West Africa’s Ebola epidemic is a “Black Swan” event that is likely to severely alter how the world approaches future global public health crises — even more so than the AIDS epidemic has done — according to a commentary published Friday in JAMA Internal Medicine by Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP).
The commentary argues that more so than any other infectious disease, Ebola is threatening regional and country stability in West Africa, as well as exposing serious flaws — driven in large part by budget cuts — in the ability of the World Health Organization (WHO) to lead a coordinated and effective response.
The commentary is co-authored by Dr. Kristine Moore, CIDRAP’s medical director, and Lawrence Gostin of the O’Neill Institute for National and Global Health Law in Washington, D.C.
Sudden and extreme
The term “Black Swan” was coined in 2007 by risk analyst and scholar Nassim Nicholas Taleb to describe an event that occurs unexpectedly (“because nothing in the past can convincingly point to its possibility”), that has a major — indeed, extreme — impact, and that becomes explained after the fact with “concocted” rationalizations.
Osterholm and his commentary co-authors propose that the unfolding Ebola epidemic has all the makings of such an event, although with one exception — “the global public health community will be working to contain it for months, or years, to come.”
They also say that because of its “Black Swan” characteristics, the Ebola epidemic offers two major lessons that should change the way all of us think about the global threats and potential effects of infectious diseases.
Lesson No. 1: “There is now clear evidence that an infectious disease such as Ebola virus disease can threaten the stability of a country’s or region’s government, economy, and social fabric,” Osterholm and his colleagues write. “Although other infectious diseases, including AIDS, malaria, tuberculosis, childhood diseases that are preventable by vaccine, and diarrheal illness, have killed more people in Liberia, Sierra Leone, and Guinea during the past year than Ebola virus disease has killed to date, those diseases have not destabilized the region. This is another painful lesson that what kills us may be very different from what frighten us or substantially affects our social system.”
The Ebola epidemic thus suggests that the urgency with which we develop vaccines for an infectious disease should not necessarily be driven by past experiences with the disease.
“An essential characteristic of a Black Swan event is the inappropriate rationalization after the fact with the benefit of hindsight,” the commentary’s authors explain. “Researchers and public health officials should have and could have imagined what a virus such as Ebola that is transmitted through direct contact could do once it infected people outside of sparsely populated rural Africa and found its way into the crowded and impoverished neighborhoods of large African cities. The lesson to be learned is that more creative imagination is needed in considering future infectious disease scenarios and in planning accordingly.”
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Lesson No. 2: The world has relied on WHO “to lead and coordinate the international response to infectious disease outbreaks of global importance,” but so far, due primarily to budget and staff cuts, the organization “has not been able to mobilize sufficient funding to implement the response plan” that its own “Ebola Response Roadmap” has called for, write Osterholm and his commentary co-authors.
“We are concerned, that, without fundamental reform, the WHO will no longer [be] able to fulfill the mandate in its constitution to be the leading, coordinating agency for global health, even though the organization may have a strong desire to do so,” they add. “If its member states were to ensure adequate funding and authority, it could become, once again, the leading global health agency — and it should.”
‘Microbes can humble us’
“Before the West Africa Ebola epidemic,” Osterholm and his co-authors conclude, “most people in the United States had never heard of the virus, and if they had, considered it to be the cause of an obscure disease that lurked in the remote forests of a faraway continent. Almost no one would have predicted that physicians in the United States would be caring for patients with Ebola virus disease, that college campuses would be wrestling with matriculation policies for international students because of concerns about importing the virus, or that US troops would be sent to West Africa.”
“Once again,” they add, “we are reminded that microbes can humble us and that we should constantly work to improve out ability to detect, predict, and response to the Black Swan events that they may cause.”
You can read the commentary in full on the JAMA Internal Medicine website.
What role the NGO’s?
Why was the WHO defunded? One reason has been the celebration of Non Governmental Organizations over the last 15 years. There was a collectively stupid decision made amongst planners that governments and international organizations funded and supported by governments were irrelevant. NGO’s so went the story were products of private sector innovation and efficiency and would replace clunky government and international Dinosaurs. Shinny new entrepreneurial ventures would leapfrog clumsy existing bureaucracies and get er done!
