Lessons From Africa’s Hard-Won Victory Over Ebola

(Bloomberg Business) — The West Africa Ebola outbreak looks to be petering out. In the week ended Jan. 25, fewer than 100 new confirmed cases were reported: 30 in Guinea, 4 in Liberia, and 65 in Sierra Leone. That’s down from more than a thousand new cases a week at the height of the outbreak. Liberia has reopened its schools for the first time since July, and the World Health Organization reports the focus has shifted from slowing transmission to ending the epidemic. The rapid decline in cases is a testament to the considerable bravery and hard work of local medical staff (488 of whom have died) as well as doctors, nurses, and other volunteers from around the world.

But the toll has been high: almost 9,000 deaths already, more than 22,000 cases, and massive disruption to the world economy costing billions of dollars. A big reason for that cost was a slow global response. The number of Ebola treatment center beds for safely isolating patients began ramping up only as the epidemic was already declining, for example. The U.S. Congress authorized $5.4 billion to fight the disease, but only in mid- December last year. Most of that money will arrive in West Africa after the epidemic ends.

Last week, Margaret Chan, the director-general of the World Health Organization, accepted her group’s share of the blame: “The world, including WHO, was too slow to see what was unfolding before us.” To improve response times, she called for stronger enforcement of the legally binding standards governing surveillance and border control that are set in the WHO International Health Regulations. Without good surveillance, disease threats can fester undetected until they are considerably harder to contain. At the moment, countries simply declare they have the capacity to meet global standards and the WHO takes their word for it. There should be a system of independent review, backed up with international assistance and support to ensure that all countries really do have the capacity to track infectious disease outbreaks and control their spread across borders.

Chan also called for a “public health reserve workforce” to support emergency response. The world has a system for responding to military threats using national armies under a United Nations flag. Today, 90,000 troops are involved in peacekeeping operations from South Sudan to the India-Pakistan border. We need a similar system to respond to international infectious disease emergencies—one that enables the World Health Organization to rapidly mobilize, deploy, and support doctors and nurses from a roster of trained volunteers across member countries.

Finally, Chan noted that Ebola has been known for almost 40 years, and yet there is no cure or vaccine. It’s largely thanks to the U.S. Defense Department’s concern that Ebola could be used in a terror or bio-warfare attack that the research effort had made any progress prior to the outbreak, with both vaccines and therapies in early trials. But the global health research system is primarily driven by market pressures. The cost of bringing a drug through the regulatory processes to market averages around $1 billion. That’s a big reason why pharmaceutical companies would rather spend money on treatments for the diseases of the rich than for conditions that largely affect people in countries like Liberia with total annual health expenditures as low as $65 per person per year (that’s less than $300 million for the whole country).

There are two approaches to deal with that problem: lower the cost of drug development and increase the market for the products that emerge. On the development side, governments could commit more resources to public research into cures. But the power of the private sector could be better harnessed as well. As much as 80 percent of product development costs for a new drug come from running “stage three” trials demanded by the Food and Drug Administration. Stage one and two trials are largely about ensuring the drugs are safe to take at recommended doses. Stage three trials are designed to demonstrate that the drug works effectively to prevent or cure a disease. If developers were permitted to sell drugs designed for low-value markets after stage two trials had demonstrated they were safe—rather than waiting until stage three—that would dramatically reduce the time and cost of development. Governments and aid agencies could subsequently help fund stage three trials for those drugs that showed promise in fighting serious public health threats like Ebola.

To increase demand, governments can club together to create an “advanced market commitment”: If a drug developer produces a vaccine or therapy that meets certain standards, donors precommit to buy it in bulk. There’s precedent for this approach. Pneumococcal diseases cause meningitis and pneumonia, but until recently there was no vaccine against the pneumococcal bacteria common in developing countries. Before the vaccine had been developed, donors including the Gates Foundation and the U.K. Department for International Development made a commitment to buy $1.5 billion worth of suitable pneumococcal vaccines at a price of $3.50 a dose. Two pharmaceutical companies responded to the challenge, and have produced vaccines that have since been rolled out across the developing world. A similar approach could be used to develop treatments and cures for potential breakout diseases from Ebola to Marburg hemorrhagic fever.

The West African Ebola outbreak looks set to end as a hard- won victory in the battle against new and emerging infectious threats, but the global war continues. The Ebola virus still circulates in the wild, and it appears to be mutating, potentially to become less deadly but more contagious, according to scientists at the Institut Pasteur in France. Meanwhile, the Nigerian government reported last week that the H5N1 strain of bird flu has been found in chickens in the country and has spread from seven to 11 states in seven days, although it has yet to infect any humans. The H5N1 virus has killed 60 percent of the 650 people worldwide who have become infected with it since it emerged in 2003.

The lesson of the Ebola crisis is that when faced with emerging infectious disease threats, the world needs to react faster and stronger—based on enhanced global cooperation and better preparation. Failing to do so could mean an even deadlier epidemic the next time.

 

To contact the author on this story: Charles Kenny at [e-mail] To contact the editor on this story: Romesh Ratnesar at [e-mail]