tag:theconversation.com,2011:/au/topics/ebola-epidemic-13194/articlesEbola epidemic – The Conversation2021-03-03T13:22:25Ztag:theconversation.com,2011:article/1561692021-03-03T13:22:25Z2021-03-03T13:22:25ZTwo gaps to fill for the 2021-2022 winter wave of COVID-19 cases<figure><img src="https://images.theconversation.com/files/387358/original/file-20210302-13-m2e61t.jpg?ixlib=rb-1.1.0&rect=9%2C42%2C2019%2C1298&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A sign in County Kildare, Ireland. in March 2020. Epidemiologists around the world worked hard to try to stop big parties in the face of rising caseloads of what would come to be called COVID-19. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sign-anouncing-the-cancellation-of-a-st-patricks-day-parade-news-photo/1207443830?adppopup=true">Niall Carson/PA Images via Getty Images</a></span></figcaption></figure><p>Epidemiologists – like oncologists and climate scientists – hate to be proven right. A year ago this week, the communications rush began from epidemiologists in academia to the public and to local governments about the imminent dangers of the COVID-19 pandemic, in the face of a weak federal response. </p>
<p>St. Patrick’s Day parades were canceled with days to spare. Hospitals were turning suspected positive cases away because of a lack of tests. <a href="https://works.bepress.com/mcandrew/2/">Epidemiologists</a> <a href="https://www.cbsnews.com/news/coronavirus-infection-outbreak-worldwide-virus-expert-warning-today-2020-03-02/">predicted</a> <a href="https://theconversation.com/how-big-will-the-coronavirus-epidemic-be-an-epidemiologist-updates-his-concerns-133133">that</a> hundreds of thousands Americans would die over the following year, with the upper boundaries <a href="https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/">above a million</a>. This was our country’s biggest challenge since 1941, and we did not meet it. </p>
<p>Despite the stream of bad news, a major success of 2020 was the pace of vaccine development. A 10-month sprint ending with completed phase 3 clinical trials for two vaccine candidates (and a <a href="https://www.fda.gov/news-events/press-announcements/fda-issues-emergency-use-authorization-third-covid-19-vaccine">third one</a> last week) is an incredible achievement. Uncredited here is the <a href="https://doi.org/10.1080/21645515.2017.1306615">experience</a> <a href="https://www.who.int/immunization/sage/meetings/2019/april/1_CEPI_Summary_WHO_SAGE_Meeting_April.pdf">gained</a> by the global health community during the rollout of <a href="https://doi.org/10.1016/S0140-6736(15)61117-5">clinical trials</a> in the West African Ebola epidemic in 2014-2015. Science during a crisis is difficult, and the scientific community responded in 2020 with an all-hands effort to design and initiate scores of trials on a moment’s notice.</p>
<p>But amid the scientific progress, what did we scientists neglect or get wrong? What will haunt us in eight months, when SARS-CoV-2 cases begin surging again, and we wonder if the winter epidemic trajectory will bring 30,000 or 300,000 more deaths? If vaccine efficacy drops, high death rates are a real possibility. </p>
<p>Our two big misses in 2020 were in behavioral modeling and real-time <a href="https://link.springer.com/chapter/10.1007/978-1-4899-7448-8_4">seroepidemiology</a>, the study of antibody measurements in blood samples. As an <a href="https://www.huck.psu.edu/people/maciej-f-boni">epidemiologist</a> with experience in the field, lab and modeling aspects of pandemic response, I believe that we must address these two gaps for the U.S. to have better forecasting, better communication and better management next winter. Even with effective vaccines, the new coronavirus will be with us for many years.</p>
<figure class="align-center ">
<img alt="Two medical workers transport a deceased patient." src="https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical personnel move a deceased patient to a refrigerated truck serving as a makeshift morgue at Brooklyn Hospital Center on April 9, 2020, in New York City.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/medical-personnel-move-a-deceased-patient-to-a-refrigerated-news-photo/1209563693?adppopup=true">Angela Weiss/AFP via Getty Images</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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</figure>
<h2>Understanding human behavior</h2>
<p>First, scientists do not understand the general <a href="https://doi.org/10.1073/pnas.0810762106">feedback loop</a> between virus transmission and human behavior. When case and death numbers rise, people get fearful and comply more fully with common-sense recommendations like mask-wearing, distancing, hygiene, reduced contacts and no group events. But when these numbers fall, people feel safer and resume risky behavior, setting the stage for a new increase in cases.</p>
<p>In 2020, we public health experts missed an opportunity to quantify this dynamic and estimate the delay inherent in a population’s behavioral response. Even the recent decline in cases in January <a href="https://twitter.com/nataliexdean/status/1362100680492601350">was attributed</a> to behavioral change by process of elimination only: It did not seem to be caused by weather, vaccines or new restrictions and was thus credited to human behavior and social distancing. But we still lack statistical evidence for how or when this started.</p>
<p>Why did we miss this? Epidemiologists had been preparing for a deadly pandemic for two decades. Our anchoring bias came from experiences with past influenza pandemics and <a href="https://doi.org/10.1038/nature04017">hypothetical avian influenza pandemics</a>, which have <a href="https://twitter.com/SRileyIDD/status/1220464674476625921">infection fatality ratios</a> (IFR) of either a very low 0.05% or very high rates of more than 25%. No one prepared for an intermediate IFR of 0.5%, where a virus could circulate unnoticed long enough for researchers to miss the first clinical signals – or a virus not gruesome enough to induce an immediate state of emergency. </p>
<p>Throughout the COVID-19 pandemic in the U.S., society’s reaction has wavered from urgency to complacency and back. Epidemiologists were not able to accurately predict these trends.</p>
<p>Going forward, we must develop data-centered models of population behavioral responses that occur during COVID-19 epidemics. For example, does experience with wintertime influenza act as an anchor, driving people to be more or less cautious as case numbers rise above or below “normal” flu rates? If scientists and public health experts can understand this behavior, we will know better when and how to institute new nonpharmaceutical interventions, such as gathering size limits or work-from-home orders. Then we will have better and more scientific justifications for early lockdowns and early interventions, with public health messaging stating clearly that an early lockdown means a short lockdown.</p>
<p>Behavioral modeling can also unlock the power of <a href="https://doi.org/10.1126/sciadv.abd5393">rapid at-home tests</a>, a promising public health tool that received no coordinated support over the past year. How does someone react if others are infected? How do people <a href="https://doi.org/10.1073/pnas.2005241118">react</a> if they themselves are infected? Without the foundational behavioral analysis in place, we will not know how to deploy at-home tests to best facilitate more careful mixing behavior.</p>
<figure class="align-center ">
<img alt="A man getting a blood test for COVID-19." src="https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=370&fit=crop&dpr=1 600w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=370&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=370&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=465&fit=crop&dpr=1 754w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=465&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=465&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A laboratory technician takes an antibody test for COVID-19 at a community care center in New York City.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/laboratory-technician-takes-an-antibody-test-for-covid-19-news-photo/1214741188?adppopup=true">Lev Radin/Pacific Press/LightRocket via Getty Images</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Faster processing of antibody data</h2>
<p>Our second big miss was in real-time analyses of antibody data to gauge how many Americans have been infected with the coronavirus. Real-time <a href="https://coronavirus.jhu.edu/map.html">case numbers</a>, <a href="https://covidtracking.com/">hospitalizations</a> and <a href="https://www.covid19mobility.org/">mobility</a> data have been crucial for understanding the different phases of the COVID-19 pandemic. </p>
