This blog was inspired by a conversation with my friend and colleague Dr Kelechi Ohiri while we watched some of the media coverage of the Ebola outbreak on cable news channels, while acutely aware of our own reality in “West Africa”.
We recently heard the story of some Korean businessmen cancelling their trip to Nairobi for a conference because of …wait for it… the Ebola outbreak in Liberia and Sierra Leone. The distance from Nairobi to Monrovia is about 5.000 kilometres, about the same distance as between London and Washington, but hey, it is Africa, and there is Ebola in Africa. The hysteria manifests in several forms; Sierra Leone’s John Kamara was barred from returning to his Greek club after playing for his country in Yaoundé, Cameroun, two students from Nigeria who applied to a Texas college were told they wouldn’t be admitted because of Ebola, and flights are now being disrupted daily due to Ebola scares. Conspiracy theories on the source of the outbreak and the virus’s potential for mutation continue to gain strength with many audiences.
While the hysteria by a few uninformed private individuals and companies may be sad and easily dismissed, it becomes a real challenge when apparently enlightened and responsible citizens take to the airwaves in the same way. There appears to be serious and increasing pressure by parts of the American population, especially Republican lawmakers, to institute an air travel ban to “isolate” West Africa (a term now used to describe a geography two times the size of Europe, with 15 countries). The apparent purpose of this is to close America off to travelers from the region and protecting Americans from exposure to the Ebola virus. This solution is being proffered by panelists invited on several prime time television channels and beamed across the world. They should know better. There is no evidence that a travel ban can work, and such a ban is likely to cause more harm than good. We will explain.
But let’s consider why this must be taken seriously.
Firstly, it will not be the first time the USA has instituted a travel ban against public health counsel. For many years, those infected with HIV were barred from entry into the USA. There is no evidence that it had any effect at all on the epidemiology of HIV in the USA, but, despite this, it remained in place for 22 years until it was repealed by the Obama administration.
Secondly, hysteria has already led to several countries around the world re-instating airport temperature and symptom screening despite all the evidence that airport screening did not work for SARS in 2006, nor did it for TB in the UK, and there is absolutely no evidence that it will work for Ebola. Despite the constant preaching on the importance of evidence-based decision making in the health sector, the UK and the US as well as several other countries, including Nigeria, have re-instated or introduced airport “screening”. This comes in the form of various types of equipment used to measure temperature as well as a self-reported symptoms screening questionnaire. The Liberian Thomas Duncan, who entered the US while incubating Ebola virus did not have a fever on arrival, and expecting honesty in those filling out airport forms is really too much to expect, especially knowing what the consequences of that honesty are likely to be. But by instituting screening at airports, governments are seen to be responding. There is a lot of pressure to be seen to be doing something, even in the absence of any evidence of effectiveness. The only benefit airport symptom and temperature screening has caused is an increase in queues and congestion. In an airport like the Murtala Mohammed International in Lagos, this causes additional chaos and congestion, providing the perfect environment for the transmission of infectious diseases. Apart from providing much needed jobs for hundreds of Nigerians, given what we know about the disease, its natural history and the incubation period of the virus, this exercise is most likely to be ineffectual and very expensive.
Talking about evidence based policy making, just a few weeks ago, there was extensive and severe criticism of the Sierra Leonean lockdown in its attempt to limit transmission, as not being based on evidence, but now everyone seems to be on the band wagon.
The very nature of international travel and international travelers makes the proposal of a travel ban naive at best and most likely to make things worse, rather than better, an argument made brilliantly by Laurie Garette, in her article “Why travel bans will only make the Ebola epidemic worse”. Thankfully most of the Public Health Leadership in the USA, including the CDC director Tom Frieden have come out strongly against this. The WHO does not recommend it as a means of controlling the outbreak. There was very little discussion in the mainstream media about a travel ban from China during the SARS outbreak in 2002 or during the Swine Flu epidemic in 2009. Maybe there is something particularly uncomfortable for some folk in America with an outbreak taking place in Africa. So are we facing another round of hysteria driven public health policy?
Despite the hysteria, the facts remain that the risk of acquiring an Ebola infection in the US, UK or anywhere in the West remains vanishingly small. The virus is not airborne, and cannot be transmitted like some other viruses such as measles or the SARS virus can. Close contact with a patient is required for transmission. Just one death from Ebola has occurred in the USA, and medical care there is light-years ahead of the medical care available in Liberia, where more than 2.000 people have died in the ongoing outbreak.
If left without a robust response, the hysteria will hurt us, and not just our brothers and sisters in Liberia, Sierra Leona and Guinea, but all of us. This outbreak must not be allowed to evolve to become our “single story”.
So what do we recommend?
Everything we know about outbreaks of infectious diseases has taught us that the best way to control an outbreak is to identify its source and focus our control efforts there. All of us in the global community, North and South must put all our resources into supporting the response in Liberia, Guinea and Sierra Leone. It is worth noting that, while various panic-driven interventions are being put in place, the UN Secretary General Ban Ki Moon is saying that there is still a significant shortfall in the resources needed for tackling the outbreak. There has been a lot of criticism of the West in responding late, we have heard little being said for our own countries in Africa. In August, the AU announced a contribution of $1M, South Africa has sent a mobile laboratory and is considering a mobile hospital. Nigeria announced that it was sending volunteers, with little description of the institutional framework for their potential deployment. Below is a graphic describing the contributions to the international Ebola response efforts. You can draw your own conclusions.
Like I said in an interview at TEDGlobal, it is time we truly commit to dealing with this outbreak as a global community, not just for the “West Africans” but for all of us. The boundaries we hold so dear are not respected by infectious diseases. While we are at it, and despite all the pressure, our leadership both political and in public health must stick to the evidence of what works. We need calm heads to lead us through this.
It is too early yet to count the heroes but they may emerge from surprising places; doctors and nurses that have paid with their lives, working in the most grueling of circumstances, communities coming together to look after orphaned children and rebuild their lives . We hope that the story of this outbreak will ultimately be one of solidarity and partnership and not of victims and saviours.
We are in the middle of an unprecedented public health emergency at our doorstep. While it is fitting to celebrate small battle victories, we must not lose sight of the context of a larger war. We need to get over our hysteria and focus on Liberia, Sierra Leone and Guinea.