The most recent outbreak of Ebola in West Africa is different—and the difference matters not just to the afflicted nations but to all of us. The outbreak is a manifestation of a public health threat to the vital national interests of the entire international community. Even as it is in the midst of a truly heroic response to the outbreak, that community—and the NGOs and humanitarian assistance actors that collaborate with it—must learn the right lessons from the current outbreak, and must do so quickly. Developing better disease monitoring, better early warning systems, more rapid public health response mechanisms, and more robust local public health infrastructure and institutions in at-risk areas throughout Africa are all essential takeaways from the ongoing spate of Ebola cases that continue to multiply across broad areas of West Africa. An additional and important lesson of this outbreak may be that public health stakeholders will themselves require substantial support, primarily of a military nature, in order to access many of the areas in which the outbreak is occurring and to undertake the sustained medical relief effort necessary to contain it. The speed with which this support can be marshaled and deployed may have just as critical an impact on controlling the outbreak as the activities of health professionals combating the disease on the front lines.
This outbreak differs from previous Ebola epidemics in terms of the extent of the afflicted area, how rapidly and how widely the disease has spread, and the degree to which it has frustrated attempts at containment. Many of the reasons for these differences have less to do with the medical characteristics of the disease than with the chronic underdevelopment, lack of adequate health services, poor governance, insecurity, and endemic poverty native to the areas in Liberia, Sierra Leone, and Guinea to which the recent outbreaks have been localized. These same features also characterize the areas in Central and East Africa where previous Ebola flare-ups have occurred, however. Cataloguing and responding to what has changed since past incidences may prove key to containing this one.
In the past, the remote villages most susceptible to Ebola were isolated from each other and from larger surrounding communities, both geographically and in terms of communication. Past outbreaks thus remained largely localized to the villages in which they occurred. Today, Africa is a smaller place, with accelerating migration from rural to urban areas. Migrants to cities from rural areas are concentrated in equally underdeveloped urban peripheries, which have grown so quickly that they have overwhelmed the capacity of African municipalities to provide basic services. As a result, the conditions of chronic underdevelopment, poor health, inadequate services, and insecurity of rural and remote areas have migrated to major urban centers.
At the same time, the increased use of cell phones on the continent has enabled news of Ebola cases and local outbreaks to spread rapidly, widely disseminating horrific accounts of the disease’s symptoms and high mortality rate. The combination of a continuous stream of firsthand accounts describing the accelerating outbreak and the inability of national and local administrations to respond effectively has generated widespread fear and uncertainty. Local mistrust of deeply corrupt and ineffective state institutions—particularly related to security, but also health services and even a decreased faith in modern medicine itself—have contributed to a “flight” response among communities in which cases of Ebola have appeared.
The movement of what might be termed “health refugees” out of outbreak areas appears to be contributing significantly to the persistence of the most recent Ebola flare-up. Some refugees are no doubt fleeing deeper into the West African bush, using remote paths and tracks that straddle border areas throughout the Mano River region, knowledge of which is ubiquitous due to their use as highways for the fighters and weapons that have accompanied past armed conflicts. Because these pulses of health refugees are remote from seaports and international airports, their movements do not threaten to spread the disease beyond the Mano River region in the immediate future. Unfortunately, they carry a significant—and far more difficult to counter—longer-term risk of spreading the disease more gradually across West Africa, into regions that will be extremely difficult for health workers to gain access to and in which it will be extremely difficult for them to operate effectively.
On the other hand, the mass migration of African citizens to the urban sprawl that surrounds the cities of Monrovia, Freetown, and Conakry is moving the epicenter of the affected region to areas with immediate access to global transportation networks. The international community, national public health organizations, and international health bodies were slow to recognize this risk. (Although the Centers for Disease Control and Prevention in Atlanta, Georgia has recently called for a more urgent and effective response.) Even now, that recognition is largely limited to restricting sea-, air-, and ground-travel across international borders. The humanitarian assistance and disaster response (HADR) community confronts major challenges in combating the outbreak in the dangerous, difficult to access, and poorly served shantytowns that surround national capitols and major cities in the outbreak areas. Population concentrations in these areas are far higher than in their rural counterparts; sanitation problems are correspondingly greater, and options for flight more limited. A major risk given this situation is the potential for a second or even tertiary Ebola outbreak to gestate in these poorly governed and insecure urban areas and gather renewed momentum.