<p>But serum collection was not preplanned, routine or processed quickly. Seroprevalence results then <a href="https://doi.org/10.1001/jamainternmed.2020.4130">came</a> <a href="https://doi.org/10.1016/S0140-6736(20)32009-2">months</a> <a href="https://doi.org/10.1001/jamainternmed.2020.7976">late</a>, appearing in publications and preprints, but not aggregated in an easy-to-understand database. </p>
<p>With no universal standardization, misinterpretation of assay validations and serological thresholds was common. Scientists debated cross-sectional serology results, and study designs had no approach to correct for <a href="https://www.buzzfeednews.com/article/stephaniemlee/stanford-coronavirus-study-bhattacharya-email">sampling biases</a> generated from correlations between past symptoms and study participation.</p>
<p>Today, we still lack confidence in estimates of the total number of Americans who have been infected, which complicates efforts to use the vaccine scale-up to accurately state what fraction of the country is now immune, or to plan for the inevitable outbreaks of new variants this spring and summer.</p>
<p>The key studies to prepare for next winter involve standardizing serological assays and estimating <a href="https://doi.org/10.1126/sciimmunol.abf8891">antibody</a> <a href="https://wwwnc.cdc.gov/eid/article/27/3/20-4543_article">waning</a> <a href="https://doi.org/10.1038/s41467-020-20247-4">rates</a> – that is, how quickly one’s antibody levels go down after infection. Measuring the post-infection waning of antibody concentrations allows us to define antibody thresholds for <a href="https://www.taylorfrancis.com/chapters/inferring-time-infection-serological-data-maciej-boni-k%C3%A5re-m%C3%B8lbak-karen-krogfelt/e/10.1201/9781315222912-15">particular time points</a> after infection. </p>
<p>That’s a lot of jargon. Put more simply, if we know that antibodies wane to level X after three months, we can use this X to determine who has been infected in the past three months. This is not a true seroprevalence or attack-rate measurement, and that’s fine. It is a measure of the three-month attack rate or the six-month attack rate, depending on the threshold chosen, and it gives us an estimate of recent population-level infection rates. This new definition resolves the arbitrary threshold problem in serology, and allows studies to report the amount of recent population immunity, which is useful for public health decisions.</p>
<p>In my view, we should have learned in 2020 that it is never too early to start preparations for epidemic control. Summer 2020 was a missed opportunity to revamp our approach to health care and epidemic response. The U.S. cannot again squander an entire summer and fail to prepare for the possibility that SARS-CoV-2 has one more nasty winter in store for us.</p><img src="https://counter.theconversation.com/content/156169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maciej F. Boni receives funding from the National Institutes of Health and the Bill and Melinda Gates Foundation.. </span></em></p>The US was not ready for the coronavirus pandemic in 2020. What can public health leaders and policymakers do to make sure we don’t face another winter of rampant disease?Maciej F. Boni, Associate Professor of Biology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1459332020-09-20T07:47:47Z2020-09-20T07:47:47ZCan COVID-19 inspire a new way of planning African cities?<figure><img src="https://images.theconversation.com/files/357703/original/file-20200911-24-76vj2f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Makoko neighbourhood in Lagos, initially founded as a fishing village.</span> <span class="attribution"><span class="source">Frédéric Soltan/Corbis via Getty Images</span></span></figcaption></figure><p>Health crises are not new in Africa. The continent has grappled with infectious diseases on all levels, from local (such as <a href="https://theconversation.com/what-115-years-of-data-tells-us-about-africas-battle-with-malaria-past-and-present-85482">malaria</a>) to regional (<a href="https://theconversation.com/ebola-in-the-drc-the-race-is-on-between-research-and-the-virus-112537">Ebola</a>) to global (<a href="https://theconversation.com/africa/covid-19">COVID-19</a>). The region has often carried a disproportionately high <a href="https://theconversation.com/african-health-research-needs-support-heres-one-programme-thats-working-144611">burden</a> of global infectious outbreaks. </p>
<p>How cities are planned is critical for managing infectious diseases. Historically, many urban planning innovations emerged in response to health crises. The global <a href="https://www.history.com/topics/inventions/history-of-cholera">cholera epidemic</a> in the 1800s led to improved urban sanitation systems. Respiratory infections in overcrowded slums in Europe <a href="https://thecityfix.com/blog/will-covid-19-affect-urban-planning-rogier-van-den-berg/">inspired</a> modern housing regulations during the industrial era. </p>
<p>Urban planning in Africa during colonisation followed a similar <a href="https://theconversation.com/how-the-legacy-of-apartheid-design-is-making-students-lives-unsafe-64770">pattern</a>. In Anglophone Africa, cholera and bubonic plague outbreaks in Nairobi (Kenya) and Lagos (Nigeria) led to new <a href="https://www.tandfonline.com/doi/abs/10.1080/02665430902933960">urban planning strategies</a>. These included slum clearance and urban infrastructure upgrades. Urban planning in <a href="https://www.tandfonline.com/doi/abs/10.1080/19376812.2016.1208770">French colonial Africa</a> similarly focused on health and hygiene issues, but also safety and security. </p>
<p>Unfortunately regional experiences with cholera, malaria and even Ebola in African cities provide little evidence that they have triggered a new urban planning ethic that prioritises infectious outbreaks. </p>
<p>References are often made to <a href="https://www.tandfonline.com/doi/abs/10.1080/19376812.2016.1208770">historical successes</a> of urban planning in Africa. But colonial use of planning for cultural and structural isolation, as well as for socio-economic and spatial segregation, limited its capacity to respond to health emergencies. With the widespread nature of COVID-19, is it reasonable to argue that it could possibly be the pandemic that inspires a new way of “doing” urban planning in Africa? </p>
<p>Our recent research <a href="https://www.tandfonline.com/doi/full/10.1080/23748834.2020.1812329">paper</a> discusses three areas that can transform urban planning in the continent to prepare for future infectious outbreaks, using lessons from COVID-19.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An aerial view shows a mass of shacks on one side and a green, spread out suburb on the other, divided by a wall." src="https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357705/original/file-20200911-14-119xrw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Spatial inequality in Johannesburg, South Africa.</span>
<span class="attribution"><span class="source">Per-Anders Pettersson/Getty Images</span></span>
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<h2>Integrating the informal</h2>
<p>The first relates to the integration of the city’s informal sector into the formal planning process. This is reflected in two ways. The first is the non-inclusion of informal settlements (mostly slums) in urban planning practice. The second is the lack of planning focus on the informal economy that results in <a href="https://theconversation.com/african-cities-must-address-social-and-economic-issues-when-upgrading-slums-97471">exclusion</a>. Yet this is a sector that constitutes more than 80% of Africa’s <a href="https://www.researchgate.net/publication/259331356_The_Informal_Economy_Worldwide_Trends_and_Characteristics">urban economy</a>. </p>
<p>In a time of COVID-19, <a href="https://theconversation.com/lagos-makes-it-hard-for-people-living-in-slums-to-cope-with-shocks-like-covid-19-138234">slums</a> and <a href="https://theconversation.com/covid-19-how-the-lockdown-has-affected-the-health-of-the-poor-in-south-africa-144374">informality</a> are critical due to the sector’s vulnerability to transmission. It is challenging to deploy testing and contact tracing , as well as adhering to social distancing rules. Many slum residents in African cities lack access to basic essential services such as water, sanitation, housing and healthcare. </p>
<p>And, given that the informal sector is characterised by unregulated <a href="https://theconversation.com/why-brutalising-food-vendors-hits-africas-growing-cities-where-it-hurts-76339">economic activities</a> including uncontrolled hawking and unplanned open markets, overcrowding is impeding social and physical distancing rules in African cities. </p>
