The Next Outbreak
IN AUGUST 2016, I sat in the lobby of the Emory Conference Center Hotel, across the street from the Centers for Disease Control and Prevention (CDC) headquarters, nursing a glass of wine and preparing for a battery of interviews the following day, when I overheard a woman speaking about her experience fighting, and recovering from, the Ebola virus. It was Nancy Writebol, the Serving in Mission volunteer who had been infected two years previously. She had returned to Emory to address a group of young nurses, and to thank the medical professionals who had treated her during her darkest hours. For the brief few moments when I was fortunate enough to meet her, she offered a warm smile and a healthy handshake. She bore no outward scars that I could see.
But on the inside, Writebol and others have hinted at the lasting damage caused by a virus that haunts her, even though she has built up the antibodies necessary to make her immune. She has described in interviews with other reporters the pain she still experiences in her knees. Stairs are a problem. Nightmares haunt her at times.
Nancy Writebol, Kent Brantly, Craig Spencer, Nina Pham, Amber Vinson, and a handful of others who have not been named by those who cared for them are the American survivors of the largest outbreak of the most deadly disease known to man. Thousands of Liberians, Guineans, and Sierra Leoneans have survived as well, but their ordeals are not over. Even today, they struggle with the aftereffects of Ebola—the joint pain, the mental stress, the cultural stigma. The stress and strain of Ebola is so great that few want to discuss it. Writebol and Brantly did not respond to my repeated requests for interviews. After many e-mails back and forth, Spencer too declined to speak about his experience. He said he understood why the other two had not responded. More than a year later, the pain is too fresh.
I began reporting this story because the intersection between human society and the nature with which we interact is fascinating. Mankind’s spread into the last remaining untouched parts of the natural ecosystem bears a cost—both to humans and to that ecosystem—with which neither side is prepared to deal. Conflict is inevitable; the outbreak of the Ebola virus in three desperately poor West African countries represents a worst-case scenario in microcosm.
What would—will?—happen when the next deadly pathogen with which we have no experience emerges? What would—will?—happen when someone infected with that pathogen boards an international airliner and winds up in the heart of London or New York or Beijing or Jakarta? I kept asking one question of those who had been so intimately involved in the response to the Ebola epidemic: Are we ready for the next one?
The answer, resoundingly, terrifyingly, is no.
Around the globe, the responders who are tasked with preventing or containing a viral epidemic are scrambling to evolve. Ebola exposed a woefully inadequate global health regime, one that proved to be in over its head almost from the beginning, thanks to years of bureaucratic bloat and international neglect. The World Health Organization (WHO) has engaged in a remarkable round of self-flagellation, consolidating some of its oversized bureaucracy and reforming itself to create a new directorate called the Health Emergencies Programme, established in 2016 with the explicit mission to deliver support to countries facing disasters, either natural or man-made.
WHO has made clear, too, that decades of stagnant appropriations from member nations, including the United States, have contributed to a budget crisis that has left what is ostensibly the world’s frontline defense against deadly pathogens so weak that it is functionally unable to fulfill the role its member states expect. In her final months in office, Margaret Chan, WHO’s director general, openly chastised member nations that have failed to deliver the money her agency needs.
“The problem can be succinctly stated,” Chan told ambassadors at an October 31, 2016, meeting of donor nations in Geneva. “You expect a great deal from WHO. The organization is uniquely mandated to deliver. But someone must invest the requisite funds.”
“The hard lessons from the Ebola outbreak underscore the need for WHO to have sufficient core capacity and readiness in place before the next crisis emerges. These are not capacities that can be built in the chaotic fray of a crisis,” she said.
She was right.
In the absence of a competent and efficient WHO, the United States stepped in, deploying more responders to a public health crisis than ever before in the nation’s history. More than 2,600 American troops spent weeks building Ebola treatment units, and more than 1,400 CDC employees swarmed the slums of big cities and the back roads of rural West Africa to track down as many victims as possible. Together with their Liberian, Guinean, and Sierra Leonean hosts, they built capacity to track, treat, and prevent a disease where none had existed.
