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Ebola: A look at what happened and what can be done

As of September 28, the World Health Organization (WHO) estimates that, so far, more than 7,100 people have been infected with and more than 3,300 have died from the Ebola virus. These estimates of what has happened are almost certainly far too low; the estimates of what will happen are terrifyingly high. The current Ebola epidemic may well become the worst human disaster in this century. And we are not doing enough about it.

Ebola is unlikely to become a major problem in the developed world. But... it seems increasingly likely that hundreds of thousands, and quite possibly millions, of men, women, and children will be struck down by this ghastly plague

What happened?

Researchers will be trying to answer that question for years. This is the 24th known outbreak of Ebola virus disease since it was first recognized in 1976. All of the other outbreaks burned themselves out quickly, after between one and 425 people had been infected. Over nearly 40 years, fewer than 2,500 people are known to have become infected and fewer than 1,500 to have died. The outbreaks were all in Central Africa; they killed people in scattered villages, with few Western connections and fewer Western media on site.

However, the current outbreak started in West Africa, not Central Africa. I suspect this change in location will prove to be the key change, not so much in how it has affected human responses but how it has affected human susceptibility. Yes, the health infrastructures in Guinea, Liberia, and Sierra Leone were very poor (and are now far worse), but they were no worse than those in the Democratic Republic of Congo, South Sudan, or Uganda, the sites of most of the earlier outbreaks. But the lands where this outbreak start are more densely populated and better connected. Instead of burning out in one or two villages, hidden away in dense jungle, the virus spread from village to village, from village to town, and eventually from town to city. When it hit Monrovia, the slum-ridden, million-person capital of Liberia, an explosion was probably inevitable. (It has recently begun to expand in Freetown, the capital of Sierra Leone, as well as Conakry, the capital of Guinea.)

The growth of the epidemic has brought with it the growth of terror and the destruction of already tenuous trust, both in governments and in modern health care. It has also brought death from other, treatable conditions that cannot now be treated in health care systems that Ebola has collapsed. It has brought restricted transportation and supplies and, as a result, in some places, sharply higher food prices. It may eventually bring, in spots, starvation.

Recriminations have already started. Why didn’t the West provide powerful help in March 2014, when the epidemic (already about a year old) began to be noticed? Or why hasn’t Western science, expensively pursuing the latest “me too” drug for common Western conditions, produced a treatment, cure, or vaccine for Ebola? These critiques seem too harsh. No previous epidemic has ever ballooned like this one, even in Central Africa. And the chance of an epidemic outside those traditional regions, let alone in the West, appeared remote.

And while some have pointed fingers at the West, others have focused on the behavior of the affected West African populations. Much has been made of their reluctance to abandon traditional methods of burying their dead, their lack of trust in modern medicine, and even their physical attacks on health care workers. But before blaming the victims for their poor infection control measures, put yourself in their shoes. A five year old – perhaps your five year old – is feverish and vomiting. She is crying and holding her arms out to you for comfort, for help. In West Africa you would not have the chance to telephone for an ambulance, with well-protected professionals to treat the child. Touching her could kill you. But what would it do to you – what would it make of you – to ignore her? As Benjamin Hale wrote in Slate, Ebola is a fantastically cruel disease, turning against us our own compassion, care, and love.

What will happen?

WHO and the Centers for Disease Prevention and Control (CDC) both estimate that the number of people infected is doubling roughly every 20 days. This means that in 20 days 6,000 infections would become 12,000 and in 100 days, 6,000 infections would become about 200,000. In 200 days – early April 2015 – there would be 6 million infections and in 400 days – roughly Halloween 2015 – we would see over 6 billion people infected, nearly as many as the world’s total population.

Unsustainable trends will stop; that rate of new infections will slow down. We will not see the world’s whole population infected with, and more than half of us dead of, Ebola before the end of 2015. It is possible that outbreak may end up largely confined to the three current epidemic countries in West Africa. Other parts of the developing world provide some hopeful signs. Both Senegal and Nigeria had cases of Ebola spilling over from its West African epicenter, one case in Senegal and twenty in Nigeria. The Nigerian outbreak started with a Liberian visitor in Lagos, Nigeria’s sprawling and poor megalopolis of untold millions. (15, 20, 25? No one is sure.) He set off a chain of twenty infections. Yet both of these outbreaks, thanks to prompt and efficient public health measures – and to the fact that they were attacked vigorously when new and small – seem to have been contained.

