In 2015, just as the Ebola outbreak in West Africa had begun to taper, I teamed up with computational geneticist Dr. Pardis Sabeti to survey more than 200 Ebola responders about their experiences during its height. Journalists don’t typically team up with their sources to work on an investigation, but our experiences demanded our collaboration.
Sabeti and her lab had been conducting extensive research in Kenema, Sierra Leone, which soon became one of the areas hardest hit by the outbreak. Her team had faced major barriers as they conducted lifesaving research that changed the way scientists understood the disease. The frustrations culminated with the death of their colleague, a renowned Sierra Leonean virologist who died of Ebola after treating so many others with the disease.
Our conversations during the efforts to stymie the spread of Ebola prompted me to compare our experiences to previous major outbreaks around the world. I began to see patterns emerge. And we wondered whether our experiences could apply to any outbreak environment. Our first look into that question only scratched the surface of what we would soon find.
Nearly all respondents to our survey had found that at times political and interpersonal challenges slowed the response to the outbreak. Many reportedly feared the politics more than the virus. Some said these various challenges put them at higher risk of contracting the virus. More than a quarter reported either witnessing, hearing about or falling victim to illegal or unethical tactics while working in their respective capacities.
Nearly all respondents to our survey had found that at times political and interpersonal challenges slowed the response to the outbreak. Many reportedly feared the politics more than the virus.
Some of the reported tactics included: money and other forms of aid disappearing before it reached its intended recipients; inadequate and knowingly defective personal protective equipment sent to health workers treating Ebola patients; harmful competitive practices like intimidation and data hoarding to prevent some from conducting research in the field.
Many of the major themes that emerged from our survey matched reports I had examined amid past major outbreaks including AIDS and SARS, Zika and MERS. Some of our survey respondents also reported experiencing the same dysfunctions ― and sometimes worse ― during previous and subsequent large-scale epidemics, regardless of the name of the pathogen. I reached out to key sources who were critical decision-makers in outbreak response, and they also confirmed what repeated stories, and now the data, showed.
As a health journalist, I have reported on previous outbreaks that were devastating in their own right. But none was as fear-inducing as the 2014 Ebola epidemic, the largest and most widespread outbreak of the disease in history. Nearly 30,000 people were infected with the virus, and more than 11,000 died in the three hardest-hit countries: Sierra Leone, Liberia and Guinea. Yes, the virus itself was an entity to fear, especially since no vaccine was available at the time. But what frightened me was everything that an outbreak brought to the environment it enveloped.
While mostly centered in West Africa, Ebola emerged in the U.S., and was in some ways a test run of our preparedness and abilities to respond to a large-scale epidemic. It did not go so well then. The 11 Ebola cases treated in the U.S. exposed the vulnerabilities of our health care system, which is significantly more developed than in West Africa.
In response to the crisis, 35 hospitals across the U.S. were designated as Ebola Treatment Centers, which meant they were deemed by state health officials to be equipped to treat those afflicted with the disease. Fortunately, many of those centers never saw an Ebola case, because the reality was that none of the facilities had the capacity to quarantine or isolate more than one Ebola patient at a time.
This made clear that if something more contagious were to hit that would require sustained use of supportive care in hospitals, the bottom of our health care system could fall out. That’s the message I had heard in covering previous outbreaks in developed countries, but health experts again sounded the alarm after Ebola: Something is coming and we are not prepared.
Health experts again sounded the alarm after Ebola: Something is coming and we are not prepared.
Outbreaks create an intense, high-stakes, pressure-filled environment. What’s happening is volatile, often unclear and rapidly evolving, and the pathogen is life-threatening. Amid this environment, a culture can form, created by both individual actors and larger agents, that at times has proven to be as lethal as the virus itself. The scenario is a test of humanity and our response to unpredictability.
Medical historian Charles Rosenberg describes an epidemic unfolding in three stages or acts. The first is revelation, where communities gradually accept the presence and spread of the disease. The second is managing randomness, where people try to identify a cause and blame others; the third is negotiating public response when, finally, measures are taken to control the epidemic.
Enter COVID-19. The scenario again unfolds like a scripted screenplay, this time with a different virus.
In West Africa, messages displayed across billboards, spray-painted on walls, announced on radio ads and printed across T-shirts implored people to take the virus seriously. “Ebola is real!” the message conveyed. Many people in some parts were already skeptical of the government and foreign agencies after having recently endured a civil war. In some cases, the skepticism and distrust led to violent resistance of outbreak responders entering neighborhoods to help trace and detect the disease.
Many outside of West Africa who had watched the Ebola outbreak unfold criticized communities that were the hardest hit for not complying with social distancing and resisting other public health measures that discouraged people from participating in age-old traditional and cultural practices, such as funerals and religious celebrations. Some of the same reactions have taken hold in the U.S., as Americans grapple with the coronavirus affecting their community structure and way of life.