Well, look at Haiti today… almost five years after the earthquake. Haiti was the first grand experiment on large scale NGO intervention and it’s still a mess. One of my favorite photo’s from Haiti is a hand written sign next to a tarp strung over some scrap wood that reads: “Two years since the earthquake and I’m still living in a tent. F*&k you NGO’s”
Osterholm (and others) have known and have been telling us that we needed to strengthen our public health systems in order to recognize outbreaks (regardless of the pathogen) and contain them quickly. We KNOW that governments are the best organizations to provide that guidance and coordination, yet we cut funding and when Ebola breaks out of the rural areas of Africa (a scenario that has been imagined actually) we’re stuck responding with a hodgepodge of weak, uncoordinated and disorganized governments with inadequate infrastructure, and dribs and drabs from international organizations that don’t have the resources. The SARS affair was supposed to leave us with a robust and well coordinated international system. Instead we sat back and assumed that the magic market of well meaning innovators and entrepreneurs would manifest any response we needed without government meddling. Ooops.
I don’t see anything going on here that wasn’t foreseen. The possibility of a spooky pathogen emerging from the jungles and hinterlands of various places and getting established in urban areas; and then spreading worldwide has been a staple of pandemic discourse for decades. Hollywood even made a movie about Ebola. Likewise the fact that epidemics and pandemics can destabilize societies and governments isn’t a recent insight especially when an outbreak happens in already destabilized regions like these areas. Maybe some people thought these areas were more stable than actually were? Nigeria for instance can look stable from a certain distance.
I think what’s taken clinicians and epidemiologists by surprise with this Ebola outbreak is how incredibly contagious this pathogen is given the fact that it’s NOT an airborne pathogen. On a basic level it looks like the protocol for direct contact pathogens has simply been inadequate, the protocols aren’t stopping transmission for some reason even in well equipped health care settings.
I’m not the doctor of the world or anything but I think it’s time to consider the possibility that this thing isn’t going to be contained in Africa, it’s just going to have to burn out. What does that scenario look like, and how does the rest of the world cope with it?
Two other lessons
1) “American exceptionalism” obviously does not extend to the biological realm. Wealth can insulate us to some degree, but only to some degree;
2) No further reminder ought to be necessary that human beings, despite occasional delusions to the contrary, are animals, and subject to the same kinds of biologically-inspired traumas as are other creatures with whom we share the planet.
Foolish
A worldwide outbreak of disease from some unknown corner of the world isn’t unprecedented. Even if we ignore HIV (not coincidentally, originating from almost the exact same location as Ebola), every flu epidemic started somewhere. The difference is that we’ve forgotten what a quick-killing pandemic looks like (again, we’re ignoring HIV–like we usually do). We live cushy lives where we can decide not to vaccinate our kids because of a very real, but ill-understood, bogey man that almost exclusively occurs in relatively wealthy populations, and keep ourselves so clean that our own bodies misbehave just to get a little action. In the grand scheme of things, we’ll find that the “escape” of Ebola from West Africa was entirely preventable. It will probably amount to very little on this side of the ocean aside from inciting a panic.
It’s not just the UN/NGO/third world
(quote)
“NIH has been working on Ebola vaccines since 2001. It’s not like we suddenly woke up and thought, ‘Oh my gosh, we should have something ready here,'” Collins told The Huffington Post on Friday. “Frankly, if we had not gone through our 10-year slide in research support, we probably would have had a vaccine in time for this that would’ve gone through clinical trials and would have been ready.”
It’s not just the production of a vaccine that has been hampered by money shortfalls. Collins also said that some therapeutics to fight Ebola “were on a slower track than would’ve been ideal, or that would have happened if we had been on a stable research support trajectory.”
“We would have been a year or two ahead of where we are, which would have made all the difference,” he said.
Speaking from NIH’s headquarters in Bethesda, Maryland, the typically upbeat Collins was somber when discussing efforts to control the Ebola epidemic. His days are now spent almost exclusively on the disease. But even after months of painstaking work, a breakthrough doesn’t seem on the immediate horizon.
