My Times column on Ebola:
It is not often I find myself agreeing with apocalyptic warnings, but the west African ebola epidemic deserves hyperbole right now.
Anthony Banbury, head of the UN ebola emergency response mission, says: “Time is our enemy. The virus is far ahead of us.” Dr David Nabarro, special envoy of the UN secretary-general, says of ebola: “I have never encountered a public health crisis like this in my life.”
However, this is a case where the hype could serve a purpose if it motivates action and thereby proves itself wrong.
Two things could happen over the next few months. The more probable is that the brave aid workers, soldiers and medical teams heading for the region, and brave local health workers and burial teams, will gradually get on top of the epidemic in the three affected countries, Sierra Leone, Guinea and Liberia, the infection rate will peak and start to drop, and the crisis will pass.
There will be cases in other countries, including Britain (and panicky reactions), but they will peter out. The epidemic’s worst legacy will be an upsurge in the death rate in west Africa from malaria and other diseases that are going untreated now for lack of spare beds and doctors.
The other possibility is that the number of cases will continue doubling every four weeks, as it is now, so that hundreds of thousands are dead by early next year. Superstitious fear of doctors and treatment centres will worsen, civil society will collapse in the region and all hope of fighting the epidemic by isolating victims will be lost.
Ebola-carrying refugees will spread the virus to mega-cities such as Lagos, and even to areas controlled by terrorists such as Boko Haram. In the rich world, travel restrictions will multiply and people will start staying away from transport hubs, plunging the world economy into trouble.
If that happens, and the infection rate is still accelerating at the turn of the year, I fear the ground war may be lost and the world may have to wait for a vaccine or new supplies of ZMapp monoclonal antibodies (made, please note, by genetic engineering in plants).
Even if these work, manufacturing them faster than the epidemic manufactures new cases will be tough and it may take years for cures to overtake cases. That’s why the public-health ground battle is so crucial. If we lose that in Sierra Leone, Liberia and Guinea, then we are not facing paper tigers such as Sars or bird flu, but something much more like the great plague of Justinian, in AD541, or the Black Death eight centuries later.
Compared with those bubonic plague pandemics, we have enormous advantages. We can know with certainty that epidemics are caused by germs and not by Jews or sin. We can deploy protective clothing, gloves, disinfectant, rehydration therapy and blood transfusions from survivors. We can identify, sequence and probe the vulnerabilities of the pathogen. We can fly well-trained health workers around the world. We really should be able to cope.
However, modernity also means that the virus can fly from one continent to another in hours, meeting hundreds of strangers along the way. And the conditions under which most of those in Monrovia and Freetown live are far too similar for comfort to the conditions of Constantinople in 541 or Pisa in 1348. Ebola has never got a hold in an urban setting before, let alone in three of the very poorest countries in the world — in cities without many hospitals or doctors, without reliable sewage systems, running water or electricity. The lesson is clear: prosperity is the best disinfectant.
The world’s complacency when ebola appeared in Guinea last December was understandable. In every one of the 33 previous outbreaks of ebola, public health measures proved able to contain it; and that means essentially isolation of patients and their contacts.
Though unusually lethal, this is not a very contagious disease. Whereas each case of measles in an unvaccinated population can lead to 17 more, even in this epidemic each ebola case is resulting in less than two more. Get that number below one with a few simple, low-tech precautions, and you soon get ebola under control. Hence the failure of governments to order a vaccine.
The virus has now killed nearly three times as many people as in all previous outbreaks of ebola put together. That has another sinister implication. Ebola has now spent ten months jumping from one human being to another, outside its natural habitat of fruit-bat blood, much longer than it has ever lived in our species.
Natural selection means that it is bound to be getting better at spreading among people, not because it is becoming airborne (viruses very rarely change their mode of transmission) but perhaps because it will find ways to become infectious before its victim becomes seriously ill. At present, ebola victims are unusual in that they do not spread the virus till they are really quite ill, and corpses are especially infectious. That is why healthcare workers are so at risk. If ebola evolves lower virulence, it may become endemic, like HIV and malaria.
Having terrified myself with such thoughts, I can also reassure myself by reciting the numbers that are going in the right direction and that suggests the ground war is still winnable. Liberia has increased its burial teams from six to 54. By mid-November the Americans should have installed 1,700 treatment beds in Liberia, and the British 700 in Sierra Leone, more than trebling the capacity of the two countries to treat cases.
That point is still a month away. There are far more cases than can be treated in treatment centres, which is why there is now a push to supply families with kits including gloves and disinfectant to treat cases at home. Hundreds of thousands of such kits are now being distributed. These may not save many lives of those already infected but if they can lower the infection rate from live victims, and better equipped burial teams can lower the infection rate from dead bodies, then it should be possible to slow and then halt the spread of the virus.
Because we neglected to develop a vaccine when we had time, beds on the ground will have to win this war, not high technology or medical science.
Science can only be the back-up plan if the disease takes root.
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