<p>Change is needed. Perhaps COVID-19 will be the wake-up call to spur the consolidation of existing and formal structures to becoming more responsive to managing health crises in slums and the informal sector.</p>
<h2>Geographic and economic imbalances</h2>
<p>Second, there are geographical and economic imbalances in urban planning in Africa. <a href="https://theconversation.com/megaprojects-in-addis-ababa-raise-questions-about-spatial-justice-141067">Investment</a> patterns and development mostly focus on the major cities with limited focus on its adjoining districts and regions. Yet what happens in cities does not stay in cities. </p>
<p>Infectious diseases often have <a href="https://theconversation.com/why-its-hard-to-stop-ebola-spreading-between-people-and-across-borders-118851">cascading effects</a> on adjoining districts and regions with functional relationships to major cities. COVID-19 has affected both cities and their adjoining regions. However, adjoining districts continue to receive limited investment in critical infrastructures such as health, housing and other essential social services. </p>
<p>Given the disruptions to the supply chain between major cities and the adjoining districts due to the pandemic, it’s about time that planning practitioners and educators learn to prioritise urban planning to reflect these imbalances. A poorly managed relationship between cities and adjoining regions can create inequality that may lead to unhealthy city-regional inter-dependencies, environmental damage and unmanaged waves of health crises. These can have ripple effects across the urban-rural spectrum. </p>
<p>Planning in Africa should ensure city-regions are more resilient by addressing imbalances to produce a more integrated city-regional planning around health, economies, transport networks and food production.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A rusty signboard for Nairobi city in the foreground with a vast green park with trees behind it and the cityscape in the distance with high-rise buildings." src="https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357704/original/file-20200911-14-mmf63o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">View over the city park towards the Nairobi skyline in Kenya. Green spaces are crucial to healthier urban planning.</span>
<span class="attribution"><span class="source">Ian Forsyth/Getty Images</span></span>
</figcaption>
</figure>
<h2>Open spaces</h2>
<p>Third, public health matters should be considered in urban planning. Health outcomes traditionally do not drive urban planning practice in Africa. In our study, urban green spaces are used as an example because the COVID-19 pandemic has highlighted their importance in managing emergencies. Literature evidence <a href="https://www.tandfonline.com/doi/full/10.1080/23748834.2020.1812329?af=R">suggests</a> that African cities are rapidly losing their green spaces. This is due to, among other things, poor urban planning. </p>
<p>A new approach should bring open spaces into the heart of how African cities are planned, and management systems for local green space must improve. Integrating larger open spaces within the urban fabric allows cities to implement emergency services and evacuation protocols during health crises. </p>
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Read more:
<a href="https://theconversation.com/urban-planning-needs-to-look-back-first-three-cities-in-ghana-show-why-144913">Urban planning needs to look back first: three cities in Ghana show why</a>
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<p>What frequently seems to be effective in advancing responses to health crises is an urban planning approach that integrates a range of infrastructure. This includes grey (such as treatment facilities and sewers), green (trees, lawns and parks) and blue (wetlands, rivers and flood plains) systems.</p>
<p>Although COVID-19 has profoundly transformed urban life globally, this article provides cautious optimism of its potential in managing future health crises in Africa. Going forward, urban planning in Africa needs to reflect the aspirations of urban residents and address multiple spatial inequalities, including access to better spaces in times of a pandemic.</p><img src="https://counter.theconversation.com/content/145933/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Brandful Cobbinah has previously received funding from the Lincoln Institute of Land Policy.</span></em></p><p class="fine-print"><em><span>Ellis Adjei Adams has previously received funding from the US National Science Foundation.</span></em></p><p class="fine-print"><em><span>Michael Odei Erdiaw-Kwasie works for Transparency International Australia. </span></em></p>If we learn from COVID-19, there are three key areas to tackle to make cities safer from outbreaks of future infectious diseases.Patrick Brandful Cobbinah, Lecturer, The University of MelbourneEllis Adjei Adams, Assistant professor, University of Notre DameMichael Odei Erdiaw-Kwasie, Research fellow, University of Southern QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1352622020-04-03T16:28:59Z2020-04-03T16:28:59ZCoronavirus: how to avoid military responses becoming double-edged swords<p>Militaries are playing a central role in national responses to the coronavirus pandemic around the world. In China, the People’s Liberation Army <a href="https://www.economist.com/international/2020/03/23/armies-are-mobilising-against-the-coronavirus">was praised for</a> speedily building hospitals and running health supply chains. In Italy, Spain and <a href="https://www.ft.com/content/bad47729-32be-4865-b68a-27506158f023">South Africa</a> soldiers are patrolling the streets to enforce lockdowns. Military personnel are operating makeshift hospitals in <a href="https://www.theguardian.com/world/video/2020/mar/26/emmanuel-macron-drafts-french-military-into-coronavirus-war-video">France</a>, while <a href="https://www.ft.com/content/c5fb1f72-6920-11ea-800d-da70cff6e4d3">German</a> and Russian militaries are building large treatment centres. </p>
<p>To various degrees, from the UK to Iran, <a href="https://www.bbc.co.uk/news/world-51984199">troops are being deployed</a> as defence ministers mobilise infrastructure, medical resources, supply chains and call in reservists. </p>
<p>In many ways, this is the defence sector at its very best. Yet if this pandemic calls for extraordinary deployments, it also calls for extraordinary precautions. </p>
<p>Research on how the military has been deployed during previous epidemics, and the way civil and military actors work together in emergencies, should help inform the way they are used now. The most recent and relevant <a href="https://www.dcaf.ch/sites/default/files/publications/documents/PB_health_security_v6.pdf">example to draw from</a> remains the 2014-15 Ebola epidemic which led to large-scale local and foreign military involvement in West Africa.</p>
<h2>A delicate balancing act</h2>
<p>In times of crisis, military engagement tends to act as a double-edged sword. Military resources and capabilities in infrastructure, treatment, logistical and communications systems can make vital contributions to the pandemic response. They can help with <a href="https://journals.sagepub.com/doi/abs/10.1177/0095327X14567364">disease surveillance and the distribution of food and supplies</a>. But military-led population control measures can also undermine public health efforts. </p>
<p>At the community level, boots on the ground can easily <a href="https://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780190624477.001.0001/acprof-9780190624477-chapter-2">alter public confidence</a> and impair crucial health communication campaigns by creating a climate of fear and criminalising people living in outbreak hotspots. </p>
<p>Mitigating these adverse effects will be crucial in low-income and crisis-affected populations, where the response to the coronavirus pandemic will have to <a href="https://www.lshtm.ac.uk/newsevents/news/2020/covid-19-control-low-income-settings-and-displaced-populations-what-can">rely on locally informed behavioural science</a> until vaccine or effective drug treatments are made available. In these communities, military involvement will need to be navigated very carefully and give way to local initiatives. In wealthier countries, such as the UK, the current health crisis is exacerbating underlying social inequalities and runs the <a href="https://theconversation.com/coronavirus-to-avoid-major-humanitarian-fallout-uk-must-act-urgently-global-health-expert-133968">risk of becoming a humanitarian crisis</a>. </p>
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Read more:
<a href="https://theconversation.com/coronavirus-vaccine-here-are-the-steps-it-will-need-to-go-through-during-development-134726">Coronavirus vaccine: here are the steps it will need to go through during development</a>
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<p>Around the world, community empowerment and global solidarity efforts will be key to finding and sharing potential cures and best practices. The real emergency will soon be around the need for solidarity across social divides to ensure effective health communications and the protection of vulnerable groups. We need to make sure that the current display of national military involvement doesn’t undermine the collective solidarity and sharing of scientific evidence that is so crucial to pandemic response. </p>
<p>When state leaders hammer war-metaphors referring to their national responses, they both galvanise public attention and legitimise military engagement. The UK National Health Service’s (NHS) coronavirus <a href="https://www.goodsamapp.org/nhs">volunteer-army</a> is one example of how positive the “war against an invisible enemy” rhetoric can be. The NHS’s civilian conscription marketing worked brilliantly. Almost half a million volunteers signed-up to help at community-level. That is absolutely, unequivocally, brilliant. </p>
<p>But equating frontline health workers to heroic soldiers and sacrificial martyrs, when governments should really be prioritising these workers’ security and wellbeing with sufficient personal protective equipment is worrying. Conflating civil and military roles in emergencies is largely thought of as detrimental to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5180349/">health workers’ safety</a>. In crisis settings, health workers often need to partner with the military to access affected people and deliver supplies. But they also strive to maintain the neutrality and independence so indispensable to community trust and effective health delivery.</p>
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Read more:
<a href="https://theconversation.com/coronavirus-if-we-are-in-a-war-against-covid-19-then-we-need-to-know-where-the-enemy-is-135274">Coronavirus: If we are in a war against COVID-19 then we need to know where the enemy is</a>
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<h2>Public health expertise first</h2>
<p>There will be no one-size-fit all strategy for military engagements in this pandemic. Countries are likely to follow their own traditions depending on available resources. </p>
<p>In underfunded and fragmented health systems, militaries often already support public health structures – pandemic or no pandemic. In some countries, such as Sri Lanka, the military is likely to be <a href="https://thepolisproject.com/militarization-of-medicine-sri-lankas-response-to-the-coronavirus-pandemic/#.XnupnC2cbOT">leading the entire coronavirus response</a>, for better or for worse. </p>
<p>But with no exit strategies for these worldwide military engagements, the fear is that these militarised responses could slip into heavy-handed interventions against citizens or neighbouring countries. The hope is that military support for responses to the pandemic will remain guided by – and subordinate to – public health expertise.</p>
<p>Researchers and experts in global health security have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856330">sounding the alarm</a> on the lack of resources and political mobilisation for a possible pandemic for years. The fact that the charity Médecins Sans Frontières called upon UN members to <a href="https://www.msf.org/bmj-only-military-can-get-ebola-epidemic-under-control-msf-head">dispatch their military capabilities</a> to West Africa during the Ebola epidemic highlighted the lack of international capacity to respond to acute public health crises. </p>
<p>Yet this call for preparedness in global health systems has increasingly been met with funding towards the <a href="https://academic.oup.com/ia/article/95/5/1093/5556752">defence sector’s emergency capacity</a>. Current national military deployments should also be a wake-up call to the continuous and reckless disengagement from national and international public health systems.</p>
<p>This pandemic is an opportunity to leverage military know-how for better and more robust responses to future pandemics. And when we finally come out of this one, we better get ready for the next.</p><img src="https://counter.theconversation.com/content/135262/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fawzia Gibson-Fall receives funding from QMUL Principal's Postgraduate Research Studentships</span></em></p>Military support for coronavirus responses must remain subordinate to public health expertise – and learn from previous epidemics.Fawzia Gibson-Fall, PhD Researcher, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1129362019-03-28T10:39:31Z2019-03-28T10:39:31ZWhen Ebola and other epidemics strike, a dysfunctional ‘outbreak culture’ hinders adequate response<figure><img src="https://images.theconversation.com/files/265913/original/file-20190326-36256-1tjlicf.jpg?ixlib=rb-1.1.0&rect=412%2C15%2C4866%2C3154&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">During high-stress deadly epidemics, even well-trained responders can get caught up in behaviors that are more harmful than helpful.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Belgium-Ebola-Virus/e3284371213b4be7830cc3a453dab5d1/2/0">AP Photo/Olivier Matthys</a></span></figcaption></figure><p>When a deadly infectious disease takes hold in a population, outbreak responders do their best to save lives and stamp out the contagion. No matter the disease or the location – whether AIDS in the U.S., SARS in China, or cholera in Yemen or Haiti – the public narrative of an outbreak often unfolds in a familiar way. An unruly and potentially fatal disease emerges and sets off a race against the clock to stop its spread, with limited or no certain treatment. </p>
<p>Less widely known is the shared secret among outbreak responders: Bad behavior among their own ranks can consume undue energy amid an already frightening scenario.</p>
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<a href="https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/265955/original/file-20190326-36256-bdtfjz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In an outbreak, the stakes are life and death and tensions can run high.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Sierra-Leone-West-Africa-Ebola/ac2766e0796f4df0aa4e1af318f0eadf/12/0">AP Photo/ Michael Duff</a></span>
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<p>We’ve both seen firsthand different elements of disorder during disease outbreaks. One of us (Pardis) led a team working in Sierra Leone tracking genomic changes in the virus during the 2014 Ebola epidemic and experienced how off-the-charts stress led to a toxic setting. As a journalist, one of us (Lara) witnessed the ensuing chaos as the media and health agencies worked to communicate Ebola risk to a fearful public. Together, we decided to try to learn more about the irrational behaviors that occur in the midst of an outbreak.</p>
<p>In a first attempt to move beyond open secrets to full transparency, we conducted an anonymous survey in 2015 of more than 200 local and foreign responders to the Ebola epidemic in West Africa. This was the <a href="https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html">largest and most widespread Ebola outbreak</a> in history. Nearly 30,000 people were infected with the virus, and more than 11,000 people died in the three hardest-hit countries: Sierra Leone, Liberia and Guinea. We asked responders about their experiences during the height of the outbreak.</p>
<p>What they told us led us to believe that a culture can form in this environment, created by individual actors and larger agents. It has little to do with the virus but can propagate its spread. As we describe in our new book “<a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674976115">Outbreak Culture</a>,” these dynamics dictate how the international community responds to a pathogen. Outbreak culture can inhibit efficient action and, in some cases, even make the epidemic worse.</p>
<p><iframe id="88LvP" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/88LvP/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Talking about what’s not working</h2>
<p>Outbreak culture is what we call the collective mindset that can emerge in the beginning stages of a disease outbreak among those trying to respond to it. It forms in the crucible of a chaotic, unpredictable and potentially fatal environment. People’s initial reactions and behaviors may be based on fear, on the instinct to protect oneself or other people or institutions, or on the desire to exploit an already confusing situation.</p>
