The conventional (smart) wisdom is that we should not panic about Ebola in the United States (or Europe). That is certainly true because, even with its huge warts, US and European health-care systems are well-equipped to handle the few cases of Ebola that might pop up.
However, we should panic. We should panic at the lack of care and concern we are showing about the epidemic where it is truly ravaging; we should panic at the lack of global foresight in not containing this epidemic, now, the only time it can be fully contained; and we should panic about what this reveals about how ineffective our global decision-making infrastructure has become. Containing Ebola is a no-brainer, and not that expensive. If we fail at this, when we know exactly what to do, how are we going to tackle the really complex problems we face?
Climate Change? Resource depletion? Other pandemics?
So, I have been panicking.
Pandemics have long been among my favorite topics to teach sociology with, not because the subject is cheery, but because they contain so many of the lessons about our modern world.
But this year, it feels like a lesson in despair, about everything that’s broken.
There are dozens of textbooks for introduction to sociology, but they all have a similar chapter order. Somehow, globalization always ends up around chapter seven, the middle of the semester, when the novelty of sociology as a topic has worn off, and the class starts to drag.
But chapter seven would always be a turning point in my class: that’s when many students would sit up and realize that this, more than anything, was their generation’s core problem.
We always started with pandemics: Ebola or the Flu.
Why should you care about the state of health care infrastructure, I’d ask, in Laos or in Gabon, besides the obvious: shared humanity?
Many would offer altruistic reasons: because we care. Of course, I’d say. Of course we should care. Of course. But, imagine you are trying to convince an uncaring organization, a bureaucracy, a self-interested power, people with money who do not want to part with their money, or people who simply don’t care?
Can you convince them they should care?
First, do you know what has killed more people than all of World War I at the end of World War I? Not the war itself. The Spanish Flu, the pandemic that swept the world thanks to increasing transportation technologies, the close quarters of barracks, and discharged soldiers who took it back to their communities.
I’d start with network theory, and our small world. In our increasingly connected world, every virus is but a hop or two away: almost all humans are close enough to someone who flies — maybe except the isolated tribes in the Amazon.
If some people fly, any virus can get to any country. In a historical experiment, social psychologist Stanley Milgram challenged people to send packages around the world only through personal contacts — it took about six hops for most packages to find their way home. (This inspired the famous play and movie “Six Degrees of Separation”, which later inspired the “Six Degrees of Kevin Bacon” game.) Today, this would likely be a smaller number because of “hubs” and bridges, people who connect otherwise disconnected clusters, have proliferated.
So, lesson number one: many divides separate us in the world, but we are all connected, very closely. It is truly a global village, of sorts. We are divided, but also united.
Viruses — which we can only vaccinate against and cannot cure like we can with bacterial infections and antibiotics — also thrive when they come across bridges: between the human and the animal host. Historically, the most dangerous viruses are ones that jump between animals, domesticated or not, and humans. The flu that jumps between poultry or swine, and humans; the filovirus that can survive in the fruit bat, but also jump to a person. Many such viruses thrive at poorer places, especially those where the original, rich ecoystem is intact. And it is poor people who will be the ones who bring their chickens into the hut in the winter, the only place with enough warmth to survive, or hunt in the bush for meat, because they can’t buy it in a supermarket.
Jumping hosts sharpens the skills of a virus to spread and kill more effectively— and few of us have immunity to such new viruses, especially those with heightened abilities.
Lesson number two: there are certainly hotspots for natural emergence of deadly pandemics, and many of them reside in the world’s poorest regions.
The final piece of the puzzle is how epidemics work. Epidemiologists talk of “r nought”, R0, the most basic epidemiological number. It is, simply put, the number of new infections each ill person generates. If it is less than 1, R0 < 1, the infection will tend to die out. Each ill person is not replaced by another ill person. Bigger than 1, every ill person infects multiple people, it will grow exponentially.
It’s like that game: put a single grain of rice into the first chess block. Double it in the next one: two grains of rice. Double it again: four grains. There are 64 blocks in a chess board. Once you go through all 64, you will have 18,446,744,073,709,551,616 grains of rice or about 636,094,623,231,363 pounds. As in trillions.
That’s how exponential math works. It gets big, very quickly.
The only way to stop this is to stop it very early. Otherwise, the avalanche becomes uncontainable.
Lesson three: exponential growth is powerful, and best countered very, very early.
By now, we are in the middle of the class of the middle of the lesson in the middle of the semester, the most dangerous time in terms of losing a student.
But I’d already see some of them start putting all this together, and sitting up.
There is no “r nought” independent of connectivity. The more connections, the more possibilities, the bigger this number.
Globalization, in essence, means we really are one big family, in sickness and in health.
The more connected we are, the easier it is for a virus to spread wide and deep, before we get a chance to contain it.
And that is partially why Ebola is now ravaging through three countries in West Africa: it broke through in cities and large-enough settlements, and due to an accumulation of reasons, including recent civil wars, at a time when they were least equipped to handle it.
Containing an outbreak requires circumscribing the outbreak (isolating and treating the ill, tracing their contacts, isolating and treating them as well) so that it can no longer find new hosts, and healing those who are ill, or mourning those who die. Circumscribing an outbreak is easier when the cases are a few, or a few dozen, or a few hundred.
In fact, we know from previous Ebola outbreaks which parameter brings down the dreaded transmission rate: “the rapid institution of control measures.” It’s that simple.
