By: Peter Brown, PhD
Obviously, this is welcome news – vaccination is the most powerful technological tool for primary prevention in the arsenal of Public Health. We need more vaccines, especially for diseases that have high case-mortality rates, like Ebola. We also need stronger research and development infrastructure to quickly produce new vaccines for novel health threats in the future. We need an Ebola vaccine in order to be prepared for future outbreaks of this terrible disease. But who will be able to use the new vaccines once they are developed?
The National Institutes of Health (NIH) – in a partnership with the government of Liberia – reacted relatively quickly to the threat of Ebola, but only after it came into the United States. During October and November 2014 in the U.S., Ebola was an epidemic of fear and stigma. The unfortunate death in Texas represented an error in medical care and infection control. Political opponents of President Obama exacerbated that epidemic with charges of incompetence and calls for historically disproven control strategies like quarantines or a travel ban. By hyping the risk and playing politics with a disease affecting tens of thousands of West Africans, certain politicians and pundits pandered to social groups predisposed to xenophobia, scientific illiteracy, and groundless distrust of Public Health authorities. The order of Governor Chris Christie to forcibly quarantine a symptomless nurse who had been volunteering in Ebola stricken areas is a case in point. Coincidentally, that same nurse has recently criticized Christie for making similarly stupid comments about measles vaccination.
Ebola treatment and control in West Africa using the same procedures and has been successful as seen in the impressive decline of case-mortality rates in clinical facilities run by Medicins Sans Frontieres (MSF), which did not require new medical inventions. What was required to stop the disease spreading in the first place? Actually, they were things simply not available in the impoverished rural areas of West Africa where the current epidemic began. Things like clean running water, rubber gloves, infection-protection suits, adequate hospital facilities that could be kept clean, sufficient resources to bring the sick to care, and the ability to safely dispose of the dead. From a Public Health perspective, no new equipment or technologies are needed either. The challenge of Ebola control (i.e. bring the transmission rate to zero) requires the implementation of long-tested tools including: case identification and containment, contact tracing, public education, and continued surveillance.
Successful Ebola treatment and control requires adequate primary health care infrastructure and facilities that simply were non-existent in the impoverished and war-torn African countries where Ebola was first recognized in 1976. The Global Health community has known about the dangers of worldwide pandemics resulting from in the terrible health care services in low-income countries for a long time. But improving health care services is an incredible challenge in impoverished nations with poor health care facilities and a shortage of personnel. Rather than emphasizing the provision of effective basic health services to all people throughout the world, the Global Health community has focused efforts on the elimination (and theoretically possible eradication) on a small number of diseases that are “targeted” for destruction, one at a time.
Although completely unknown to most Americans before last year, Ebola is not a new problem. The CDC’s chronology of Ebola lists 35 different outbreaks in 14 different countries in the last 40 years. Most of these outbreaks were relatively small and found in under-equipped rural health posts; this was dramatically described in Laurie Garrett’s classic, The Coming Plague (1995). The incredible surge of cases in the West African epidemic that began in March 2014 has required international attention, finances, equipment, and volunteer staff, although local West African medical personnel are accomplishing the lion’s share of the work. A critical difference with the 2014 epidemic was its location in urban areas where population density adds to the transmission of infections. The human toll has been horrific – as of February 6, 2015 there have been more than 22,560 reported cases and 9, 015 deaths. But that tally needs to be put in the context of over 500,000 malaria deaths in 2014.
Paul Farmer, the anthropologist/physician/activist and co-founder of Partners in Health recently said: “This is not a natural disaster, it is the terrorism of poverty.” His diary entries from Liberia published in the London Review of Books in October describe brutal conditions of bone-crushing poverty upon which high risks of infection – from a wide variety of diseases – are built. From Farmer’s viewpoint, the global threats of “emerging diseases” like Ebola are the result of brutal and growing inequalities. This is an important lesson to keep in mind when we read the welcome news of the two Ebola vaccine trials.
Who benefits when new vaccines and medical procedures are invented? In the short run, it tends to be the people from rich countries who are traveling to poor countries. History shows that vaccine development has always been spearheaded by the military and utilized by expatriates, medical personnel, tourists, and local elite. New vaccines – for example the HPV vaccine that protects against cervical cancer – are too expensive ($300-$500) for most of the population of low-income countries where the per-capita health budget is as low as $35. And some vaccines, such as a malaria vaccine, are never available, even after four decades of well-funded research.
We must welcome the announcement of the human trials of two Ebola vaccines in Liberia. At the same time, we must remember that a new vaccine will not reach the ultimate causes of the diseases of poverty.
 The have been arguments between MSF and Partners in Health (PIH) whether PIC lines for aggressive rehydration are necessary http://www.nytimes.com/2015/01/02/health/ebola-doctors-are-divided-on-iv-therapy-in-africa.html?_r=0
 http://www.who.int/features/factfiles/malaria/en/ Note that the malaria death rate in 2014 was reduced remarkably since 2000.
 He is also my friend.