<p>Nearly all our survey respondents had found that political and interpersonal challenges slowed them down. Public conflicts between international response agencies “led to a delay in response activities, duplication of activities and lack of communication of important information,” one survey respondent wrote. For example, because many agencies came in with their own set of protocols, some said that continuous turnover of responders at different agencies prevented communicating or developing standards that were practiced throughout the response. </p>
<p>Delays were especially detrimental to scientists on the ground who were conducting research in the midst of the outbreak. The 2014 Ebola epidemic was among the first outbreaks during which rigorous <a href="https://doi.org/10.1177/1740774515619877">field research</a> to analyze <a href="https://doi.org/10.1126/science.1259657">transmission routes</a> and to test experimental therapies happened while the outbreak was still in full swing.</p>
<p>“Initially, it was difficult as everyone was concern[ed] about their turf and getting the glory,” another wrote. </p>
<p>The harmful competitive environment coupled with the chaos of Ebola spreading, one respondent wrote, led to “manipulation of data for publication” even though the study in question wasn’t actually conducted. Another reported witnessing data collectors attempt to obtain specimens from patients “in an unethical way and without cultural sensitivity.” </p>
<p>Indeed, more than a quarter of survey respondents reported either witnessing, hearing about, or falling victim to illegal or unethical tactics while working in their respective capacities to the response.</p>
<p>Other responses highlighted the misuse of equipment. Some workers took advantage of humanitarian funds by “renting” cars that did not exist, or buying fuel for personal cars. </p>
<p>“I saw staff who [were] in theory on pay by the international community but who would then not show [up] to work,” one respondent wrote.</p>
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<span class="caption">Appropriate protective gear is vital for all responders during an Ebola outbreak.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Liberia-Ebola/56299b0029f3489bbb75f5fb83eac7b4/9/0">AP Photo/Abbas Dulleh</a></span>
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<p>“I was witness to international agencies’ knowing deployment of substandard PPE [personal protective equipment] that did not meet specifications to protect healthcare workers from infection,” wrote another respondent, not specifying the name of the agencies or the brand of equipment. “These national staff, then, did not have access to high-level Ebola care if they were infected.” </p>
<p>Additional accounts mentioned health workers misusing equipment and providing preferential treatment to selected families. Several respondents saw local leaders leave their posts to protect themselves: “I witnessed government health workers in a supervisory capacity who had left their post, leaving subordinates to assume the risk and responsibility for caring for people with [Ebola].” This choice, like many others, was probably motivated by fear of the virus.</p>
<h2>Survey snapshots can lead to change</h2>
<p>Our survey included only a fraction of the thousands of people who <a href="https://www.who.int/csr/disease/ebola/training/review/en/">responded to the Ebola outbreak</a> and we understand their sentiments may not be representative of all responders. More foreign responders participated in the survey than local health workers. Both groups’ experiences are essential to improving outbreak culture. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=459&fit=crop&dpr=1 600w, https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=459&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=459&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=577&fit=crop&dpr=1 754w, https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=577&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/265957/original/file-20190326-36256-10ttqtp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=577&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">International volunteers are only part of the response story.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Sierra-Leone-Volunteer-Doctor/cce489ad22eb4a308ef67ad1ea99785c/13/0">AP Photo</a></span>
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<p>Two important aspects of our survey are that it was anonymous, so participants were able to respond freely, and it was blameless, asking participants to offer solutions to improve the culture of outbreak response rather than name offenders.</p>
<p>Our aim was to get a representative, honest glimpse into some shared experiences and challenges of outbreak response. It follows the principles of truth and reconciliation – or the Sierra Leonean practice of “Fambul Tok,” which translates to “family talk.” This tradition does not seek punishment, but a collective move toward a better community. </p>
<p>In the same way, we imagine that creating an exit survey to “check the temperature” of all responders in real-time as they return from a hot zone or in the midst of their work is a beneficial way to make adjustments to response operations as they’re happening. </p>
<p>In “<a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674976115">Outbreak Culture</a>,” we document that many of the <a href="https://www.nytimes.com/2016/12/01/world/americas/united-nations-apology-haiti-cholera.html">same obstacles</a> occurred during other disease outbreaks in other regions of the world prior to the 2014 Ebola outbreak. We are now seeing them re-emerge as the world faces another daunting Ebola outbreak, <a href="https://www.who.int/ebola/situation-reports/drc-2018/en/">this time in the Democratic Republic of Congo</a> where responders are being met with increased hostility and violence.</p>
<p>It’s time to take a sober look at even the most devastating facts of the medical community’s outbreak culture. This can be a critical step toward creating a new version that will allow responders to beat the next disease outbreak.</p><img src="https://counter.theconversation.com/content/112936/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pardis Sabeti is affiliated with a new company called SHERLOCK as a founder. It will develop diagnostics for a range of conditions. It should not have any direct relation that I am aware of to the contents of this article. I also advise and invest in companies related to women's health and PTSD unrelated in any way to this article. </span></em></p><p class="fine-print"><em><span>Lara Salahi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The high stress conditions of an outbreak can spread a dysfunctional culture among those working to fight it. A survey after the 2015 Ebola epidemic quantified the issue – and suggests a better way.Lara Salahi, Assistant Professor of Broadcast and Digital Journalism, Endicott CollegePardis Sabeti, Professor of Organismic and Evolutionary Biology and of Immunology and Infectious Diseases, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1029342018-09-12T10:40:38Z2018-09-12T10:40:38ZGame theory can help prevent disease outbreaks<figure><img src="https://images.theconversation.com/files/235988/original/file-20180912-133895-cbmqav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/world-map-whit-dashed-trace-line-563621422?src=Nz3yieGZsxLzgCV5XtKOlQ-1-13">Eva Cornejo Coba/Shutterstock</a></span></figcaption></figure><p>When multiple passengers on a flight from Dubai to New York recently were taken ill with flu-like symptoms, the plane was <a href="https://www.cnbc.com/2018/09/06/passengers-quarantined-jet-appear-to-have-the-flu.html">understandably quarantined</a>. It’s not too hard to imagine how international travel could quickly help <a href="https://theconversation.com/flu-plane-are-we-really-ready-for-a-global-pandemic-102789">spread a new disease</a> around the world. But surprisingly, grounding planes in such a situation might not always be the best strategy, and not just because of the economic impact.</p>
<p>When it comes to decisions about health, what’s best for us as individuals might not always be the best thing for the wider population, and vice versa. This can make it difficult for authorities to take decisions to protect the whole population. But there’s a way we can make sense of such a dilemma that’s more typically used in economics: game theory. </p>
<p>Game theory attempts to predict how an individual within a group will choose between different strategies, when the outcome of the situation depends on how everyone else in the group behaves. The difficulty is that you can’t work out an individual’s optimal strategy without knowing what all the others will do.</p>
