The Ebola Outbreak: The Need For U.S. Action

Biologics Are Not Natural Monopolies

On September 21, 2019, the World Health Organization (WHO) posted a worrying statement: the Ebola outbreak that has been simmering in the Democratic Republic of the Congo (DRC) for the past year may have spread to Tanzania.  Despite unofficial reports of three suspected cases, Tanzanian authorities insist that there have been no confirmed cases of Ebola in their country but have not yet agreed to confirmation testing at a WHO lab, leaving global health officials concerned.

There may or may not be Ebola in Tanzania. But in some ways, that’s not the most important takeaway from the latest development. This news alert is a symbol of a much deeper concern: the DRC outbreak is in a tinderbox, and the entire surrounding region could easily go up in flames.

The second-largest Ebola outbreak in history has received far too little attention, despite the major threat it poses both regionally and globally. Since it begin in August 2018, over 3,000 people have become infected and over 2,000 have died.  Although the outbreak has been largely contained within the borders of the DRC, a few cases have shown up in Uganda as well.  And the outbreak is happening in a border region, where travel from country to country is a natural part of daily life. While the disease remains reasonably localized, the lesson of the Ebola outbreak that occurred in Liberia and other Western African nations in 2014 – that an outbreak anywhere can quickly become global – applies here. Just as it took U.S. leadership to bring the 2014 outbreak under control, it will likely take U.S. leadership again to bring this outbreak in the DRC to a close.

Important Progress Since 2014

There are several important differences between the current Ebola outbreak in the DRC and the West African outbreak of 2014. First, unlike the impacted countries in West Africa, the DRC has previous experience with Ebola. Doctors and health officials have handled this before, and they have more established protocols in place for treating infected patients, managing the appropriate services, and educating the public.

Second, WHO’s response is far more effective now than it was in 2014. WHO seems to have learned important lessons – it has been deeply engaged on the front lines, supporting the DRC Ministry of Health, and transparently sharing data and its approach with the global public. WHO recently labeled the outbreak as a Public Health Emergency of International Concern (PHEIC), a legal term that allows for a more concerted international response, including bolstering of funds needed to fight the outbreak. There have only been four PHEIC declarations in history, so such a declaration usually signals a particularly dangerous outbreak that requires a global response.

Finally, since the 2014 outbreak, two new vaccines have been developed that have been instrumental to containing the spread of the virus. The Merck vaccine has been widely deployed by WHO in an effort to halt the further spread of Ebola according to a widely used strategy known as “ring vaccination,” which involves vaccinating all those who potentially have had contact with an infected person and all the contacts of those people as well. The Merck vaccine has near 100 percent efficacy, having been tested in a large clinical trial (although it has not yet been licensed). The second vaccine, developed by Johnson and Johnson (J&J), is being tested among those who are not at immediate risk.

While the J&J vaccine is also expected to be highly effective (based on immune responses in early phases of the testing), we still lack the data from large-scale human trials to determine that for sure. Indeed, it takes using these vaccines during outbreaks to understand their true efficacy, and this outbreak will provide an opportunity to better learn how well the J&J vaccine works. 

In addition to the vaccines, two new immunologic therapies, both antibodies, have been found to be highly effective in reducing mortality from Ebola, giving health authorities even more tools that they were lacking in the West African outbreak.

The Outbreak In the War Zone

Despite this progress, the risk of spread is still substantial and widely underestimated, especially by policymakers outside of Africa. This outbreak is happening in a war zone, which has led to attacks on health workers and clinics, like the ones that caused Doctors Without Borders to shut down its treatment centers earlier this year.  The violence, especially when it targets health care workers, has made it far more difficult to track down contacts of cases, care for people who are sick, and provide the public with basic preventive services.

The conflict has also caused substantial population displacement and migration, increasing the risk that the virus migrates. And the ongoing violence has contributed to a tenuous relationship between the DRC government and its people, undermining the trust critical to effective emergency response.

The Role Of U.S. Leadership

In 2014, President Obama worked closely with Congress to allocate $6 billion in emergency aid – and, just as importantly, engage the full force of the U.S. military to tackle the epidemic. Although the 2014 outbreak was much larger, the Trump Administration’s current response is inadequate for the size of the problem. While the U.S. is sending some health personnel, they are being kept far from the front lines of the outbreak. And there are mixed signals coming from the Administration. While USAID, for instance, just pledged more money to support the response to the current outbreak, the White House continues to propose budget cuts that would weaken funding for infectious diseases and global health systems.

It is reasonable to worry that it will take another case of Ebola within our country to galvanize more public support, but waiting for that to happen would be the wrong approach. In our hyperconnected world, the best way to protect the American people is to build health and security for all. An ongoing outbreak, in addition to the suffering it will cause the people of the DRC, creates an ongoing risk for spread. It takes just one case of someone from the infected zone who ends up in a major city to spread Ebola around the globe.

Bringing The DRC Outbreak To An End

Given these concerns, what should the international community do to bring this outbreak to a close? First, all countries need to bolster their support for WHO’s efforts. To date, the international response has been good, but it needs to be more robust: WHO estimates that it needs $287.9 million in funding to support the outbreak response efforts from July through December 2019. So far, they have received only $54 million, with more pledged. This is inadequate for the size of the crisis.

Second, the U.S. needs to enlist a more muscular response. While the American military probably cannot play the same role it did in Liberia because we don’t have the same, longstanding closeness with DRC that we did with Liberia – and given the need to build trust with communities, the use of the military should always be a last resort. However, U.S. leadership is critical to ensuring that health care workers on the front lines are protected. Whether that protection comes through enlisting a United Nations force, or an African Union force (both of which might have more legitimacy), or through the creation of a global health response corps (as the Centers for Strategic and International Studies calls for), U.S. support for a security response is necessary.  We also need to allow more of our personnel closer to the front lines.

Finally, on-the-ground efforts are needed to facilitate more trust in a community whose history of colonialism and exploitation has led them to distrust Westerners. In a country where 36 percent of the population believe that Ebola was fabricated to undermine stability, tackling mistrust is a vital part of any solution.

This Ebola outbreak in the DRC, despite leading to the deaths of more than 2,000 people, has not received the global attention it deserves.  The new vaccines and treatments are helpful, and the robust response by WHO has been heartening, but it is not enough. We may soon get confirmation of Ebola in Tanzania—or it may turn out to be something else. Either way, as long as the outbreak continues, the risk of spread is real, whether that spread is regional or global. In a highly globalized world, borders can’t keep diseases out.

It will take American leadership, working with our allies in Europe and Africa, to bring this disease to a close. One year and 2,000 deaths later, the time for more robust action is well overdue.

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