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Unpacking WHO’s Shocking Ebola Maps–Mead Over
00:25:28
As the Ebola epidemic continued to spread in West Africa, with more than 3,000 cases and 1,500 deaths, I invited CGD senior fellow , a health economist and one of the world’s top experts on the economics of HIV/AIDS, to discuss newly...
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- [00:09]
A
Welcome to the Global Prosperity wonkcast. I'm Lawrence McDonald. With me in the studio today is Mead over. He's a senior fellow here at the center for Global Development, a health economist who's worked in particular on infectious diseases, primarily hiv. But our topic today is Ebola. Mead, welcome to the show.
- [00:27]
B
Nice to be here.
- [00:28]
A
Lawrence, you and I spent more than the usual amount of time preparing for this wonkast because the situation is changing so rapidly. And one of the things that you showed me is a new document tweeted out by the WHO World Health Organization within the last, I guess, 24 hours that contains two remarkable maps, one of the extent of spread of Ebola and the other of the availability of labs and treatment centers and other research responses. Let's talk, if we may, start with the map about spread. What struck you when you looked at that map? And I should say for those who are have access to the website, these maps will be posted there as well.
- [01:10]
B
These maps are very helpful to those of us who are trying to grasp what's happening in real time on the ground in West Africa. The map of the epidemic itself, of the reported cases, is very useful because it shows in black circles the total numbers of cases and exactly where they're located within the three countries, Sierra Leone, guinea and Liberia. And then the remarkable thing is that they also have circles representing the recent cases which have been reported in the last 21 days. And you'll note that most of the cases are recent, and that's an indication that this epidemic is growing very rapidly. The other thing to note is that the reported cases at least do not seem to be close to the border of the neighboring countries of Senegal or Guinea Bissau. But there are reported cases that are close to the border with Mali, and there are reported cases that are close to the border with Cote d'. Ivoire. So while this epidemic has been confined to these three countries primarily as we speak today, the governments of Cote d', Ivoire, Mali and Senegal and Guinea Bissau are all on the alert, as they should be. And there's really a need for all of those countries to strengthen their health infrastructures at their borders.
- [02:47]
A
Let's turn to the second map, the one of the availability of. I almost said treatment, but of course there is no treatment other than treating the symptoms. But there are blocks on this map for treatment centers, referring centers, laboratories, contact tracing, and they're shown in either green or which is functional, yellow, partially functional, and red non functional. What do we see when we look at those blocks?
- [03:20]
B
Well, first, this is exactly the kind of mapping that the governance themselves need to do. And so I congratulate WHO for producing an excellent model of a map at that three country sort of macro level. The. I think the impact that those maps have on me is that we've got a long ways to go. There is only about a dozen or so locations where they have even begun to think about placing treatment referral centers, laboratories, and starting to do contact tracing.
- [04:00]
A
You and I could just spot two green Ls. That would be functional. Laboratory.
- [04:04]
B
The laboratory is absolutely necessary. We. We only see two here. And yet the laboratory is required to confirm a diagnosis of Ebola. And since Ebola's symptoms in the initial stage are simply fever, and as we know, fever is constantly present among children throughout the world and also in Africa for entirely benign reasons. So the inability to confirm a diagnosis as Ebola is a tremendous handicap to the health center. It makes it harder for the physicians to protect themselves, physicians and nurses to protect themselves. It means that there's a need to quarantine people who don't need, who would not need to be quarantined. And since quarantining is extremely difficult, it's a hardship, obviously, for those quarantined. It calls for a great deal of manpower. The need for more laboratories is really urgent.
- [05:01]
A
Speaking of quarantines, we can see her on the map. Monrovia. Before the show, you and I were talking about the decision of President Ellen Johnson's relief to quarantine large, informal settlement West Point. From what we can tell on the map in Monrovia, there is no lab. Maybe there's one. Maybe the map's incomplete. But this would look to me like the best available information just put together by who. While the information is probably not perfect, it's looking pretty dire in terms of what's not available on the ground.
- [05:37]
B
That's right. I do think that the labs are key, and it's discouraging not to see on the map any labs in Monrovia. I find it difficult to believe that there aren't any. We know that the WHO is there. The center for Disease Control is there. There's been a recent interview with President Sirleaf conducted by Katie Couric that I saw on Yahoo, which is really, I thought, a very impressive performance by a national leader in the midst of crisis. And she clearly has access to information that's up to date and involves, would require laboratory confirmation. So the information she reported. So I have a feeling that this, even though it was published today, is probably already out of date. And in the process of being revised.