During one of our interviews in his office just blocks from the White House, Ron Klain, the man who facilitated the U.S. government response to the crisis and whose nights were interrupted by constant false alarms about potential Ebola patients walking in to medical facilities across America, made a startling point about the American intervention: There aren’t many other countries in the world where the United States could have done so much.
Though Liberia, Sierra Leone, and Guinea had suffered so much, the world had gotten lucky that the outbreak had occurred there, and not somewhere like the Middle East or Southeast Asia. The legacy of colonialism meant the United States, the United Kingdom, and to a lesser extent the government of France had the relationships, along with the money and the manpower, necessary to come to the aid of their close allies.
“We were able to divide the load between three Western countries. That’s like a coalition-building fantasy game. That’s never going to happen again,” Klain said. “The disease broke out in one of a few countries on earth where the arrival of 3,000 U.S. troops was seen as a happy event, was seen as a blessed event.”
“If this outbreak had been in Pakistan, or Indonesia? ‘Good news, we’re sending 3,000 troops from Fort Campbell, Kentucky, with guns.’ No!” Klain said. “The most likely places where this is going to happen [next] are not places where you can send the 101st Airborne without fighting their way in.”
The outbreak that claimed so many lives across international borders might have ended up like every other Ebola outbreak—a hot but brief-burning fire that ran out of fuel before it could spread—if Guinean and WHO officials had only recognized what they were looking at when they first arrived in Meliandou in December 2013. Indeed, at the same time the three West African nations were battling the virus, another outbreak struck the Democratic Republic of the Congo (DRC), in August 2014. The DRC has such a well-practiced Ebola response, given the myriad outbreaks that have taken place within its borders in the past three decades, that the virus never expanded beyond a few rural villages. Only sixty-six people contracted the virus, and forty-nine died.
But to stop a deadly outbreak, nations must have a competent and capable public health agency with four key elements: surveillance systems to identify an outbreak in its earliest stages, trained virus detectives to track down potential contacts, laboratory capacity to identify whatever is causing that outbreak, and rapid response teams capable of deploying in time to stop it from going any farther.
As it stands, the international community has had trouble agreeing on the very definitions countries use to evaluate their own health systems. Before the outbreak in West Africa, the hodgepodge of international consensus left it up to individual countries to evaluate their own health systems, and their ability to respond to deadly threats from natural pathogens, through a byzantine set of protocols and metrics that were virtually meaningless in their complexity. Now, a tool known as the Joint External Evaluation gives nations a common set of standards by which to judge their own capacity. The evaluation is voluntary, but it allows the international community to see potential blind spots that might otherwise have gone overlooked.
“We … have to convince the world that attention to the health infrastructure of their country is as important as anything else they do with their country,” Anthony Fauci said.
Even before the extent of the Ebola outbreak was known, the Obama administration began pushing countries to join the Global Health Security Agenda, an international partnership that would put a premium on capacity building and a worldwide alarm system to sound warnings about the next killer virus that had undergone pilot programs in Uganda and Vietnam. Written into the supplemental spending bill Congress passed to curtail the outbreak were hundreds of millions of dollars aimed at bolstering that alarm system by funding new CDC-like agencies in dozens of countries.
But there are still nations that lack surveillance and detection capacity, which makes public health officials nervous. The global health chain is only as strong as its weakest link.
“We could get hit from one of those blind spots,” Frieden said in one of our interviews. “So it’s in our self-interest to close those blind spots.”
Frieden’s CDC has evolved tremendously in the wake of the outbreak in West Africa. An agency that was once proud of itself for deploying a dozen or so epidemiologists to fight a remote outbreak had sent more than 1,400 staffers to Liberia, Guinea, and Sierra Leone, tracked thousands of cases and tens of thousands of contacts, and trained an army of new health-care workers in all three countries.