<p>Take vaccination as an <a href="http://www.pnas.org/content/101/36/13391">example</a>. While vaccines have been repeatedly <a href="https://www.cdc.gov/vaccinesafety/research/iomreports/index.html">proven safe</a>, they can have short-term negative effects (financial cost, pain from injection, a temporary reaction from the immune system). So a family deciding whether to have a flu vaccine has to weigh up these costs against the benefit of getting vaccinated to protect themselves from the disease.</p>
<p>Given that flu can be deadly, it might seem like a no-brainer to accept the costs of vaccination. But if almost everybody else in the population gets vaccinated, the family will still be relatively protected from the disease because they are much less likely to come into contact with it. And so not getting vaccinated might appear to be the better choice. </p>
<p>The problem, of course, is that if every family thinks like this, then no one will be protected and a major outbreak could easily occur. Our example family may or may not be fine but the population as a whole suffers.</p>
<p>We’ve seen the catastrophic results of this problem with the measles, mumps and rubella (MMR) vaccine. After the vaccine was <a href="https://theconversation.com/autism-and-vaccines-more-than-half-of-people-in-britain-france-italy-still-think-there-may-be-a-link-101930">falsely linked</a> to autism, vaccination rates in Europe and the US dropped. This has led <a href="https://www.telegraph.co.uk/news/2018/07/02/national-measles-warning-five-fold-rise-cases-england/">to an increase</a> in the incidence of measles and mumps, <a href="https://www.bmj.com/content/362/bmj.k3596">resulting in deaths</a> and serious permanent injuries. </p>
<p>Game theory explains that, in situations like this, the best strategy for an individual can often be in conflict with the optimal strategy for the well-being of the whole group. What determines the outcome of an outbreak is the interaction between the individuals involved and how risk is perceived to those individuals and to the group as a whole.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/235993/original/file-20180912-133898-9ybxh6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vaccination has only tiny risks to the individual but big benefits for everyone.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-makes-vaccination-child-599228528?src=enwg57uFOJPUw6FaAlawpg-1-61">Oksana Kuzmina/Shutterstock</a></span>
</figcaption>
</figure>
<p>We can apply the same thinking to travel restrictions during an outbreak of disease. When the an epidemic of Ebola virus disease emerged in West Africa in 2014, preventing people flying to and from the region might have seemed like a good way of containing the situation and protecting individuals. But researchers <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415609/">later showed</a> that such measures only delayed the onset of the epidemic in different regions and may have stopped aid workers getting to the most affected areas.</p>
<p>So how can we work out the best strategy in this kind of situation? Typically, the answer is to use the “<a href="https://theconversation.com/john-nash-and-his-contribution-to-game-theory-and-economics-42355">Nash equilibrium</a>”, named after the famous mathematician <a href="https://theconversation.com/john-nash-a-beautiful-mind-and-its-exquisite-mathematics-42333">John Nash</a> portrayed in the movie <a href="https://www.imdb.com/title/tt0268978/">A Beautiful Mind</a>. You reach a Nash equilibrium when changing your own strategy won’t improve your situation, as long as everyone else’s strategy stays the same. Understanding the Nash equilibrium helps us understand the optimal strategies for all individuals in a group. </p>
<p>In some cases, however, the optimal individual and population strategies can actually be the same. This mostly occurs when the population is “open”, meaning it includes people joining and leaving.</p>
<h2>Individual and group interests sometimes match</h2>
<p>An example of this was shown in a recent study, published in the <a href="http://rsif.royalsocietypublishing.org/lookup/doi/10.1098/rsif.2018.0515">Journal of the Royal Society Interface</a>, that looked at a situation where people from one area could choose whether or not to travel to another area affected by disease. If the risk of disease was perceived as high because the outbreak was severe and was publicised with frequent news updates, then individuals would choose not to travel. This would be in line with the authorities’ desire for a travel ban. But if the outbreak wasn’t severe, then the travel ban would be lifted and tourists would be more likely to want to travel.</p>
<p>For most of the parameters the study considered, the optimal individual and group-level strategies coincided in this way. But sometimes there was still a discrepancy, for example when the number of individuals choosing to travel exceeded the optimum. This could lead to those people importing the disease back to their homeland, followed by a large outbreak there. </p>
<p>The difficulty is that, realistically, these discrepancies could emerge suddenly because many factors, such as the climate or virus evolution, could affect how quickly the disease spreads. What’s more, media coverage of the risk and relevant educational programmes could also influence visitors’ perception of the risk, regardless of official guidelines.</p>
<p>What game theory can do is help us make sense of all these factors to find out when individuals are most likely to act in a way that goes against the best interests of the group. Public authorities can then implement appropriate control measures in order to minimise the impact of an outbreak.</p><img src="https://counter.theconversation.com/content/102934/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Istvan Zoltan Kiss receives funding from Leverhulme Trust, EPSRC, LMS, IMA, University of Sussex, DEFRA, SEEDA.</span></em></p><p class="fine-print"><em><span>Nicos Georgiou receives funding from EPSRC. </span></em></p>Banning travel might not always be the best way to respond to a disease outbreak.Istvan Zoltan Kiss, Professor of Applied Mathematics, University of SussexNicos Georgiou, Senior Lecturer in Mathematics, Probability and Statistics, University of SussexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1010482018-08-08T06:36:01Z2018-08-08T06:36:01ZEbola returns to the DRC for the 10th time: here’s what we know<figure><img src="https://images.theconversation.com/files/230909/original/file-20180807-191041-1agm1b3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An experimental Ebola vaccine is being tried to contain the current outbreak in the DRC.</span> <span class="attribution"><span class="source">EPA-EFE</span></span></figcaption></figure><p><em>Barely a week after declaring the end of the ninth Ebola virus outbreak in the Democratic Republic of Congo (DRC), officials announced another in the North Kivu and Ituri Provinces, in the eastern part of the country. The Conversation Africa’s Ozayr Patel spoke to Jacqueline Weyer to found out more about the 10th Ebola outbreak in the country.</em> </p>
<p><strong>Where has the outbreak happened and what are the challenges in making sure it’s contained?</strong></p>
<p>The current outbreak is reported from the eastern provinces of <a href="https://www.aljazeera.com/news/2018/08/drc-ebola-deaths-confirmed-dozens-believed-infected-180805050652124.html">North Kivu and Ituri</a>. These are remote locations with a distance of more than 3000 kilometres separating them from the capital of Kinshasa. The provinces border Uganda and Rwanda and measures are being put in place to prevent the disease <a href="http://www.who.int/csr/don/4-august-2018-ebola-drc/en">spreading across the border</a>. </p>
<p>There are quite a few challenges to managing the outbreak. One of them is that this part of the DRC has been politically unstable for 20 years. This will, however, not be the first outbreak happening and being contained in conflicted territories.</p>
<p><strong>Can the country employ the same tactics it’s used before to battle this outbreak?</strong></p>
<p>Historically, containment efforts during these outbreaks have included tracing and monitoring anyone who has had contact with someone who is known to have contracted the Ebola virus. In addition, known cases of the Ebola virus disease are isolated to curb the spread of the disease. </p>
<p>The premise of these efforts is to essentially get ahead of the virus’s chain of transmission, and to break it. These methods are still effective and continue to be the mainstay of containment efforts. </p>