- [06:27]
A
So this shows, if nothing else, the fact that the information itself is often scarce and unreliable. I want to turn to a blog that you put up last week about lessons from the HIV epidemic. You've spent most of your career working on aids. They're both caused by viruses, of course. The AIDS virus has an incredibly long gestation period, as much as eight to 10 years, with no symptoms. Ebola is matter of days or weeks, I gather. What sort of lessons are there to draw between these two diseases?
- [06:59]
B
Well, the diseases do have similarities, as I suppose, to all epidemics. But remember that, as you point out, HIV requires eight to 10 years before one has symptoms. With HIV, the individual is infectious, especially during the first few weeks of infection. Infection, and then becomes infectious again after the 2,000 to 3,000 days have gone by. In the case of Ebola, the person is not infectious at all on the first day of their infection, but at the time they develop symptoms, including fever, then they become infectious. And that requires up to 21 days. So if you think about the comparison of over 2,000 days with 21 days, and Ebola is about 100 times as fast as HIV. And that's what makes it so scary. The fact that it's so fast means that in contrast to hiv, we don't have time to react. We don't have time to react emotionally, and we don't have time to react logistically. And especially fragile governments in West Africa are going to have tremendous difficulty. There is a lesson that I pointed out in my blog that comes from hiv, and that is that it's absolutely essential to protect health workers when you have an infectious disease which is not curable. In the beginning, of course, HIV was not treatable even, and Ebola today is not treatable. And in these situations, health workers are quite right to be frightened to go to work. Those that do go to work, and some of those in Monrovia, were highlighted in a New York Times article on the front page the other day that I tweeted. Those who do go to work are showing tremendous courage and they need all the support they can get. And in particular, they need protective gear. They need that protective gear. I'm pleased that USAID and who, among other donors, are now in the process of shipping tons and tons of protective gear to Africa. But when you look at this map that you and I were looking at here, Lawrence, you notice that there's a vast expanse here. There aren't very many roads. The infections taking place in lots of little villages which are not Even indicated on the map to have a treatment center of any sort. You made an interesting real need to get that stuff out there.
- [09:25]
A
You made an interesting point about the nature of the protective gear when we were selecting a photo to go with your blog, that the photos often show what you call Moonsotes. These total, you know, body armor, top to toe. That that may not be the most appropriate thing in some of these low resource settings. Why is that?
- [09:44]
B
Well, actually choosing the appropriate level of protection has been, I think, a challenge for who and I congratulate them on the document that they released about 10 days ago, which I blogged, because it did try to strike a middle ground between the moon suits that might be used in an American or a high resource setting with plenty of air conditioning. Yeah, when there's plenty of air conditioning and the individuals have the resources to spend on expensive suits. The other thing that moon suits require is extremely elaborate cleaning. There are nooks and crannies and these are reusable suits. In order to clean them, it's actually quite difficult. So who came down with recommendations which were less onerous than the moon suits.
- [10:37]
A
Also less expensive, Basically gloves and masks.
- [10:41]
B
That's right. But there's a sad story about a very prestigious doctor, prestigious young doctor, who actually recently died of Ebola, despite the fact that he was described by the staff of the major hospital in Monrovia as taking extreme precautions to protect himself. The explanation in that New York Times article was that he had trained to protect himself against the Marburg virus, which is another hemorrhagic fever virus, also very dangerous, but that Ebola is in fact more infectious than Marburg and of course much more infectious than hiv. So now the common the recommendation is that people should be double gloving and putting on protective shoes, also two layers and wearing not only a full body covering, but also an apron and goggles, etc. And the issue is whether these can be cleaned. The safest thing, of course, is to dispose of them by burning them. And that's what's being recommended in many cases. But of course, if each suit can only be used 2 or 3 hours in the hot 100 degree weather and then must be burned, the need for more replacement suits is all the more great. And really it's going to be a logistical challenge to get that equipment out there.