After thousands of cases, this gets harder and harder.
After millions, it is practically impossible.
That’s what is happening now, in Sierra Leone, and in Guinea, and Liberia. There are almost 10,000 cases in those three countries, and half of those people are already dead. In some places, the fatality rate is up to 70%.
On the other hand, Paul Farmer of Partners in Health, one of my favorite organizations in the world, who just returned from Monrovia, Liberia, estimates that 90% of those who receive proper hydration care should survive. The numbers could well work: of the seven people who were treated in the US, only one has died, and his treatment was delayed. Four are already out of the hospital, and two are reportedly doing well.
And crucially, as with all viruses, survivors of Ebola gain immunity, at least to this strain.
In fact, countries with even slightly better health-care, not at the US level, can control this epidemic by circumscribing it: On October 17th, WHO declared Senegal free of Ebola. Later, Nigeria, too, was declared free. Ebola, because of the speed with which it kills, and the short incubation period, is not that hard to contain if contained early — Ebola has a weakness as a virus: it doesn’t have too long to reproduce before it kills or is beaten by its victim, hence its “r nought” is not that high, compared with other viruses which take a longer time lying stealthily in the body. Ebola’s speed and deadliness, paradoxically, gives us an advantage for containing it—if we act early.
On the other hand, at the current level of meager, vastly under-resourced effort in the core countries, the WHO estimates 10,000 cases per week in just a few months. Cases in Liberia are still doubling every two weeks.
There could be a million cases, CDC estimates, by the end of 2014.
Let that sink in. A million Ebola victims in just a few months.
At that point, we end up with another endemic virus, similar to other ones that still survive like polio (so close to being wiped out but wars keep interfering), measles for which we have vaccines, and HIV and malaria (a parasite) for which we don’t have vaccines and which kill millions every year.
What I just summarized in fewer than 2,000 words or so isn’t even basic epidemiology. It is the basics of basics of basics of epidemiology, and this is something every policy maker on the planet should understand after talking for 10 minutes to an expert of their choice in their own country.
A few weeks ago, the United Nations Secretary general Ban Ki Moon asked for about $1 billion to contain this epidemic, in 2014, before it settled for good. (Travel restrictions work if the affected are small numbers, and will not work when we have millions of cases — a few will get out within the incubation period and remember — this disease does not just travel on dark-skinned people.)
Further, the longer we allow Ebola to experiment on us, the more dangerous it may get. A version with a slightly lower fatality rate along with a longer incubation period may be very, very hard to contain.
One billion dollars. About 1/16th of a WhatsApp. One blockbuster movie.
This is but a rounding error for the global economy. It is a meager amount needed, to forestall having to lose much, much, much more later.
And the United Nations reported that it had received about $100K deposited (you read that right) and only about $250 million were made in commitments, that may or may not arrive in time. (There are other sources of funds but the response is clearly, unequivocally inadequate. Liberia is lacking gloves and plastic buckets. The basics.).
Every day we let this pass as is, the harder it will be to eventually exterminate it — not to mention the unacceptable human misery. And cruelly, the disease is ravaging caregivers most, because as people become more sick, they shed more and more of the virus through their bodily fluids.
Ebola kills the most human of us, first, those who are unwilling to abandon the ill, the dying.
And there is so much to do, so so within our reach.
We can send massive amounts of protective equipment. Liberia doesn’t even have enough plastic gloves — they reportedly asked for 110,000 because they just have 2,100. When Centers for Disease Control first went to Liberia in August, when there were only a handful of cases, it found that the hospitals had no gloves. This situation should be unthinkable. Unfortunately, it’s not.
Survivors of the disease acquire immunity, at least to this strain, and there are thousands of them now in the most affected countries — poised to be hired and trained, with proper equipment, so that the newly infected can also be cared for properly, and hence also survive in much larger numbers. Many organizations, from Doctors Without Borders to Partners in Health, are very good at providing community based care, by hiring and training locals, so that epidemics can be contained and treated.
Letting Ebola take root would not just cause more deaths we can prevent, but also would require taking away resources in regions already stretched thin. The spikes in hunger and infant mortality are almost inevitable.
By the end of that sociology class, my first-year college students would all get this basic math, and the basic humanity. The course we must take is a no-brainer, from every point of view: a sense of humanity, and if you cannot be moved by that, by a sense of self-interest and rationality.
We have one chance to stop this awful disease in its tracks, this year.
In 2015, that option will be gone.
Mass media is too busy generating the wrong panic — the infinitesimal chances of Ebola in the US now, rather than how to roll it back it in West Africa.
The UN is reduced to begging and being ignored.
There is heroic NGO work. Partners in Health — which specializes in hiring and training locals — and Doctors Without Borders — experienced at moving resources quickly and operating at challenging environments — are both phenomenal organizations — and I’m donating to both what I can this year. I don’t really believe in framing “charity” as a solution at this scale, but I believe in solidarity. However, this should not come down to whether or not a few people donate — our collective institutions should collect and organize these resources, and direct this effort. While PIH and MSF can and will do a lot, this cannot be on their shoulders alone.
So I panic and despair, about what this lack of response says about us, our institutions, our humanity.
How can we make our institutions work, for us, at a global scale? That remains the core challenge of 21st century, without which we will fail at many more tests, at great suffering.