In deploying so many staffers, the CDC also learned that the effects of an outbreak go beyond the effects of a virus. Frieden, who had been New York City’s health commissioner in the aftermath of September 11, knew the potential dangers that mental health issues posed in the wake of such a traumatic experience. After the terror attacks, New York City had created a health registry that tracked 70,000 or so people who had been exposed to the dust and grit from the collapsing World Trade Center towers. While those who came down with respiratory issues had the most severe medical issues, their numbers were dwarfed by the thousands more who experienced crippling depression or posttraumatic stress disorder.
The same thing happened to those CDC staffers who came home from West Africa. “Even our most experienced people were really shaken by what they saw,” Frieden said later.
Leisha Nolen had felt so lethargic when she returned from her first deployment, at the height of the outbreak. The CDC opened a special office dedicated to helping those who were coming back, offering counseling, time off, anything that would be necessary to a mental recovery. Hundreds of their employees took advantage of those offers. Dan Martin, who had worried about his friend John Redd’s possible exposure, spoke out frequently about his decision to talk to a mental health professional, in hopes that his experience would help persuade others to seek out their own help.
“It took months to talk it out,” Barry Fields, whose position running a lab at the ELWA hospital in Monrovia put him in close proximity with some of the sickest patients, said in August 2016. “I’m still talking it out.”
But the epidemiologists, virologists, and laboratory technicians who had deployed from Atlanta came home with a deep sense of satisfaction. They had fought the most substantial outbreak in their lifetimes, one that could have become a global pandemic.
“We had been at the brink of an abyss, that it was absolutely possible that Ebola would get completely out of control and stay out of control for years,” Frieden said. “We were able to avoid that catastrophe.”
Perhaps most important, the CDC had, for the first time, developed a serious working relationship with the United States Agency for International Development Office of Foreign Disaster Assistance (USAID OFDA). Both Frieden and Jeremy Konyndyk, who headed the OFDA, had been surprised at the barriers built between the community of those who respond to natural and man-made disasters and the community of those who responded to outbreaks. They both thought that those barriers were false walls.
“An Ebola outbreak was not generally seen as something that would fall under the disaster response or humanitarian response community. The outbreak community was fairly distinct,” Konyndyk said. “We need to do much more to bridge the divide globally between the emergency community and the outbreak community.” The U.S. Congress is considering measures to establish a permanent bridge, through a Global Rapid Response Team.
The lessons that public health officials learned from the Ebola outbreak in West Africa have already been put into practice, the agencies responsible for responding to a viral outbreak already tested. Even before the final cases of Ebola were extinguished in West Africa, a new virus began appearing on international radars, one that spread far more easily than Ebola.
Like Ebola, the Zika virus was named for its geographic origin. The virus was first identified in the Zika Forest, a tiny strip of land along the Ugandan shores of Lake Victoria. Also like Ebola, Zika is not new—the first virologists to come across it had been on the hunt for Yellow Fever. They identified the Zika virus in a rhesus monkey in 1947.1
It is, in some ways, the opposite of Ebola. While scientists are still searching for the reservoir host that allows Ebola to lurk at the periphery of human existence, they know well where Zika resides, in Aedes africanus and Aedes aegypti, two of the most common mosquito species in the world. Though Zika poses little threat to healthy adults, the ubiquity of its reservoir host amplifies the potential to spread across the globe. Though Ebola is among the most deadly pathogens in the world, its relative lack of transmissibility hinders its ability to easily cause a global pandemic.
Zika broke out of central Africa first in 2007, when it showed up on the island of Yap in Micronesia. Micronesia is remote, but Brazil is not, and by 2015, WHO had reported the first series of cases in South America’s most populous country. Within months, the virus had raced north, through Suriname, across the Panama Canal into El Salvador, Guatemala, and Mexico, and through the Caribbean islands of Martinique, Barbados, and Haiti.
On December 31, 2015, WHO reported its first case on American soil, on the island of Puerto Rico.
The staff inside any White House takes its direction from the tone and tenor set by the president they serve, and under President Obama, officials had maintained their cool during the Ebola outbreak, even when critics called them aloof and out of touch. But Obama had paid the political price for calm when Americans wanted evidence of decisive action, and he would not make the same mistake as Zika-plagued mosquitoes flew north.
