Sunday, March 22, 2015

One Year Later, Ebola Outbreak Offers Lessons for Next Epidemic
New York Times
MARCH 22, 2015

One year has passed since the declaration of what became the largest Ebola outbreak in history, with more than 10,000 deaths.

The virus escaped control as countries and global agencies failed to acknowledge and contend with the magnitude of its spread. Treatment centers were overwhelmed. Sick people died on city streets, and new cases multiplied inside health care facilities, killing a significant proportion of the already inadequate health work force of the three most affected countries — Liberia, Sierra Leone and Guinea.

However, after two American aid workers and a traveler to Nigeria fell ill last summer, setting off a panic, a huge global initiative to combat Ebola swung into place. The effort has been messy, inefficient and expensive, often lagging the epidemic’s twists in tragic ways.

But the effort has also established expertise that may be built upon to prevent similar tragedies in the future — and shown personal and institutional bravery.

“None of us have ever been involved in anything of this magnitude, complexity and potential severity before,” said Dr. David Nabarro, the United Nations special envoy for Ebola. “There’s a huge process of analysis and lesson learning underway.”

The African Union for the first time sent hundreds of health personnel to confront a medical crisis even as the logistics of their arrival were rocky. The United States Centers for Disease Control and Prevention worked with multinational teams led by the World Health Organization in more than a dozen unaffected African countries to help prevent the disease from spreading further. It was part of the largest international deployment in the C.D.C.’s nearly 70-year history, supported by a congressional appropriation of more than $1 billion made available for the larger American response.

Despite difficulty filling positions, the W.H.O. now reports that it has more than 700 people working at 77 field sites, the largest emergency response in its history.

Charities with no background treating Ebola patients began running hospitals specialized for Ebola care, some of which were built by militaries and others staffed by hundreds of personnel from China and Cuba who were also facing Ebola for the first time and trying to overcome language challenges.

The affected countries established strong crisis teams and mobilized thousands of health workers, grave diggers and student outreach groups to fight Ebola. They have worked in dangerous conditions, often without pay, sometimes shunned by their families. And unlike many foreign workers, they have not been offered the option of medical evacuation to Western countries.

“The level of resourcefulness and dedication shown by Sierra Leoneans involved in the front lines is the most extraordinary civic mobilization action I’ve ever seen in my country,” said O. B. Sisay, director of the situation room at the National Ebola Response Center in Freetown, which formerly housed a special war crimes court. “To some extent that has helped cement a sense of nationhood here."

Throughout most of the crisis, experimental Ebola treatments and vaccines were offered almost exclusively to international aid workers; now scientists are testing them in Africa under accelerated research protocols that include regulatory and ethical approval in the affected countries and abroad.

Ban Ki-moon, secretary general of the United Nations, established the United Nations Mission for Ebola Emergency Response, its first international mission devoted to public health, though it has been widely criticized as being lumbering, expensive and unfocused.

Still, the global effort has not yet eliminated the epidemic. The combined number of new cases each week in Guinea and Sierra Leone has flatlined for months in the 100-to-200 range, consonant with the largest historical outbreaks. Liberia announced on Friday its first positive Ebola test in three weeks.

Aid workers, meanwhile, are scrambling to deal with violent resistance to Ebola treatment and safe burials. Responders are questioning whether, in a rush to improve technical assistance, they gave short shrift to understanding societal dynamics.

Most important, perhaps, Ebola has laid bare the inadequacy of current global mechanisms for detecting outbreaks and quickly mobilizing a response.

“We need something more robust than an ad hoc system that we set up halfway through it,” said Dr. Bruce Aylward, who leads Ebola response efforts for the W.H.O., which has come under particular criticism.

Reforms have been proposed, but agencies have been slow to acknowledge their mistakes publicly and reckon with them, decreasing the chances that change will occur.

Both the W.H.O. and Doctors without Borders documented probable Ebola cases in Sierra Leone when the epidemic was first recognized in March 2014 in Guinea, but the cases were not followed up effectively. Consequently, Sierra Leone’s outbreak, which might have been stopped at a few cases, instead smoldered for two months before bursting into public view in May and spilling into Liberia, a New York Times investigation showed.