The answer to the question of why the most recent Ebola outbreak should galvanize the international community into action is neither self-evident nor simply humanitarian in nature. It is a question the major actors on the world stage—those nations with the resources, institutions, and capacity to generate the necessary response quickly—must examine and answer critically. After all, as horrific as Ebola is, the number of infected individuals is still fairly limited, and the impact on the developed world—including the nations of Europe and North America, as well as global economic powerhouses like China—has been minimal. On a straightforward yet universally sobering level, however, the international community should move to address the latest outbreak because the same conditions that fostered the rapid spread and persistence of Ebola are likely to have a similar effect on other diseases, which may be far more communicable and pose a much greater threat. Imagine if the disease in question had been similar to the SARS or MERS virus, or even as mundane as a new and particularly virulent strain of influenza. The Spanish Flu infected some 500 million worldwide in 1918, ultimately killing between 50 and 100 million of those afflicted. Were such an outbreak to occur under similar conditions to those of the recent spate of West African Ebola, especially absent early recognition of the extent of the outbreak and timely measures to limit it, a global pandemic could result. In addition to the terrible suffering and loss of life within West African nations, the ongoing epidemic delivers a dire warning about how much worse things could get.
On a level that should be encouraging to the international community, however, the current outbreak also offers an opportunity to develop a better understanding of how pandemic diseases manifest in the dynamic world of the 21st century. As international actors marshal the resources to support the courageous doctors, nurses, and local health workers who are laboring selflessly—and at great personal risk—to contain this outbreak, they must quickly learn how to distribute those human resources more swiftly to the affected areas of greatest need. The world must more rapidly furnish and deploy the equipment, personnel, security, communications, and logistics necessary to enable the effort to contain the outbreak. In the hardest hit areas of West Africa, this will probably require military support: rotary winged aviation, heavy air lift, trucks, fuel, power generation, and shelters, all of the resources necessary to enable an effective public health response. The world can and must learn from this opportunity, as it learned from the 2010 earthquake in Haiti, to collaboratively build more effective mechanisms to quickly identify major outbreaks with pandemic potential and efficiently respond to contain those outbreaks.
A cautionary note must be sounded with respect to deploying military forces in support of the containment effort, however. The use of military forces should be undertaken to support health workers combat the outbreak, not in an attempt to isolate entire affected communities. Unfortunately, the latter appears to have been the initial response of both the Sierra Leonean and Liberian governments. Isolating these communities with military or police forces is likely to further increase the fear and suspicion with which local populations in the area already regard state security services. Moreover, it is unlikely to prevent the continued flight of refugees from affected areas, and may in fact exacerbate them if local residents perceive the state to have abandoned their villages and communities. Instead, both national and international military forces can and should play critical roles in helping health workers reach vulnerable communities. Police officers and military personnel can also collaborate with health workers to better inform the public of common-sense measures to increase infected family and community members’ chances of survival while minimizing the likelihood of immediate caregivers, family, or community members themselves contracting the disease. The cell phones that are ubiquitous in even the most remote villages could become an important tool in this effort.
In the longer term, the states most at risk of serious outbreaks must effectively reduce their vulnerabilities to such diseases. Improving governance, particularly at the local level and in the area of public service delivery, will be essential to realizing this goal. Public health capacity, infrastructure, and surveillance must all improve as well. Security sector reform, focused not just on traditional physical security (including police, justice, and military forces) but on human security for the most at-risk communities, will be a key enabler of more immediate local response efforts. While addressing these issues is the primary responsibility of the states most at risk of a pandemic outbreak, every nation has a vital interest in assisting those states—and the communities within them—to reduce the risk of outbreak and increase regional and global resilience should an outbreak occur. When one’s neighbor’s house is on fire, it is a foolish homeowner who does not run to help put out the flames. And in today’s globalized world, everyone is our neighbor.
Disclaimer: This article was prepared and authored in the author’s personal capacity. The opinions expressed herein are the author’s own and are not offered on behalf of the Africa Center for Strategic Studies, the United States government, or any other third party.