Tracking and Tackling Ebola

Summary

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More or Less: Tracking and Tackling Ebola

BBC Radio 4 | First broadcast: November 8, 2014
Host: Tim Harford
Guest: Hans Rosling (Professor of International Health, Karolinska Institute; Chair, Gapminder Foundation)

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Episode Overview

In this episode, Tim Harford speaks with acclaimed statistician and health expert Hans Rosling, who had recently returned from Liberia amidst the Ebola outbreak. The discussion centers on understanding Ebola statistics—how they should be interpreted, the realities behind the numbers, and the broader impact on Liberia's society, healthcare, and resilience.

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Key Discussion Points and Insights

1. Current State of Ebola in Liberia ([00:19] - [02:08])

• Second Phase of the Epidemic:
  Rosling describes the outbreak's trajectory in Liberia—after peaking in Monrovia (the capital) in August and September, daily new cases have decreased but plateaued at 20–25 per day.
• Endemic vs. Epidemic:
  "So this is not a simplistic epidemic that goes up and then goes down and disappear, but it's all over the country... We are fighting a low intensity epidemic." ([01:29], Hans Rosling)
• Geographic Spread:
  All 15 Liberian counties had reported cases recently; local outbreaks "flare up" in different areas.

2. Understanding the Reproductive Number ([02:08] - [04:25])

• Definition and Significance:
  The reproductive number (R) had dropped from nearly 2 ("one infected person on average infected two others") to about 1, indicating stabilizing transmission rates.
  "It meant that the disease doubled in one month ... 1, 2, 4, 8, 16, 32, 64, 128. That is the danger with this doubling." ([02:34], Hans Rosling)
• Cluster Outbreaks & Quarantine:
  Transmission often spikes after funerals. Local populations adopted quarantine practices proactively:
  “In the village, when one family is infected, they would make a ring around that house in the ground ... People themselves understand what quarantine is.” ([03:08], Hans Rosling)
• Challenge of the Second Phase:
  Isolated cases are harder to catch; "To take it from the peak down to low, that was easier than take it from low to nothing." ([04:12], Hans Rosling)

3. Impact on the Healthcare System ([04:25] - [05:24])

• Healthcare Worker Adaptation:
  Initially, there was a shortage of international support; local doctors created their own treatment centers, collaborating with Ugandan colleagues.
• International Cooperation:
  "I'm sitting at the planning meeting and I have one U.S. general on one side and the Chinese general on the other ... and on the opposite side of the table sits a health professional from Cuba. And we all work very nicely together." ([04:59], Hans Rosling)
• Local Resilience and Capacity:
  Rosling highlights the rise of a "new Africa" that confronts crises together with international partners.

4. Critique of Media Reporting ([05:24] - [06:19])

• Cumulative Numbers vs. Daily Cases:
  Rosling criticizes media focus on ever-rising cumulative case counts, advocating instead for daily new cases as a better measure of the epidemic’s trajectory:
  "Media just want as many zeros as possible... The important thing is that it was 28 yesterday and we had to follow cases per day." ([05:49], Hans Rosling)
• Example:
  Lofa county had 365 total cases but recently recorded zero new daily cases—an optimistic sign.

5. Gender Breakdown of Cases ([06:19] - [06:55])

• Roles Balance Exposure:
  Infection rates among men and women are "surprisingly similar"; differences in funeral and caregiving roles result in balanced transmission risk:
  "It's the women who would care for the sick one, but it's the men who would dig the grave ... it's sort of evened out." ([06:44], Hans Rosling)

6. Long-term Lessons and Liberia’s Recovery ([06:55] - [08:16])

• Recovery and Resilience:
  Child mortality rate had dramatically improved in the decade since Liberia's civil war (from 25% to 8%) before Ebola.
• Liberian Capability:
  "They are up to international standards and no one left the country on those crucial positions ... they have only one determination. It's not to get a poor country without Ebola. They want to develop their country to be a wealthy and good country in the future." ([07:35], Hans Rosling)
• Empowerment Through Crisis:
  Rosling argues that resilience and professionalism shown during Ebola can strengthen the country's future development.

