Co-authored with Terrol Graham, M.P.H.
The first person treated for Ebola in the United States died last week. He had travelled to America from Liberia after helping an infected individual in his country. Now, alarmingly, two health care workers who cared for this patient in a Texas hospital intensive care unit are the first people to be infected with the virus in America. Tragically, despite extensive emergency preparedness planning and reports issued in the aftermath of 9/11, the anthrax attacks, SARS, and H1N1 flu, the world is still unprepared to fight Ebola. It now appears that these reports never translated into the global actions needed for a surge response anywhere in the world when a new infectious disease killer emerges.
Pathogens don't respect borders. With 2 million people crossing national boundaries every day, the spread of an infectious disease is just a bus ride or plane trip away. Today, one in four deaths worldwide is due to an infectious illness. More than 40 new infectious diseases have emerged since 1972, including AIDS, Ebola, West Nile encephalitis, Lyme disease, and MERS. And new illnesses will continue to emerge as a result of the changing environment, human behaviors, and animals and humans living in close proximity in many parts of the world.
Ebola, an illness that was first reported in West Africa in 1976, has already infected more than 8,900 people and claimed more than 4,400 lives during its most recent outbreak. With an estimated 70 percent fatality rate, the disease will take an enormous human and economic toll in West Africa and around the world if there is not a rapid, effective, and coordinated response. According to the World Health Organization (WHO), an estimated 10,000 cases a week could occur by the end of December if the disease is not contained. Ebola-related deaths are already escalating exponentially in the region, and a recent CDC worst-case scenario estimates more than 1.4 million cases there by January 2015 if it is not controlled now.
Sadly, we must learn once again from this current public health emergency that plans cannot just be developed and put on a shelf. They must be designed for immediate implementation with a global command structure and ready reserve of personnel and resources for rapid deployment to anywhere in the world to control disease spread. Furthermore, vaccine, antibiotic, and antiviral development is often a neglected priority for the pharmaceutical industry and governments until a lethal disease emerges.
For lessons learned from other public health crises, we only have to look back 30 years to the emergence of HIV/AIDS in America when the disease was shrouded, as Ebola is today, in a cloud of mystery, fear, and misinformation. There was stigma toward infected people, inertia on the part of officials, and a delayed systemic public, medical and scientific response while the disease spread worldwide. But because of effective advocacy, investments in research, health care provider training and a Surgeon General's Report issued to all Americans educating them about how to prevent acquiring the illness, our nation in collaboration with other countries ultimately mounted a vigorous response to HIV/AIDS. Today, as a result of scientific advances leading to the discovery of antiretroviral drugs in combination with evidenced-based behavioral interventions, millions of lives have been saved.
Innovative programs such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), are helping to build health systems to deliver treatment and preventive services in many parts of the developing world. PEPFAR offers an important lesson about the power of the US government to save lives when a global health emergency demands attention and America's innovation and resources are deployed to address it. But with 36 million people having died from AIDS since the beginning of the epidemic and 35 million individuals currently infected with HIV worldwide, more work remains to be done. The lessons learned from responding to HIV/AIDS, anthrax, pandemic flu, and other infectious disease threats in recent years must now help inform the United States and the global community's efforts to eradicate Ebola. Without accelerated action to contain and prevent Ebola's further transmission, the world could be facing another AIDS-like pandemic.
Thankfully, actions are now underway that should help reduce this disease's spread. President Obama recently released the United States Ebola Relief Plan, committing more than $750 million to this effort with leadership from the Centers for Disease Control and Prevention (CDC), the U.S. Army, the U.S. Department of State, USAID, and the National Institutes of Health (NIH). A command center in Liberia has been established with a commitment of more than 4,000 military personnel to distribute medical supplies and protective equipment, oversee the building of medical treatment facilities, provide logistical support and engineering, as well as sanitation and mortuary technical assistance.
The United Nations (UN) Security Council adopted a resolution co-sponsored by 130 countries declaring Ebola a security threat to all nations. The U.N. General Assembly has established the U.N. Mission for Ebola Emergency Response (UNMEER) to help stop the outbreak, treat the infected, ensure the delivery of essential services, preserve stability, and prevent further outbreaks.
While the global response is gaining momentum, many nations have still not made significant contributions and the response has been fragmented. Last week, the U.N. called for a 20-fold increase in funds to combat this disease. Currently, there is not enough collaboration between governments, U.N. agencies, NGOs, foundations, and private sector entities. There is an urgent need for an accelerated response with greater funding, resources and integration between these multiple streams of support. To help achieve this goal, the Obama Administration convened a Global Health Security Agenda Summit and implored countries to commit to the implementation of action steps ranging from improved disease surveillance to workforce development to medical countermeasures that can strengthen global health security architecture.