<p>In addition to this classic approach health officials now have a <a href="https://www.historyofvaccines.org/content/articles/ebola-virus-disease-and-ebola-vaccines">vaccination</a> to support outbreak management. </p>
<p>Several candidate vaccines have been developed for the Ebola virus. They remain at different stages of <a href="https://www.nih.gov/news-events/nih-research-matters/progress-two-ebola-vaccines">clinical trails</a>. One of these vaccines, used during the West Africa outbreak, was also employed during the previous Ebola outbreak in the DRC, with more than 3000 doses <a href="http://www.who.int/ebola/drc-2018/faq-vaccine/en/">administered</a>. </p>
<p>The vaccine is based on a benign virus that doesn’t cause illness in humans but provokes an immune response in the body without causing the disease - we call this type of vaccine a recombinant vaccine. The antibodies produced in response to this vaccination may then protect the recipient when an exposure happens. </p>
<p><strong>Why has the DRC experienced so many outbreaks of Ebola?</strong></p>
<p>Ebola is what’s known as a zoonotic disease – it can be transmitted from animals to humans. Although the natural ecology of the Ebola virus remains to be fully understood, scientists believe that the virus is naturally found in certain species of <a href="https://www.cdc.gov/vhf/ebola/resources/virus-ecology.html">forest-dwelling bats</a>. The virus can then be transmitted from the infected bats to other forest-dwelling animals, or to humans. Several outbreaks have been traced back to people who were very likely to have had contact with bush meat. Contact with raw blood and tissues of an infected animal is of particular concern. </p>
<p>Once the virus enters the human population it spreads through direct contact with the infected bodily fluids and blood of an an affected person. So, it is typically close contacts such as family and friends caring for the sick, who are at most risk. Burial rituals are also linked with the perpetuation of outbreaks as mourners have direct contact with the deceased. Health care workers are also at high risk of infection. </p>
<p>The ten outbreaks recorded from the DRC between 1976 and 2018 have not been reported from the same <a href="http://www.who.int/ebola/historical-outbreaks-drc/en">exact locations</a>. This implies that the virus is widely spread in its natural reservoir throughout the DRC, which is heavily forested. But it also indicates that the spread to humans is seemingly a rare event.</p><img src="https://counter.theconversation.com/content/101048/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacqueline Weyer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There have been ten Ebola outbreaks recorded from the DRC between 1976 and 2018 from different locations. This implies that the virus is widely spread.Jacqueline Weyer, Senior Medical Scientist, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/707622016-12-23T12:33:04Z2016-12-23T12:33:04ZThe new ‘100% effective’ Ebola vaccine owes a debt to the scientists who beat smallpox<figure><img src="https://images.theconversation.com/files/151451/original/image-20161223-17321-zmg1iy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">WHO/S. Hawkey</span></span></figcaption></figure><p>Almost a year after the <a href="http://www.who.int/mediacentre/news/releases/2016/ebola-zero-liberia/en/">official end of the Ebola</a> outbreak in West Africa, the final results from one of the only Ebola vaccine trials <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32621-6/fulltext">are now in</a> – and they look very promising. This is the only data we have on a vaccine against a virus in the <em>Ebolavirus</em> group in humans, and it looks very safe and highly effective during an outbreak setting.</p>
<p>Writing in the journal <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32621-6/fulltext">The Lancet</a>, an international team led by the World Health Organisation (WHO) has shown the ‘rVSV-ZEBOV’ vaccine produced by Merck can protect both individuals and a whole population, through its trials in Guinea. How they were able to run such a successful scientific study with such impressive results in the midst of an ongoing, serious epidemic serves an invaluable lesson to the public health community. This is especially true when other trials against Ebola <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0162199">were cut short</a> or never got <a href="https://theconversation.com/why-we-need-volunteers-for-the-first-human-ebola-trials-31158">as far as this one</a>.</p>
<p>The West African outbreak of Ebola virus disease <a href="https://theconversation.com/explainer-what-is-ebola-virus-25071">began in December 2013</a>, infecting nearly 29,000 people and killing <a href="http://www.who.int/csr/disease/ebola/en/">about one third of those</a>. It was brought to an end <a href="http://www.who.int/mediacentre/news/releases/2016/ebola-liberia/en/">in June 2016</a> through the hard work of local groups working with international teams of medical staff, using established methods to identify cases, isolate the patients and trace who else they had had contact with.</p>
<p>But success was never guaranteed and pursuing a vaccine that can protect an entire population is a critical part of a strategy for ending and preventing epidemics now and in the future. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/151453/original/image-20161223-17285-1sj4es0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Setting up trials.</span>
<span class="attribution"><span class="source">WHO/S. Hawkey</span></span>
</figcaption>
</figure>
<p><a href="https://theconversation.com/ebola-vaccines-were-always-in-the-pipeline-now-were-starting-to-see-the-results-35770">The rVSV-ZEBOV vaccine</a> had looked extremely effective in gold-standard preclinical testing in non-human primates. But no large investigations in humans had been carried out until <a href="https://theconversation.com/high-hopes-rest-on-800-vials-of-experimental-ebola-vaccine-shipped-from-canada-33201">the recent outbreak occurred</a>.</p>
<p>Testing a vaccine during a serious outbreak poses a problem for scientists. Ideally, you would give 50% of the population the vaccine and leave the other 50% as a control group, simply counting how many people get disease in one half compared to the other. But if there aren’t enough cases of the disease, it might be difficult to observe what effect the vaccine really has. And there’s a serious ethical issue in withholding a vaccine that has a good chance of being safe and effective from half the population, which may lead to more death and allow the disease to spread further.</p>
<p>This trial got around these issues by implementing a vaccine strategy that goes back to the days of smallpox elimination half a century ago: <a href="https://wwwnc.cdc.gov/eid/article/22/1/15-1410_article">ring vaccination</a>. This involves identifying people who already have the disease – the index cases – and tracing all the individuals in contact with them, and then the contacts of those contacts, which are usually friends, family and carers. You then vaccinate all the people you can in theses clusters around the outbreak victims. </p>
<p>The Ebola team split their clusters of people randomly into groups for immediate vaccination or delayed vaccination after 21 days. This meant that they could work out how effective the vaccine was, just by counting how many people – and how many clusters – had Ebola and compare the immediately vaccinated to the delayed group. They even had a “never vaccinated” group of people they couldn’t vaccinate, for example because they didn’t consent, they could also compare to.</p>
<h2>100% effective</h2>
<p>The rVSV-ZEBOV vaccine looked so safe and effective <a href="http://www.thelancet.com/pb/assets/raw/Lancet/pdfs/S0140673615611175.pdf">during an interim analysis</a> that the team had to stop the delayed vaccination and vaccinate everybody they could, including even children. The further analysis in this study supports those initial conclusions. They found no cases of the disease in the immediately treated group compared to 23 cases in 11 clusters in the delayed or never vaccinated group.</p>
<p>When they zoomed in on each cluster, they could even see that vaccinating individuals in a cluster would stop unvaccinated people in the same cluster getting infected. This suggested they had developed what’s known as <a href="http://vk.ovg.ox.ac.uk/herd-immunity">herd immunity</a>, where enough people in a group are immune to prevent an outbreak – protecting even those who aren’t vaccinated. Because of this success, it looks like the trial probably helped bring the outbreak in Guinea to an end. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/151454/original/image-20161223-17282-xsryc0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Working with patients.</span>
