas?

Dr. Schaffner: Well, this is a classic needle-in-the haystack problem. It is very difficult to avoid as long as there is free mobility across borders. Screening is an appealing concept at first glance, but it turns out to be fraught with practical difficulties: Who would do the screening? In West Africa, and for that matter most countries, public health workers already have their hands full. Who would pay for the necessary lab tests? Would you even necessarily catch those infected if they were asymptomatic?

Currently, in West Africa, travelers are screened with a questionnaire and by having their temperature taken. Both are imperfect. Even the temperature might prove ineffective because of diurnal temperature variation — that is, a sick person might have fever only in the afternoon or evening, but is traveling in the morning.

And as far as quarantining those coming into the country from affected areas, well, the task would be overwhelming. Each would have to be quarantined for 21 days in the case of Ebola, and there are simply too many travelers. Where would they be housed that met quarantine standards and who would pay?

TRUE: Can you talk about how our ability to respond has changed over the past decade?

Dr. Schaffner: Without a doubt, our ability to respond has expanded tremendously over time. Our airline capacity, our military capacity, our ability to share information and expertise with even the most remote locations has transformed what is possible. The Internet is among the biggest contributors to that expansion, because of the ability it has afforded to collect and share public health data worldwide. It doesn’t depend on governments to provide information; individuals, physicians, laboratories, public health workers, all kinds of people can provide information via the Internet. The Centers for Disease Control and Prevention (CDC) have a group of people that do nothing but monitor it, worldwide, for reports and rumors about outbreaks and the spread of disease. Social alone has given us a tool for predicting the path a disease is taking.

But the formal sharing of information is also essential. And for that it takes jawboning by groups like the WHO that push countries to be good global citizens. Why don’t they automatically? There are consequences when countries do the right thing. They don’t want to be stigmatized; they don’t want tourists to stop coming or business to shy away. Look, for example, at Mexico and the 2009 outbreak of H1N1 influenza. This was an unusual country for a new influenza strain to surface. The Mexican government stepped up and provided information right away about the origins and the scope — and they took a huge economic hit because of that. Tourists stopped going, almost immediately. Business people said, “Well, I’ll conduct this meeting by phone, and maybe in a few months I’ll come down for a visit.”

In West Africa, the quality of the information that’s coming out of these countries is, at the moment, on the fringes. In Senegal and Nigeria, it is really pretty precise. But neither have many cases. In the three most affected, the story is different. In Guinea, it’s okay, but in Liberia and Sierra Leone, the data are mush. There are many more cases than have been officially reported; we basically know that. But what we don’t have very good information about is, who exactly is being affected, which communities are being affected, how rapidly is the virus spreading. Without that, it makes an effective response difficult.

The coordination is not always there either. One need only look at the response to the Haitian earthquake and cholera [in 2010]. All the NGOs involved, including the WHO, were pursuing their own narrow missions. They all came in intending to do good, but there wasn’t a leader of the orchestra; the trombones and the violins were playing very, very independently.

The implications of failure are vast, even beyond the spread of a potentially deadly epidemic. Many of these outbreaks occur in places that are already fragile, economically and politically. And what starts as a public health crisis can quickly deteriorate into political instability and economic turmoil.

TRUE: The public has a role to play during any outbreak. How well do we communicate across various populations?

Dr. Schaffner: The media, including social media, are so expansive today. I think the hang-up is that we in public health still don’t have enough talent to actually take advantage of all the media opportunities and to communicate in a way that is accessible to the public.

But here too we see the problem of conflicting motivations. Media outlets have their own agendas about the kind of story they’re looking to publish. As a person who interacts with TV, electronic and print reporters all the time, I can tell you that an expert has to work very hard with them to get comprehensive, educational messages out. The average story on a TV newscast is so brief. As a person who regards interactions with the media as an educational opportunity, I think one of the great constraints is the fact that the attention span of the population is now so abbreviated, and that the major media operations, particularly television where a huge proportion of the population gets its news, is not well-designed as it’s run at present to provide a comprehensive and coherent educational story. We’re not talking about The MacNeil/Lehrer NewsHour where we have somebody having a reasonable conversation for 10 minutes on a subject, providing carefully thought-through pieces of information.

And then there’s social, where there is less control over the accuracy, and the potential for misinformation really exponentially expands. Everywhere there is the pressure to hype — to focus on the spread and the fear — “Ebola patient transferred to Atlanta”— rather than how one prevents the spread or precautions to keep the population healthy. I understand their financial motivations, but then I think back to the questions of why countries don’t report when they should. The leaders have an agenda just like the people who run TV networks have an agenda, and it’s not always my public health educational agenda.

Photo: Ebola outbreak (Getty Images)

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About the author

Dr. William Schaffner, MD, is the immediate past president of the National Foundation for Infectious Diseases, which is part of National Institutes of Health in Bethesda, Maryland. He also serves as professor and chair of the department of preventive medicine and professor of medicine in the division of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tennessee. Additionally, he serves as a hospital epidemiologist at Vanderbilt University Hospital.

Dr. Schaffner has authored or co-authored more than 400 published studies, reviews and book chapters on infectious diseases. He currently serves on the editorial board of a number of scientific journals, including Journal of Infectious Diseases, Vaccine and the CDC’s Morbidity and Mortality Weekly Report (MMWR).