“With Zika, we were out very early and very often from here,” Amy Pope said in an interview in the ornate conference room inside the Eisenhower Executive Office Building once reserved for the secretary of war. “Then, we kind of took a back seat and we didn’t see our role as publicizing what was happening on Ebola.… I think in hindsight our better course of action was to be more proactive. With Zika, here’s what it is. Here’s what we’re requesting money for. Here’s where our gaps are. And that’s all in response to Ebola.”
But even with more weapons in the arsenal, the global response has not stopped hundreds of children from suffering Zika’s most horrific effects, like microcephaly, which causes infants to be born with underdeveloped brains. In the United States, Congress refused the Obama administration’s requests to allocate billions of dollars to fight Zika, despite bipartisan support from Florida Senator Marco Rubio, a Republican whose state suffered the lion’s share of infections on the mainland. Instead, Congress forced the White House to reallocate millions of dollars initially intended to fight Ebola, and to bolster the health systems both at home and abroad. Even after the Ebola scare, politics got in the way of the longer-term mission of building the global capacity to stop the next big outbreak.
What every epidemiologist, virologist, and public health expert agrees on is that the question the world faces is not whether the next big outbreak is coming, it is when. And mankind is sowing the seeds that will both speed the next outbreak and probably exacerbate its spread.
“You’ll see other zoonotic diseases. I think you’re going to see them more frequently. The idea that they’re going to be, as they have been in the past, small and rural in nature is, in my view, unlikely. You just have a different level of urban integration and migration now, even in places like Asia and Africa,” the former USAID director Rajiv Shah said.
Technological innovation beginning with jet aircraft has created a world in which almost anyone is only a plane connection away from the nearest hub airport, and from there only a handful of hours from New York or London or Beijing. A growing middle class in Africa, the Middle East, South America, and Asia means that more of us than ever have the financial ability to travel the globe.
At the same time, widespread poverty and the exploding human population means that we are living more densely than ever before and spreading our settlements farther into nature that has never contended with modern human civilization. In equatorial nations, slums abut wilderness, and the expansion of human settlements is decimating rainforests at a torrid pace. Human industrial activity is changing the global climate so much that tropical and subtropical zones are expanding north and south, away from the equator, which means mosquitoes and other creatures that could host new pathogens can now venture ever farther into newly habitable climate. The expansion of human civilization, an interconnected world, and a changing climate all conspire to pave the way for the spread of the fire of the next deadly pathogen.
Scientists fear that next pathogen will be some horrible combination of the worst traits of diseases like Ebola, Zika, and the common flu. A virus with the lethality of Ebola, carried by something as widespread as the common mosquito like Zika, and transmissible between humans like the flu is the stuff of Tom Frieden’s nightmares.
“We always worry about flu. Flu is always the one that could do just terrible things, and that’s something that we need to be continuously” vigilant about, Frieden said. “It spreads readily, and it kills a relatively high proportion of people if you get the wrong strain.” He cited the Spanish influenza as our nearest comparison, a disease that infected as much as a quarter of the world’s population during the early part of the twentieth century, killing 40 million people in the process.2 Devastating though it was, that virus only killed about one in forty victims, or about 2.5 percent of those infected. Even something doubly as lethal, or less than a tenth as deadly as Ebola, would kill hundreds of millions of people today.
The next fire is coming, maybe from Kinshasa, maybe from Karachi, maybe from Kolkata or Kuala Lumpur or Kansas City. Someday in the future, it will leap from its host species into an unsuspecting human, who may then board a plane or infect a neighbor. As it spreads from Patient Zero, the global community will need to race back into the fire, identify the pathogen, identify a treatment and stop it before it spreads out of control.
The Ebola virus disease that ravaged Liberia, Guinea, and Sierra Leone was a devastating tragedy that claimed more than 11,000 lives, left three nations in ruins, and exposed a global health system left scrambling to stop its spread. If Ebola leaves a lasting legacy, Shah said, it should be as a wakeup call.
“There are so many much more scary pathogens out there,” he said in his office overlooking Pennsylvania Avenue, just a block from the White House. “The world is still completely unprepared for it.”