To effectively address emerging disease threats like Ebola today and other illnesses in the years ahead, a global emergency response plan must be developed and deployed with eight critical components that can be rapidly implemented at the beginning of an outbreak:
1) Appoint Leadership -- Global leadership must be identified immediately to help coordinate country, NGO, private sector and foundation funding as well as personnel and resources to ensure an effective response and reduce duplication of efforts. The World Health Organization (WHO) could possibly play this role but currently lacks the resources and personnel. The establishment of a "Medical NATO" has been proposed that could serve in this command and coordination role. America's leadership, funding and technical contributions are essential to any global effort.
2) Deploy trained health and lab personnel -- The world needs an active reserve of trained personnel to fight infectious diseases when an outbreak occurs anywhere in the world. Nations must identify and train health care providers and lab workers for this proposed World Health Corps who are certified, listed in a registry, and willing to help at the time of a global health emergency. In the United States, the Commissioned Corps of the U.S. Public Health Service -- a 6,500-member Uniformed Service of health professionals -- should ensure that many of its members are prepared to respond and deploy to health emergencies; these service members working with military personnel would be part of a coalition of in-country and international medical professionals who deploy in the early stages of a disease outbreak. The U.S. Department of Health and Human Services (HHS) also supports the Medical Reserve Corps, a domestic network of locally trained and based volunteers for the purposes of aiding in the case of emergencies. Consideration should be given to scaling up and internationalizing their mandate with appropriate training to address infectious disease control. Importantly, other nations should develop cadres of skilled professionals and community workers to participate in such global response teams. It is also essential to practice emergency preparedness responses and to ensure that health care providers are adequately trained and remain updated in caring for people with contagious infectious illnesses. After the ICU nurse at a Texas hospital became infected caring for the patient with Ebola there, the CDC conducted a comprehensive review of safety protocols for addressing the disease to ensure that frontline health care providers and those in contact with them are adequately protected. According to the agency, any case in a health care worker is unacceptable. As a result, the CDC will now send a rapid response team of the world's leading experts within hours to any hospital in America with a confirmed Ebola case to assist staff at these facilities with all aspects of patient care.
3) Establish regional stockpiles of medical supplies -- Stockpiles of protective gear and medical supplies as well as materials to build portable clinics and hospitals are needed across all regions of the world. Such stockpiles were established in America after 9/11 and must be maintained and updated. Home preparedness and disinfectant kits would also be very helpful. Tried and true public health interventions can contain the spread of many infectious illnesses including Ebola. In West Africa, supplies have been sent but some shipments are sitting in seaports not reaching those in need because of domestic bureaucratic disagreements and red tape. In the U.S., pandemic preparedness has stalled in recent years as a result of a $1 billion reduction in funding at the CDC for these efforts since the 2001 terrorist and anthrax attacks. These decreases impede state and local health departments from maintaining and expanding their capabilities to respond to an epidemic. Advanced manufacturing should focus on developing light weight, inexpensive protective gear for use in public health emergencies.
4) Invest in research -- We must continue to invest in research. It is essential to discovering cures, new treatments and prevention strategies for infectious diseases. Fast tracking of these efforts is needed given the lethality of Ebola since currently there is no proven vaccine or therapy. An effective vaccine would provide the best and most cost-effective method to prevent Ebola's devastating spread. Vaccine trials are now underway on accelerated timelines. Moreover, several experimental medicines to treat the disease are in the development pipeline. An experimental drug, zMAPP, recently used to treat several Ebola-infected individuals was produced by a pharmaceutical company with funding from U.S. government agencies including NIH, BARDA, and the Defense Threat Reduction Agency. The production methods used to manufacture the medicine was supported by the Defense Advanced Research Projects Agency (DARPA). Work is ongoing to produce more of this medication and evaluate its effectiveness. Whole blood and plasma transfusions from recovered patients who have high levels of antibodies to the Ebola virus have been used since 1976 when the disease first emerged in Central Africa with some suggestion of efficacy. Several patients infected during this current Ebola outbreak have received this type of convalescent blood and serum therapy. Studies are being conducted to determine whether this approach will work safely for patients in affected countries. If the results are positive, convalescent serum therapy could be scaled up to treat more people infected with the virus. Medications approved for use in the treatment of other diseases are also being explored as options for Ebola therapies. Point of care diagnostics that can produce results rapidly and differentiate between diseases must be a high priority for research and development. Furthermore, a new generation of antibiotics is urgently needed for treatment of drug resistant infectious diseases that pose yet another health threat today for people in the United States and worldwide. To this effect, the Obama Administration recently announced an initiative to spur innovation in this area. These medical needs make a compelling case for why our nation's research investments much be increased. The Biomedical Advanced Research and Development Authority (BARDA) established after the bioterrorist attacks in 2001 and the new biological technologies division at DARPA, an agency at DOD that supports innovative diagnostic and therapeutic approaches would benefit from enhanced support.