7. Indirect Health Impact ([08:16] - [08:37])

• Collateral Damage:
  More deaths likely occurred from interrupted services for malaria and childbirth than from Ebola itself:
  "There were more people who died from the lack of health service in malaria and conditions related to childbirth than that died Ebola, but that was inevitable during the crisis." ([08:24], Hans Rosling)

8. Timeline and Outlook ([08:37] - [08:50])

• Looking Ahead:
  “We only know one thing, we are going to win. We are talking about months. We have to finish it before a year. So I told my grandkids I won’t be home for Christmas.” ([08:40], Hans Rosling)

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Notable Quotes and Memorable Moments

• On the Challenge of Epidemics:
  “This is not a simplistic epidemic that goes up and then goes down and disappear, but it's all over the country ... we are fighting a low intensity epidemic.” ([01:29], Hans Rosling)

• On Quarantine: “People themselves understand what quarantine is.” ([03:08], Hans Rosling)

• On Media Reporting:
  “Media just want as many zeros as possible... The important thing is that it was 28 yesterday and we had to follow cases per day.” ([05:49], Hans Rosling)

• On Liberia’s Progress:
  “The child mortality during the war was almost 250 per 1,000. That means one child in four was dying. Just before the Ebola epidemic, it was down to 8%...” ([07:17], Hans Rosling)

• On International Cooperation:
  “I’m sitting at the planning meeting and I have one U.S. general on one side and the Chinese general on the other side. And on the opposite side of the table sits a health professional from Cuba. And we all work very nicely together.” ([04:59], Hans Rosling)

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Important Segment Timestamps

• [00:19] – Introduction to Hans Rosling and overview of Ebola numbers
• [02:08] – Explanation of the reproductive number
• [04:25] – Effects on local healthcare systems
• [05:24] – Discussion on cumulative versus daily reporting
• [06:19] – Gender breakdown of Ebola cases
• [06:55] – Lessons for Liberia and broader resilience
• [08:16] – Health system strain and indirect deaths
• [08:37] – Forecasting the end of the epidemic

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Conclusion

Rosling’s message blends realism about the challenges of controlling Ebola with optimism about Liberia’s resilience and international solidarity. He urges a focus on meaningful statistics, recognizes the courage of healthcare workers and the general population, and foresees eventual victory—though not without more months of hard effort.

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Transcript

[Hans Rosling]

This is the short edition of More

[Tim Harford]

or Less first broadcast on the BBC World Service.

[BBC Announcer]

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[Tim Harford]

hello, this is More or Less on the BBC World Service and I'm Tim Harford. This week I was fortunate enough to speak to Hans Rosling. Hans is professor of International Health at the Karolinska Institute of in Sweden. He's also the co founder and chairman of the Gapminder foundation, which tries to make sense of the world's data. A couple of weeks ago, Hans flew to Liberia to join the fight against Ebola. I started by asking him what the numbers are currently telling us about Ebola in Liberia.

[Hans Rosling]

It's very clear that we are now in a second phase. Ebola in Liberia started coming over the border into Lofa County. Then it moved down during the summer and hit the capital Monrovia really badly in August and September. But now the numbers in the capital is down. But it's down from 75 a day down to around 25 a day or 20 a day. But now it has stopped. It is no longer falling. It is at an intermediate level. And over the last, let's say, seven, eight days, we record exactly the same number of newly infected people per day. So this is not a simplistic epidemic that goes up and then goes down and disappear, but it's all over the country. All of the 15 counties have had cases over the last weeks. And this means that we are fighting a low intensity epidemic, or endemic disease as we used to call them, because it's going on with almost the same amount of people in country every week. But it flares up in one of the counties and then it's controlled there and then it jumps up at another place. This will take time to get rid of.

[Tim Harford]

Just talk me through, please, this slightly technical term, the reproductive number. I understand that the reproductive number has come down to one. Is that true? And what does it mean?

[Hans Rosling]

