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Learning from Ebola failures is key for crafting better plans for public health emergencies

Outbreak Culture: The Ebola Crisis and the Next Epidemic

Pardis Sabeti and Lara Salahi
Harvard University Press
2018
275 pp.
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“Knowing is not enough; we must apply. Willing is not enough; we must do.” This observation, made many years ago by Johann von Goethe, might well have been said about the West African Ebola outbreak of 2014–2016, when neither advanced technology nor humanitarian intent was sufficient to avert a major health crisis.

In Outbreak Culture, geneticist Pardis Sabeti joins journalist Lara Salahi to examine the epidemic from the perspective of the clinical workers, researchers, and health agency personnel who experienced it firsthand. They note in particular three factors that foster a culture that can compromise outbreak response: (i) fear; (ii) the instinct to protect oneself, others, or institutions; and (iii) the desire to exploit. The book focuses on what happens when these motives collide, indicting poor policies, ineffective decision-making, and bad actors.

An illustrative prologue depicts the tragic death of Sheikh Humarr Khan, the physician director of the Kenema Government Hospital who succumbed to Ebola infection in July of 2014. Before his death, physicians struggled to reconcile ethical questions: Should they use a new experimental treatment? If he subsequently perished, would the attempt be viewed by the public as a noble failure or the exploitation of yet another African life? Would offering him a new treatment be equitable? Could a patient without Khan’s training provide truly informed consent to receive such a therapy?

The authors deftly weave surveys, interviews, and retrospectives on previous outbreaks into a concise depiction of the Ebola epidemic, with particular focus on human behaviors that exacerbated the course of the outbreak. They describe the negative impacts of the egregious quarantine in Liberia and acknowledge the contribution of local burial practices to viral transmission, but they also remind readers how poorly health care workers returning to the United States were treated and how inadequately the country responded to a mere handful of cases.

Accountability proved a critical problem in the Ebola response. Funds often flowed directly to individuals, fostering corruption: Less than 2% were directed to the pressing needs of local responders.

Sabeti and Salahi present a wealth of evidence supporting the imperative that outbreak response must operate in a coordinated, real-time manner. The construction of 11 U.S.–built Ebola treatment units is an emblematic example: Just two units were ever occupied because they were no longer needed by the time they were completed.

OLIVIA ACLAND/BARCROFT IMAGES/BARCROFT MEDIA/GETTY IMAGES

An Ebola treatment center sits empty in Freetown, Sierra Leone, in November 2016.

Lags in detection and mobilization and delays in the establishment of best clinical practice proved costly. Failures synergized: When the Sierra Leone Ministry of Health and Sanitation counted only laboratory-confirmed Ebola deaths, yet had just two phlebotomists in the field collecting blood samples, cases were underreported. Meanwhile, response was compromised by a deficit of collaboration: 43% of the authors’ survey respondents reported data hoarding.

Sabeti and Salahi provide a set of principles to improve outbreak response. They propose a foundation of universal ethical standards coupled with increased accountability. They note that cooperation could be incentivized, from eliminating stigma and discomfort in implementing quarantine to reforming data sharing and patent systems in order to promote collaboration.

Most provocative is the authors’ vision of a system of global readiness—one that combines a military-styled response and centralized governance. Given that substantial compliance issues exist even under existing World Health Organization health regulations, could such an integrated authority gain the support of national governments and the cooperation of local populations? In an era of increasing nationalism and waning support of international efforts, the bar to achieve such an ambitious vision appears high.

Yet in a time when it can be easier to sequence a virus than to obtain a clinical sample or share genomic data, changing outbreak culture demands systems innovations and policy commitments. As Sabeti’s colleague Nathan Yozwiak notes, “The limitations are human, they’re not technical anymore.”

About the author

The reviewer is visiting associate professor and interim chair of the Department of Health, Nursing and Nutrition at the University of the District of Columbia, Washington, DC, USA.