On Dec. 28, 2013, a 1-year-old boy named Emile Ouamouno died of Ebola in Meliandou, Guinea. After Emile died — he was the index case, or first recorded death, for this year’s catastrophic Ebola outbreak — so did 11 other people in his village, including his mother and sister. Meliandou sits near the point where the borders of Guinea, Liberia and Sierra Leone converge, and the virus traveled easily through the countries, which lacked the resources to stop it. By the end of this year, the West African Ebola outbreak had killed nearly 7,000 people.
There are some signs, however, that the outbreak is starting to taper off. The World Health Organization (WHO) reports that the pace of new Ebola cases is fluctuating in Guinea and has slowed in Liberia and Sierra Leone, aside from an alarming recent spike in one district. Meliandou has had no new cases since April.
That doesn’t mean the public health response is complete. If this year was focused on getting the staff, stuff and systems to the hardest-hit parts of the region, 2015 will be about immunization, infrastructure and investment. Without them, West Africa could see not only a resurgence of Ebola but also a reversal of the gains in health that have been painstakingly made over the last two decades.
Experimental treatments for Ebola, which has neither a cure nor a vaccine, have languished for years as companies struggled to secure funding for research. This year’s outbreak changed that calculation. The WHO has thrown its weight behind blood therapy, which uses transfusions from Ebola survivors who may pass on their immunity. The Bill and Melinda Gates Foundation is supporting clinical trials of blood therapy early next year in Guinea. Two vaccines and two drugs, TKM-Ebola and ZMapp, which appears to have had some success in a few patients, are also being tested.
But vaccines and drugs alone are not enough. Effective mass immunization campaigns rely on health care workers, refrigeration equipment and public health networks — the staff, stuff and systems that West Africa doesn’t have. Liberia, for example, has just 90 doctors for its population of 4.3 million people.
Nigeria’s experience shows what’s possible when that infrastructure is in place. On July 20, a dying Ebola patient flew to Lagos and then traveled to Port Harcourt, where he spread the disease to 20 people. Nigeria has its share of public health issues (it is one of only three countries, for example, where polio is still endemic), but it was able to stop a wide Ebola outbreak by adapting the resources it had on hand. It repurposed its polio command center as an anti-Ebola headquarters, turned a teaching hospital into a testing lab and deployed nearly 200 health workers to do 18,500 face-to-face interviews with people who might have been exposed. By the end of October, the WHO declared Nigeria Ebola-free.
Guinea, Liberia and Sierra Leone are in no position to build this infrastructure on their own. They were among the poorest countries in the world even before the outbreak, and the World Bank estimates that Ebola will cost their economies, conservatively, $1.6 billion. The collective annual output of the three countries is only $13 billion. Instead, Lawrence Gostin, a professor and public health expert at Georgetown University Law Center, has proposed the creation of an “international health systems fund” to support health infrastructure in poor countries.
The need to invest in West Africa’s health care now is crucial, since the Ebola outbreak threatens to wipe out gains in tuberculosis, malaria and maternal and child health. Estrella Lasry, a tropical-medicine specialist for Doctors Without Borders in New York, told the journal Nature that efforts to distribute malaria medicine, bed nets and other treatments for preventable diseases have been brought to a halt by Ebola. “It’s a disaster in all ways possible,” she said. “The public health impact will be huge.”
Writing in the British medical journal The Lancet, Gostin estimated that it would take a commitment of several billion dollars to poor countries to strengthen their health systems. The alternative is leaving companies to build private sanctuaries against Ebola (as Firestone did in Liberia) or sending in thousands of troops. In comparison, sustained funding for health, he wrote, “is a wise and affordable investment.”