“Could we have pushed more forcefully in Sierra Leone at the beginning?” a Doctors Without Borders anniversary report, due to be released Monday, asked rhetorically.

The W.H.O., which in January prepared a corrected history of the origins of the Sierra Leone outbreak, still has not posted it online.

Instead, the agencies are pointing fingers at one another. Doctors without Borders, practically the only private charity with specialized Ebola treatment experience beforehand, provided most of the medical aid in the early months. Overwhelmed, it called repeatedly for global action. In its report, the group, also known as M.S.F., assailed the United States and other governments for failing, among other things, to send specialized biohazard response units to treat patients.

“We considered the only organizations in the world that might have the means to fill the gap immediately might be military units with some level of biological warfare expertise,” Christopher Stokes, general director of M.S.F., is quoted as saying in the report. Dr. Joanne Liu, the group’s international president, added, “U.S. helicopters would not even transport laboratory samples or healthy personnel returning from treating patients.”

Jeremy Konyndyk, director of the Office of Foreign Disaster Assistance at the United States Agency for International Development, said in an interview that those criticisms reflected a misunderstanding of the American military’s capabilities.

Health workers in Liberia and elsewhere in West Africa are finding they have to ration care, operating under constraints they often find frustrating.

As Ebola ravages West Africa, Liberians are losing an integral part of their culture, in which the double-cheek kiss was once the standard greeting.

“There was a perception among M.S.F. and more broadly that surely somewhere in the Pentagon there must be some rapid biohazard response team that could go and do this,” Mr. Konyndyk said. “That just wasn’t the case.”

Instead, at the urging of Mr. Konyndyk and others, American charities and the United States Public Health Service agreed to operate treatment units that the United States military and others would build and the United States government would fund. Other governments, including the British, French and Chinese, also helped build and support treatment units, run by a range of international agencies, and the World Bank made hundreds of millions of dollars available.

“It did feel very intimidating, you know, the protocols, the protective suits, the care that had to be taken,” said Joel R. Charny, vice president for humanitarian policy and practice at InterAction, an alliance of United States-based relief and development groups. “I sat in on a lot of discussions of InterAction in the fall over insurance and medical evacuation.”

While only around half or fewer of the patients cared for in the units have typically survived, reflecting a lack of specific treatments for Ebola or sophisticated monitoring, the effort has had a good safety record for workers, even with the infection of an American aid worker and a Sierra Leonean clinician in March.

Doctors Without Borders, in the new report, said there had been 28 infections and 14 deaths among its 5,300 Ebola workers in the past year.

The number of new infections had declined sharply in Liberia by the time many of the American-sponsored treatment centers were set up, but Mr. Konyndyk said systems for safe burials, improved laboratory capacity, distribution of protective gear and supplies and social mobilization within communities had made a difference. “The interventions that were easy to scale rapidly had a pretty significant impact,” he said.

Most successful, perhaps, was the prevention of the epidemic from spreading more widely. When Ebola reached Mali, Nigeria, and Senegal, it was quickly stopped there.

“It wasn’t that they were well prepared, because they weren’t, but they were a bit prepared, and that made a difference,” said Dr. Aylward of the W.H.O. The challenge now is to determine “what part of the bit of the preparedness they had in place paid such a huge dividend, and how do you take advantage of that.”

In 17 priority African countries, the W.H.O., the C.D.C. and other organizations have worked to establish Ebola detection and response plans and strengthen laboratory capabilities.

In January, after the first set of visits to 14 countries, the teams rated countries on their preparedness. All but four were rated at less than 28 percent prepared for an outbreak.

A W.H.O.-led program to revisit and continue working with the vulnerable countries has been planned, but only $8 million of the initiative’s $50 million budget has been raised so far, a W.H.O. spokeswoman said.

“Six months ago, the world was worried. There was a lot of self-interest in making sure this thing was stopped,” Dr. Aylward said, adding, “The biggest mistake the world could do right now is blink.”

Rick Gladstone contributed reporting.

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