- [12:17]
A
We're going to take a short break. When we come back, I want to ask you about another WHO document that has come out within the last 48 hours, which is their roadmap in which they estimate that the disease could strike as many as 20,000. But they also say that the current number of reported cases, somewhere between 3,000 and 4,000, may be a significant underestimate. I want to ask you about what looks to me like a possible contradiction in their predictions. We'll be back in a moment. Welcome back to the Global Prosperity wonkast. I'm Lawrence MacDonald. My guest today is center for Global Development Senior Fellow Mead over. He's a world leading expert in the economics of infectious diseases. He's worked primarily on hiv, aids. But our topic today is the Ebola epidemic in West Africa. Mead, what do you think about the new WHO roadmap that's recently been released?
- [13:30]
B
Well, I congratulate WHO on putting this document together. Obviously they're doing so with only limited information. We talked before the break about how the information seems to be changing from day to day and even from hour to hour. I think they've done the right thing. They are. I particularly support WHO's recommendation that international community not quarantine the three most affected countries, Sierra Leone, guinea and Liberia, very badly need to have the flight schedules of international airlines continued. And they need that in order for the flow of international aid to continue. We need to figure out how to compensate the staff of the airlines to make and also to ask for volunteers because this is clearly going to be viewed by those, those pilots, those airline staff as dangerous, dangerous duty. But with the proper precautions, with the precautions that WHO has recommended for the clinicians, those airline staff can be protected. And without the international links, these countries are going to be extraordinarily handicapped.
- [14:53]
A
It's a question of flying in personnel and equipment and presumably also then enabling people to get out once they're there. But I imagine demand for travel to these countries, at least inbound demand, is going to be pretty weak.
- [15:06]
B
The inbound demand will be entirely, almost entirely driven, I would imagine, by the international response. So I hope it won't be weak because I'm very much hoping that volunteers will come forward, that people will be sufficiently courageous to go forward with WHO's recommendations and help the Liberians, the Sierra Leone people and the people of guinea to confront this disease.
- [15:36]
A
Should people be worried that if flights resume that infected people who are not yet symptomatic will get on the planes and then get off in Mumbai or Hong Kong or Shanghai or Los Angeles and suddenly we'll have Ebola outbreaks there?
- [15:53]
B
There has to be an international agreement that people who are coming out of these countries be quarantined. That's what I would recommend and that.
- [16:02]
A
The volunteers who quarantined with or without.
- [16:05]
B
Symptoms, even without, I would argue if they've been working with. If they're volunteers who have traveled to West Africa in order to help treat patients, I would argue that, yes, they should be quarantined for 21 days and that that should be part of the service understanding that volunteer organizations have when they recruit people to go and help in West Africa.
- [16:27]
A
So if I'm a volunteer and I'm willing to go in and risk my life and serve in helping to address the epidemic, then part of the understanding is when I come out, I will be quarantined, presumably at somebody else's expense and in a suitably comfortable situation, but I won't be able to just walk out of the airport.
- [16:45]
B
That's what I would recommend. And I think the international community needs to set up arrangements like this in order to help the affected countries.
- [16:53]
A
The who, if I remember correctly, had a short section on the financing of the response. I think it was in the neighborhood of half a billion dollars, maybe $400 million. Does that seem to you about appropriate? And is this something you think the donors are going to be willing to come forward with at this stage?
- [17:11]
B
I think that it's important that the funding for this not be a constraint. The $400 million is much more than countries have so far allocated, and therefore it's an ask, and it's a credible ask. To start with earlier, you alluded to the fact that WHO is making a very tentative projection that they might be able. That the three countries with WHO and international support might be able to control this epidemic within six to nine months.
- [17:48]
A
With 20,000 cases, right?
- [17:50]
B
With 20,000 cases. But of course, we know very little at this point. The epidemic curve is still accelerating. It has not even begun to reach its inflection point yet, as far as we can see.
- [18:03]
A
In fact, I think there was a difference because I also looked at the WHO roadmap itself and at the press coverage. I think the press seized on the 20,000 number, and for a casual reader, it seemed to say could be as high as 20,000. When you actually read the WHO roadmap, it says it could be as high as 20,000 if we respond appropriately and bring in equipment and quarantine and do all these things to address the epidemic. They didn't give a higher number, so the press couldn't use a higher number. But there's a big caveat there. The WH has shown we need to respond effectively. And what they're not saying Is. Or it could be way, way higher.
- [18:43]
B
It could be way, way higher, especially when that curve hasn't reached its inflection point yet. You know, an epidemic curve. Looking back retrospectively at the SARS epidemic, at the avian flu epidemic, and even now at the HIV epidemic, we see the epidemic curve looks like an S. It has a sigmoid shape, goes up.
