Editor’s note: Dr. William Foege is the physician-epidemiologist credited with devising the strategy that rid the world of smallpox, former head of the CDC (when AIDS first emerged) and, full disclosure, is also a good friend to Humanosphere. We asked him to offer perspective on all the finger-pointing attending the Ebola hysteria.
By Bill Foege
It is easier to be a critic than a participant or helpful observer.
That goes for me as well, but I am concerned that the straight-forward, science-based approach taken by public health officials to limit Ebola’s potential spread in this country has spawned such harsh criticism that the critics themselves may be a bigger risk to public safety than this virus.
It’s important to realize Ebola is a living creature. Control of infectious diseases is a continuous evolutionary contest between microorganisms and humans fighting for turf. Science inches ahead as it gains more understanding of those organisms, which often leads to new medications and vaccines. Then we may find those very organisms evolving in response.
Chloroquine was once a wonder drug against malaria and we could almost see the inevitable defeat of that enemy. But the parasite found how to resist and essentially sideline that drug. Antibiotics seemed ready to make some infectious diseases obsolete. But gonorrhea defied penicillin; staph overcame many antibiotics; and tuberculosis learned to live with multiple drugs. All these organisms are too small to have a brain. Yet they figured out how to beat us.
Vaccines are better than drugs, in general, because organisms don’t develop resistance. But even with these great tools, these organisms have co-opted some parents who refuse immunizations for their children. So measles and whooping cough are now able to rebound even in the face of great protective vaccines.
But humans are also ingenious. Working with the best information available, public health workers continue to change strategies. Smallpox workers evolved and suddenly a virus that had perfected its business plan for immortality was outflanked and it disappeared in a few years. Through a similar concerted global campaign, measles deaths have plummeted from over 3 million a year to less than 10 percent of that figure.
This same evolution is now occurring with Ebola. With the experience of 38 years and multiple outbreaks in Africa, the pattern seemed clear. Transmission between humans could be broken in fewer than five or 10 generations of the virus, a time frame of months. Humans would then remain free until the next transfer of the virus from bats to humans.
With another human case, the scenario would be repeated with intense human efforts to find cases, isolate them, treat them and avoid virus spread. Public health workers would find contacts, isolate them at the first sign of illness and help the community to dispose of the dead to stop viral transmission to others. Within months, the outbreak would cease.
But in 2014, the virus changed tactics and took advantage of a slow human response. The change in tactics led to a new phenomenon, spread of the virus to high population density areas. Control measures should have remained the same, mimicking the surveillance/containment strategies of smallpox eradication. But the greater volume of cases complicated isolation of patients.
The need to find, follow and refer for isolation large numbers of contacts overwhelmed an anemic public health response. Indeed, the need to find and follow all contacts of patients was not on the WHO “critical steps” list as late as October 2014. The result has been a disaster for West Africa. Half way measures are not sufficient and the public health community is now adapting and attempting to organize a large scale response.
Doctors Without Borders combined the experience of earlier outbreaks with the treatment of thousands of cases during this outbreak. They have done this under such difficult field conditions that it was assumed that most large hospitals in the United States could have done the same thing safely. That turned out not to be true and protocols quickly reflected this new information.
While the autonomy of state and local jurisdictions is a given in this country, the federal government has responded with assistance and personnel exceeding any previous investigation and control effort. Human evolution and response to unexpected problems will contain the virus in this country.
The screening of travelers is not simple and it is certainly not fool-proof. But again, public health recommendations have been tightened to improve the chances of finding people entering the country with the virus. Some of the same people critical of the public health approach seem very tolerant of politicians calling for a travel ban from affected countries or governors placing travelers in quarantine.
Past experience indicates that people are clever enough to travel to other countries first if they really want to come to this country. And they will hide their exposure to Ebola patients if it means being placed in quarantine. That simply increases our risk. There is no evidence that such quarantine would be better than finding contacts and taking their temperatures twice a day to detect the first evidence of illness.
When the governor of New York says he is instituting quarantine out of an abundance of caution, most can read the real reason as an “abundance of politics.”
Will there be more cases in the United States? The chances are high that some will get past the travel-filter and that we have not as yet seen every possible error in blocking transmission in this country. But with steady and solid decisions based on past experience and new findings, the response will stop every chain of transmission promptly.
In fact, the public health response in this country has been far better than we could have expected, given the cutbacks in the public health infrastructure of recent years made worse by the private care system sometimes making decisions based on cost or insurance status rather than health needs.
Time will make clear the value of the wisdom of the advice given by the CDC and state health authorities. The hard work of thousands of health workers is not helped by media-generated panic or illogical political decisions.
Finally, as worrisome as Ebola is, it pales next to 1,000 deaths a day due to tobacco, thanks to reluctant politicians over the decades, or to the more than 1,000 deaths a week due to infections patients did not have when they entered the hospital, or the staggering toll of guns and influenza.
If only we, as a country, could show as much ingenuity in responding to our major health problems as we show with our criticism of the public health workers laboring to make the world safer.
Bill Foege, while working as a medical missionary in Africa and on assignment for the CDC, came up with the strategy known as “ring containment,” which led to the eradication of smallpox. In 2012, President Obama honored Foege for his public health work with the Presidential Medal of Freedom. Foege is also on the board of directors for Humanosphere.