Money, or rather the lack of it, is a big part of the problem. NIH’s purchasing power is down 23 percent from what it was a decade ago, and its budget has remained almost static. In fiscal year 2004, the agency’s budget was $28.03 billion. In FY 2013, it was $29.31 billion — barely a change, even before adjusting for inflation. The situation is even more pronounced at the National Institute of Allergy and Infectious Diseases, a subdivision of NIH, where the budget has fallen from $4.30 billion in FY 2004 to $4.25 billion in FY 2013.
The growing severity of the Ebola crisis in West Africa and the fear of an outbreak in America haven’t loosened the purse strings. NIH has not received any additional money. Instead, Collins and others have had to “take dollars that would’ve gone to something else” — such as a universal influenza vaccine — “and redirect them to this.”
Collins said he’d like Congress to pass emergency supplemental appropriations to help with the work. But, he added, “nobody seems enthusiastic about that.”
(end quote)
Bringing the “thrid:”NIH has been working on Ebola vaccines since 2001. It’s not like we suddenly woke up and thought, ‘Oh my gosh, we should have something ready here,'” Collins told The Huffington Post on Friday. “Frankly, if we had not gone through our 10-year slide in research support, we probably would have had a vaccine in time for this that would’ve gone through clinical trials and would have been ready.”
It’s not just the production of a vaccine that has been hampered by money shortfalls. Collins also said that some therapeutics to fight Ebola “were on a slower track than would’ve been ideal, or that would have happened if we had been on a stable research support trajectory.”
“We would have been a year or two ahead of where we are, which would have made all the difference,” he said.
Speaking from NIH’s headquarters in Bethesda, Maryland, the typically upbeat Collins was somber when discussing efforts to control the Ebola epidemic. His days are now spent almost exclusively on the disease. But even after months of painstaking work, a breakthrough doesn’t seem on the immediate horizon.
Money, or rather the lack of it, is a big part of the problem. NIH’s purchasing power is down 23 percent from what it was a decade ago, and its budget has remained almost static. In fiscal year 2004, the agency’s budget was $28.03 billion. In FY 2013, it was $29.31 billion — barely a change, even before adjusting for inflation. The situation is even more pronounced at the National Institute of Allergy and Infectious Diseases, a subdivision of NIH, where the budget has fallen from $4.30 billion in FY 2004 to $4.25 billion in FY 2013. (Story continues below.)
francis collins
The growing severity of the Ebola crisis in West Africa and the fear of an outbreak in America haven’t loosened the purse strings. NIH has not received any additional money. Instead, Collins and others have had to “take dollars that would’ve gone to something else” — such as a universal influenza vaccine — “and redirect them to this.”
Collins said he’d like Congress to pass emergency supplemental appropriations to help with the work. But, he added, “nobody seems enthusiastic about that.”
Several Democratic lawmakers have in fact introduced legislation that would increase NIH funds to $46.2 billion in 2021. But there is no indication that such a bill will move forward any time soon.
http://www.huffingtonpost.com/2014/10/12/ebola-vaccine_n_5974148.html
(end quote)
We’ve been gambling and medical people shouldn’t be surprised with the results.
What about Oserholm and his warnings on increased antibiotic resistant bacteria?
That will come home straight to the US with its overuse of antibiotics.
Excellent point Mr. Rovick!
Absolutely, Mr. Rovick’s point regarding research money is hitting us on several fronts. For one thing, budget cuts for general science research have hampered our technological innovations and the budget cuts for medical research have meant that the private sector, pharmaceutical companies etc. pick up the slack and claim to have spent billions in research that they must recoup with high sale prices. When the private sector picks up the slack we lose general science and public access to research findings. We also lose the ability to direct research, when the private sector picks up the slack they spend their resources on tweaking a molecule here and there so they can claim to have a “new” cancer med or antihistamine.
On an even more wicked level it’s very difficult for researchers at universities to lodge complaints because they’re still applying for NIH and other government grants so complaining about the grant process is not a good career move.
I know a couple really bright and dedicated medical researchers that are about ready to throw in the towel because grant money is getting sooooo tight and unreliable. Research doesn’t necessarily have a finite objective, it’s exploration, you don’t want start exploring and then lose your grant after a year. We need more stability and reliability if we’re going to expect good scientist will launch into years of research.