- [19:03]
A
And then comes down.
- [19:05]
B
It actually accelerates at first. The curve gets steeper and steeper until it reaches an inflection point, at which point it begins to decelerate and finally flattens out. And that would be the curve of cumulative cases. So the thing that we have to be aware of, and that who is all too aware of, is that that curve is still accelerating. We have not yet seen it reach the inflection point. And when it does do so, then we can start to predict with somewhat more confidence how big the total cumulative impact will be.
- [19:37]
A
I want to turn last to economic impact. This is something you worked on a lot as a macroeconomist on hiv. There were a lot of predictions about very widespread economic impact. I don't know if it's possible in hindsight to know. Some parts of Africa have done rather well despite having serious epidemics. To put it in perspective back of the envelope, there have been about 1300 confirmed deaths from Ebola, annual deaths from malaria, about 400,000 in Africa, and HIV about three times that level at 1.2 million. So there's a very high level of disease in Africa. These are all contagious diseases. Would it be appropriate to say, gee, in the grand scheme of things, with 1.2 million HIV deaths and 400 million malaria deaths, the concern about Ebola is way, way out of perspective, and it's just a panic. Is that what we should conclude?
- [20:39]
B
So if you hadn't added that very last phrase, Lawrence, I would have agreed with you. But first of all, let's go back and think about hiv. HIV is a very, very slow epidemic. As we said before, it did in fact have the effects, some of the same effects we see in Ebola. For example, health workers were afraid to go to work, for example. There was stigmatization of people who were thought to be HIV infected, and there was some economic impact due to those things. But because the cultures of West Africa saw this epidemic unfold so slowly and so many people with HIV continued to be healthy for 8, 10 years, 12 years before getting sick, continued to be productive, continued to contribute to their communities, to parent their children, I would say that the economic impact was rather small. The Impact came primarily from the fact that when people did become sick, they needed to be treated and they were withdrawn from the labor supply. And also there was a very dominant feature of the HIV epidemic, which was that it killed prime age adults, many of whom were parents, and left many orphans behind. So those things really, we don't see the same thing going on in Ebola. Ebola is much more like these very rapid epidemics like avian flu and SARS that we've seen more recently, where it's really the panic that is the economic impact. In the case of the SARS epidemic, the total economic impact due to trade disruption, et cetera, was estimated to be about $40 billion. But there were only 800 deaths. So that's about $50 million of impact per death from the SARS epidemic. But almost all of it, all but a tiny fraction of it, came from the aversion behavior of individuals. It came from flight cancellations, it came from business meetings that were canceled, investments that were canceled, tourism that was canceled, slowdown in economic activity that was perceived in the affected countries in Asia and also even to some degree, in Canada. So in the case of the Ebola epidemic, where Instead of only 800 deaths, we're already seeing thousands, and we unfortunately fear that there will be tens of thousands. Certainly the direct impact in the form of. In the form of sick people and dead people is far greater. The direct health impact is greater. But still we're talking about a tiny fraction of the populations of these countries.
- [23:40]
A
And tiny compared to the death tolls of these other diseases, and tiny compared.
- [23:43]
B
To the death tolls from malaria and tuberculosis and hiv, all of which are many multiples more deadly. So on a continuing basis. So the economic impact from Ebola is going to come from this aversion behavior, and it's going to come from the panic. That doesn't make it any the less real. But it does mean that wise policy and wise leadership in the three African countries can potentially reduce the economic impact. We've got to see progress on the ground, We've got to see these treatment centers up and running in order to give the people confidence. But the international community can also help by doing whatever is necessary to maintain those air links, to maintain those sea links, and to keep these three countries as part of the international community.
- [24:36]
A
Meadowver, I think we'll leave it right there. An eloquent plea both for a good sense and compassion in responding to this challenge of the Ebola epidemic in West Africa. Thanks so much for joining me. This has been the global prosperity wonkcast from the center for Global Development. My guest today is Mead over, and we've been discussing the international response to the Ebola epidemic. You can find the Wonkast online on itunes and on stitcher. Just search for wonkcast or CGD and sign up to hear a new interview every week. Until next time, I'm Lawrence MacDonald. Thanks for listening.
- [25:20]
B
It.