Ebola is unlikely to become a major problem in the developed world. Some people will end up being newly diagnosed with Ebola in North America and Europe (and possibly elsewhere) – we just had the first person diagnosed in the United States – but, with proper attention paid to controlling the spread of the virus, developed countries have public health infrastructures that should be able to keep the infections and deaths to a relative handful.

But even if this epidemic does not spread substantially beyond its current locations, it seems increasingly likely that hundreds of thousands, and quite possibly millions, of men, women, and children will be struck down by this ghastly plague. Liberia has a population of 4.4 million, Sierra Leone 6.2 million, and Guinea’s population 10.6 million; each has a capital city area with more than a million people and an increasing number of infections. The current rate of new infections, or something close to it, will not have to continue for long to affect substantial percentages of those populations.

And it not right to say that North American and Europe will escape all the malign effects of Ebola, and, more particularly, effects of the fear of Ebola. There is more to fear from Ebola than fear itself, but the fear itself will be costly. Fools like Donald Trump have already decried the treatment in the U.S. of an infected American physician. When we have more cases diagnosed in the U.S., which hospitals will accept them – and how much other business will they lose? And if we get several cases in a city, how many people will avoid traveling there or will, in panic, try to flee them? But our losses, though real, will not be measured in hundreds of thousands or millions of lives.

What is to be done?

What is to be done? More supplies, more facilities, and, most drastically, more personnel. Liberia now has over 450 beds in Ebola treatment facilities but doesn’t have the health care personnel to staff many of them. In contrast to past disasters, foreign volunteers have not been flooding in. I can’t blame them. One of the worst aspects of this outbreak is how many hundreds of health care personnel – who at least know what precautions to take – have been infected and have died. My wife is a recently retired physician. If she announced she wanted to treat Ebola patients in West Africa, I would be very proud... and even more terrified. I suspect I would try very hard to convince her not to go.

And if you, like me, are not a qualified (and very, very brave) health-care provider, what can you do? We can, and, when possible, should give money. There are worthy charities that will always need money: Médicins San Frontières (Doctors Without Borders), Red Cross/Red Crescent, UNICEF, AmeriCares, Samaritan’s Purse, and more. (CNN.com, among others, has a list.) But private donations are a drop in the bucket. We can and should push for our governments to fill, and then to overfill, that bucket, with money and with help, which they are beginning to do. But, in the long run, I’m not sure how much we can do, other than to sympathize. And to grieve.

Is there any spark of light in this terrible darkness? Perhaps. Certainly, the next Ebola outbreak, especially if outside a Central African village, will receive quicker, and more effective, attention. And maybe the world will prepare better for the next nasty infectious disease epidemic, and the next, and the next. Maybe we’ll collectively pay for a global ready response team to intervene early enough to make a big difference. About a decade ago CDC paid a firm to create a special “biocontainment” unit for air transport of people with terrible infectious diseases. By 2009 budget problems had forced it to drop its contract for using that unit. Today, it is seeking, on an emergency basis, without competitive bidding, to make a new contract with the same firm. Maybe next time we’ll be readier. And these dead will not have died in vain. Wholly. Or so we can hope.

Of course, around the world, about 55 million people will die this year. Cancer, heart disease, malaria, tuberculosis, and even diarrhea will all kill more than Ebola even in the next 12 months. What’s another million, more or less; particularly when it is highly unlikely anyone reading this will know any of the victims?

It is one thousand thousands of people – people who, like us, eat, drink, sleep, and feel joy and fear, love and anguish. It is people whose deaths come suddenly and unexpectedly, and not solitarily but along with the extinction of their families and the decimation of their communities. As they are human, and as we want to remain human, we must, at the very least, care. And grieve. This is going to be an immense catastrophe, not just for West Africa, but for all humanity.

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if promontory were, as well as if a manor of thy friends or thine own were. Any man’s death diminishes me, for I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”

Hank Greely, JD, is a Stanford law professor and an expert on the legal, ethical, and social issues surrounding health law and the biosciences. He is director of the Center for Law and the Biosciences, and he chairs the steering committee of the Stanford Center for Biomedical Ethics. This post originally appeared on the Stanford Lawyer blog.

Previously: Dr. Paul Farmer: We should be saving Ebola patients, Ebola panel says 1.4 million cases possible, building trust key to containmentExpert panel discusses challenges of controlling Ebola in West Africa, Should we worry? Stanford’s global health chief weighs in on Ebola and Biosecurity experts discuss Ebola and related public health concerns and policy implications

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