When it was at its peak, it was almost two. That means one infected person on average infected two others. That doesn't sound so dangerous. But since the period of transmission from one getting infected to them getting sick and then infecting others, that's about three weeks. So it meant that the disease doubled in one month and then it goes from 1, 2, 4, 8, 16, 32, 64, 128. That is the danger with this doubling in each passage of, of the virus through humans. Now, on average, one person infect one other. Of course, there are like five, 10 cases that doesn't infect anyone because there's such a lot of precaution taken by people and the health service. But then every now and then there is one remote funeral and then five to six get infected. So we see these clusters of outbreak and the task is to catch them as early as possible. Before neighbors had got infected. So we really need to have a good assistance for people. People understand this themselves. So in the village, when one family is infected, they would make a ring around that house in the ground and say, you don't go over this line. We don't step over the line. Here's the water, here's the food. You need people on themselves understand what quarantine is. So a lot of this success in the first phase was won by the population themselves. And second phase, that's more scary because it will be a case here and a case there. Just yesterday we had two who came back from a funeral back in their home village in another county, you know, and it turned out it was Ebola, but it had been an old person who died in a way which you would thought was this way that old people pass away. So it's more difficult to stop it now when it's at the low level than when it was at the peak. To take it from the peak down to low, that was easier than take it from low to nothing.

[Tim Harford]

What impact is this having on the health care systems and what's it doing to the hospitals, to the clinics?

[Hans Rosling]

Nurses in this country, doctors, medical assistants, they had to be very careful treating patients. But what they did when the international community was late in providing additional Ebola treatment centers, the medicines on frontier were here. They were not enough. Then the doctors from here started their own treatment center, who together with Ugandan specialists, they started their treatment. So to me, what I have seen here is the new Africa. I've seen an Africa that stands the test together with its partner. UN is here. They are really good here. It's quite an experience to be here because I'm sitting at the planning meeting and I have one U.S. general on one side and the Chinese general on the other side. And. And on the opposite side of the table sits a health professional from Cuba. And we all work very nicely together.

[Tim Harford]

Now. The situation's clearly improving, but of course the cumulative numbers keep going up. I mean, cumulative numbers clearly don't go down. And the media here, including the BBC, they keep reporting these cumulative numbers which keep going up. Is that a helpful way to explain how the epidemic is progressing.

[Hans Rosling]

No, it's a bad habit of media. Media just want as many zeros as possible, you know, so they would. They would prefer then to tell that in Liberia we'd have about 2,700 cases or 3,000 cases. The important thing is that it was 28 yesterday and we had to follow cases per day. I can take Lofa province, for instance, that have had 365 cases cumulative. And the last week it was.0000 every day. That's really, you know, hopeful that we can see the first effect is where we now have very low numbers because everyone is aware.

[Tim Harford]

Now we've had an email from a listener in Zambia who asked about the gender breakdown, whether we know anything about whether men or women have been most affected by the Ebola virus. Is that something that you know anything about?

[Hans Rosling]

It's surprisingly similar. And my interpretation is that it's the women who would care for the sick one, but it's the men who would dig the grave and take care of the body for the funeral. So in the process of a dear family member dying, women have one role and men have another role, and it's sort of evened out.

[Tim Harford]

You've given us a mixed message, Hans. You've told us about the danger, about the tragedy, but also about the courage and the way people have been working together and the way that this disease is being slowly got under control. When this is all over, what are the long term lessons?

[Hans Rosling]

What I have been showing in the data from Liberia is how well the country did the 10 years before this from the civil war. The child mortality during the war was almost 250 per 1,000. That means one child in four was dying. Just before the Ebola epidemic, it was down to 8%, from 25% to 8%. So the country was in many ways doing well. And what I've seen here on the quality of the highly educated and capable Liberians, they are up to international standards and no one left the country on those crucial positions. And they have only one determination. It's not to get a poor country without Ebola. They want to develop their country to be a wealthy and good country in the future. And that determination you can see, and I think country can in a certain way gain strength of having gone through this process and see that they did it. Because when you are on ground, you see that it's mainly the population and the professionals here in the country that won the battle in the first phase.

[Tim Harford]

The doctors and the nurses in Liberia are clearly in tremendous danger. What impact is this having on them.

[Hans Rosling]

We know from estimates that there were more people who died from the lack of health service in malaria and conditions related to childbirth than that died Ebola, but that was inevitable during the crisis.

[Tim Harford]

When do you think this will be finished?

[Hans Rosling]

We only know one thing, we are going to win. We are talking about months. We have to finish it before a year. So I told my grandkids I won't be home for Christmas.

[Tim Harford]

Hans Rosling, thank you very much. I'm afraid that's all we've got time for this week. If you have any numbers you want investigating, please email us at More or lessbc Co. You can also listen to other editions of More or Less exploring subjects from the chances of someone running a sub two hour marathon to whether the UK is really poorer than most of the states in America. That's all on our website, bbcworldservice.com more or less

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