Like Ebola, some Americans still do not believe in the existence or severity of COVID-19, the disease caused by the coronavirus. Disinformation campaigns chalk it up to a variation of the flu. In some parts of the country, places of worship keep operating and group gatherings continue, defying public health directives to stay home.
Although lessons were learned during the Ebola outbreak, the culture of outbreak response has not changed and some of the same challenges apply.
The major challenges recounted to us during the Ebola outbreak had little to do with the virus itself. Instead, the virus was a lethal backdrop to the actions and, at times, inactions of individuals, groups, agencies and organizations during the intense environment of outbreak response. Although lessons were learned during the Ebola outbreak, the culture of response has not changed and some of the same challenges apply.
Months passed between information and action with Ebola, in part because information was concealed and controlled. Fear of the social and economic consequences also paralyzed necessary action. The virus raged and ravaged until countries and agencies could no longer turn away. Even as response ramped up, collaborative efforts were stifled by pointing fingers for the dangerous delay.
Placing blame on people and agencies during the COVID-19 response is not only adding to the chaos and confusion, but stalling the critical mindset and resources needed in this global fight against the only thing that should be fought against: the virus. Inconsistent messages and response measures ― this time in the midst of an election year ― have again turned outbreak response into a political tug-of-war.
Governments and agencies have time and again chosen to rely on responding after the fact rather than investing in readiness, and that has served as a prime breeding ground for our current outbreak culture. Favoring response can fuel a culture driven by political motivation, life-threatening fear, personal gain and isolation. Behaviors as a consequence of this culture can lead to confusion, collusion and culpability amid an already chaotic environment. Loss of human life has again become the consequence.
Frontline health workers in the Ebola response were exponentially more likely to die from Ebola than any other group. They continued to work despite shortages of protective equipment and inadequate training on ways to prevent getting infected. Also, local health workers who best knew the community they cared for too often did not have a seat at the table where policy decisions were made. These are just some factors that have replayed in some variation in the larger response to COVID-19.
The parallel experiences drawn from past outbreaks, and now COVID-19, serve as another reminder to me that we are one global community. The health of one person in the world can quickly matter to the health of every person anywhere in the world. Viruses do not recognize national borders, nor do they recognize political, social, ethnic or religious differences. If we are to effectively combat outbreaks, we must shift our culture to operate the same way.
Viruses do not recognize national borders, nor do they recognize political, social, ethnic or religious differences. If we are to effectively combat outbreaks, we must shift our culture to operate the same way.
It is possible to alter the culture of outbreak response, but it is not something that can be done during the pandemic. The quiet space between epidemics offers the best chance to build up a state of perpetual preparedness. Investing in readiness involves creating a military-style governance structure dedicated to global health security. Such a global, centralized system would share information across agencies and regions, would help build capacity when there is no outbreak but also ensure accountability in the midst of a response.
When we look back at this pandemic, we will no doubt find that ― just as with Ebola ― having invested in preparedness would have been far less costly in time, money and lives than our response.
Ebola responders likened the outbreak environment to that of a war, and it’s a sentiment being echoed in some of the hospitals hardest hit by COVID-19. Far more people around the world have died from infectious diseases than in war, yet more is invested in military response than in outbreak preparedness. Improving the capacity of health systems has done more to create a stable socioeconomic and political environment than any exercise of military power. If infectious disease outbreaks are regarded with the same level of concern as warfare, the world would invest in and achieve the level of readiness needed to respond with precision and speed.
The Ebola outbreak is in some ways a looking glass into the future of life with ― and possibly after ― COVID-19. The fallout from Ebola was significant. Entire social and health care systems collapsed in the hardest-hit countries in West Africa and the rebuilding of community and health systems continues to this day. Many who lived through the Ebola epidemic in the hardest-hit areas witnessed the societal breakdown and emotional trauma that accompanied the outbreak. An upsurge in the incidence of mental health disorders occurred, including depression, anxiety, post-traumatic stress and substance abuse. Now, as an invisible contagion continues to spread quick and wide, major psychosocial consequences to the halting “normal life” likely will result.
Every outbreak I have reported on has served as a traumatic reminder to me of human fragility; the horrific manifestation of some of the diseases continue to play out in my mind. This pandemic is also a reminder of how familiar outbreak environments have become. We are gradually, albeit reluctantly, accepting its presence and negotiating a difficult response.
When the pandemic subsides, it will become yet another opportunity to change outbreak culture before the next one appears. If the past provides any clues, though, an outbreak of pandemic proportion may still not be enough for us to seize it.
Lara Salahi is an award-winning health journalist and co-author of Outbreak Culture: The Ebola Crisis and the Next Epidemic. She is also an assistant professor of journalism at Endicott College in Beverly, Massachusetts.
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