Given the lifesaving importance of scientific advances and innovation in the fight against Ebola and other illnesses, it is particularly alarming that the purchasing power for new grants by the National Institutes of Health (NIH) has declined by 23 percent from what is was a decade ago given inflation and relative flat funding for the agency. Furthermore, the budget for the component of the NIH that focuses on diseases like Ebola, the National Institute of Allergies and Infectious Diseases (NIAID), has declined from $4.30 billion in FY 2004 to $4.25 billion in FY 2013. The NIH had been working on an Ebola vaccine since 2001 but according to the agency's Director, reductions in funding slowed efforts to further develop and evaluate this intervention. So far, additional support has not been provided to NIH for scientific initiatives to fight Ebola and must be redirected from other disease priorities. The NIH's and other research agency budgets must be significantly increased if we are to effectively combat emerging diseases as well as other illnesses that threaten the health of people in the 21st century.
5) Build health infrastructure -- Improved surveillance mechanisms are needed to track disease spread and communicate findings in a seamless system worldwide. Fragile health systems in affected countries have been unable to meet the challenges of the epidemic so far. These nations must significantly invest in their health systems capacity for sustainable solutions to address future outbreaks for humanitarian, economic and national security reasons. However, at this time, these West African countries will require emergency aid and resources to effectively respond to the Ebola epidemic. Community health workers should be trained to safely provide care, distribute supplies and information about Ebola. A critical component in containing the epidemic is engagement with community members and local leaders to build trust and overcome the stigma and fear associated with the disease. Mobile emergency clinics should be established and deployed. PEPFAR and Global Fund investments in affected countries should be scaled up to focus on health systems strengthening. This will not only enhance prevention and treatment of AIDS, TB and Malaria but help developing nations fight outbreaks of diseases like Ebola as well. Governments and NGOS should partner with the private sector to use their logistics routes and infrastructure to deploy supplies during global health emergencies. In America, we must mobilize our public health preparedness network, ensure that effective emergency protocols are in place, that health care providers have the necessary training and practice before an outbreak occurs, and that resources and personnel are kept on ready alert.
6) Use social media and information technologies -- Technologies including mobile phones and social media should be harnessed to track the spread of Ebola and other diseases and disseminate educational and prevention information. A website to serve as an information hub for emergency global health preparedness should be established with model response plans, training videos, instructions for home care and field clinic development, as well as educational materials for the public and health care providers that can be translated into various languages. Lessons learned from other public health emergencies such as SARS, the Haiti earthquake, the tsunamis, and pandemic flu preparedness should be included on the website as well.
7) Address complex political, legal and ethical issues -- A global pandemic generates myriad issues of country, state and local responsibilities for infectious disease surveillance and control. Issues related to case reporting, disaster relief, travel, quarantine, disposal of contaminated materials, burials of people who have died from the disease, administration of experimental therapies, and jurisdictional responsibilities must be resolved wherever possible before an epidemic emerges and spirals out of control.
8) Establish an END EBOLA Fund -- A fund should be established to receive and distribute private sector contributions from individuals, businesses, and Foundations to help meet the financial needs for Ebola control, research and relief efforts. This fund, similar to what was established after the tsunamis in Indonesia, Hurricane Katrina, and the Haiti earthquake might be chaired by high profile individuals to help mobilize contributions from people worldwide to fight Ebola, support research, enhance services, prevent further spread of the disease worldwide, and distribute aid to those who have been affected including many orphans. Two models have been used in the past for such purposes. One strategy is to establish a new non-profit organization for this purpose; the second approach is to use a fund to collect and then distribute contributions to existing organizations that are responding to the Ebola crisis. A toll free-telephone number, website and text messaging capabilities should be established as components of such an END EBOLA Fund. The CDC Foundation has already received several significant private sector contributions to assist with Ebola control efforts.
Ebola might have been more rapidly contained if such a plan was immediately implemented. But it's not too late if current actions follow this kind of roadmap. Looking to the future, we've learned that leadership, personnel, resources, and technology must be ready to respond effectively in real time at the beginning of an outbreak if we are to move from peril to progress in fighting a potential epidemic. As Louis Pasteur once said, "Chance favors the prepared mind." Throughout the 20th century, infectious diseases including HIV, influenza, TB, and smallpox have killed millions of people -- more than all wars combined during this time period -- and remain clear and present dangers to humanity, economic development and national security in an interconnected 21st century world. We must remain vigilant against them.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of The Huffington Post. She is Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research in Washington, D.C. Dr. Blumenthal also serves as a Clinical Professor at Tufts and Georgetown University Schools of Medicine and a Senior Fellow in Health Policy at New America. Admiral Blumenthal served for more than 20 years in senior health leadership positions in the federal government in the Administrations of four U.S. Presidents including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, and as Senior Global Health Advisor in the U.S. Department of Health and Human Services. She also served as a White House advisor on health. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. She has chaired numerous national and global commissions and conferences and is the author of many scientific publications. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the 2009 Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation. She is the recipient of the Rosalind Franklin Centennial Life in Discovery Award. Her work has included a focus on infectious diseases including HIV/AIDS since the beginning of the epidemic in the early 1980's and she was involved in the federal government's response to bioterrorism in 2001.
Terrol Graham serves as an Allan Rosenfield Public Policy Fellow with amfAR, The Foundation for AIDS Research in Washington, D.C. Terrol earned his Masters of Public Health degree from Yale University and his B.A. in History from Wake Forest University