<span class="attribution"><span class="source">WHO/S. Hawkey</span></span>
</figcaption>
</figure>
<p>While the data suggests the vaccine is 100% effective, this is not likely to be <a href="https://theconversation.com/news-about-the-success-of-a-new-ebola-vaccine-may-be-too-good-to-be-true-45801">the definitive number</a>. Biology simply does not work like that. This is especially true when the numbers looked at are so small (23 cases in the control group). The potential inaccuracy of this number likely reflects the challenges in conducting a vaccine trial such as this, for a disease like EVD in the middle of a very serious outbreak. </p>
<p>There is also the fact that no vaccine is perfect. Even one of our very best vaccines, the measles vaccine, is only about <a href="http://www.nvic.org/vaccines-and-diseases/measles/measles-vaccine-effectiveness.aspx">95% effective</a>. Previous studies have even shown that rVSV-ZEBOV produces an immune response in only <a href="https://www.niaid.nih.gov/news-events/experimental-ebola-vaccines-well-tolerated-immunogenic-phase-2-study">94% of individuals</a>. Being certain about the effectiveness is important because <a href="https://wwwnc.cdc.gov/eid/article/22/1/15-1410_article">computer models suggest</a> that ring vaccination for Ebola may only be successful when there aren’t that many cases. </p>
<p>Despite being carried out under some of the most challenging conditions, the trial reported here appears to be an exceptionally well-run study, comprehensive in its nature and with a very positive result. This surely cements this vaccine as one important tool in controlling outbreaks of Ebola in the future. It also gives us a way to test new vaccines for other viruses that can crop up and take us by surprise, such as <a href="http://www.who.int/csr/disease/lassafever/en/">Lassa fever virus</a> and <a href="http://www.who.int/csr/disease/nipah/en/">Nipah viruses</a>. We just have to hope that scientists have got more vaccines in the pipeline for us to test.</p><img src="https://counter.theconversation.com/content/70762/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Connor G G Bamford does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The final trials of the first effective Ebola vaccine show it’s safe to use against an outbreak.Connor G G Bamford, Post-doctoral Research Assistant, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/628882016-09-20T20:30:56Z2016-09-20T20:30:56ZHow can we get pharma companies to do more for global health? Try ranking them<p>The World Health Organization <a href="http://apps.who.int/medicinedocs/en/d/Js6160e/9.html#Js6160e.9">reports that a third of the world’s population</a> cannot access important medicines for some of the world’s most devastating diseases, like malaria and tuberculosis.</p>
<p>There are many reasons these drugs are out of reach of so many people, but the fact that few medicines to treat diseases like malaria and tuberculosis are developed and that the prices are high for the drugs that are developed are major factors.</p>
<p>I study ethics and work on questions about the obligations of pharmaceutical companies, and I believe that these companies have a moral and legal obligation to ensure access to essential medicines. The legal human right to health is embodied in Article 12 of the International Covenant on Economic, Social and Cultural Rights. It <a href="http://www.ohchr.org/EN/Issues/Health/Pages/SRRightHealthIndex.aspx">states that everyone has a right</a> “to the enjoyment of the highest attainable standard of physical and mental health.” This right is essential for protecting individuals’ ability to live minimally good lives.</p>
<p>When companies set high prices, lobby to extend patent protections on important medicines and do not develop enough new drugs for neglected diseases, they fail to live up to these obligations. </p>
<p>I head the Global Health Organization, which produces an index assessing the impact of drugs that treat some of the world’s most devastating diseases. As I argue in a recently <a href="http://www.ncbi.nlm.nih.gov/pubmed/27338607">published article</a> in The Journal of Law, Medicine and Ethics, this could create an incentive for companies to live up to their obligations. For instance, in the future if consumers in the developed world know which companies are doing the most for global health, they may choose to purchase products from those companies.</p>
<h2>Why are drugs so expensive?</h2>
<p>In parts of Africa and Asia about half the population cannot get the drugs that they need for diseases like malaria, tuberculosis (TB) and HIV/AIDS. This is often because these drugs are under patent and profit-driven companies can charge high prices for them even in poor countries. Moreover companies push to extend their patents through lobbying and international trade agreements.</p>
<p>For instance, delamanid, one of two new treatments for multidrug-resistant tuberculosis, must be taken with several other medicines, and the regimen can cost <a href="https://www.statnews.com/pharmalot/2016/02/25/drug-pricing-doctors-without-borders-tuberculosis/">US$1,000 to $4,500</a> for a six-month course of treatment. This is more than what <a href="http://www.un.org/en/development/desa/policy/cdp/ldc/ldc_criteria.shtml">most people make in a year</a> in many developing countries. Few developing country governments can afford the expense. </p>
<p>Companies say <a href="http://www.phrma.org/innovation/intellectual-property">patent protection is essential</a> for doing research and development on new drugs and technologies. But historical evidence suggests that patents may <a href="http://www.cambridge.org/us/academic/subjects/economics/industrial-economics/against-intellectual-monopoly?format=HB">not be a particularly effective way of promoting new research</a>. Indeed, until recently, several key innovator countries such as Italy, Germany and Switzerland had relatively weak patent protection. </p>
<h2>Why are so few essential medicines developed?</h2>
<p>The fact is that even with patents on important medicines for the world’s most widespread and devastating diseases, few are developed. Of the 1,393 medicines marketed between 1975-1999, only <a href="http://www.ncbi.nlm.nih.gov/pubmed/12090998">16 were for tropical diseases</a>.</p>
<p>The patent system on its own does not seem to be creating enough incentive to address the health problems in poor countries. Companies cannot make enough money from selling drugs to poor people in developing countries to <a href="http://www.ncbi.nlm.nih.gov/pubmed/27338607">justify the research and development expense</a>.</p>
<p>While there are many innovative <a href="http://www.ncbi.nlm.nih.gov/pubmed/14625999">strategies</a> that <a href="http://www.who.int/pmnch/topics/economics/20100505_medicinesaccessible/en/">lower the costs of existing drugs</a> and encourage the development of <a href="http://priorityreviewvoucher.org">new ones</a>, they are <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC340954/">not sufficient</a> to fully address the problem. For instance, even with increased funding for global health, from 2000-2011, only <a href="http://dx.doi.org/10.1016/S2214-109X(13)70078-0">1 percent of new chemical entities approved were for neglected disease</a>.</p>
<p>There is little reason to think we can reform the patent system to push companies to develop enough drugs for neglected diseases any time soon, but consumer action in developed countries may give companies another incentive to produce, and lower the prices on, drugs for neglected diseases. This is where the Global Health Index comes in.</p>
<h2>Supporting companies supporting the common good</h2>
<p>The Global Health Organization is supported by a <a href="http://globalcollaboration">collaboration</a> of researchers from universities and civil society organizations from around the world. We developed the Global Health Index to measure drug impact in terms of <a href="http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/">Disability Adjusted Life Years</a> saved – which incorporates both sickness averted and deaths prevented by looking at the need for the medicines, their effectiveness and access to them. </p>
<p>The index can show which drugs are making a real difference and which are not. As late as 2010, for instance, some relatively ineffective drugs for HIV/AIDS were still widely used. This is probably due to high prices for better alternatives. So, if companies lowered prices for the more effective drugs, more lives might be saved. So far, we’ve found that drugs on which Sanofi, Novartis and Pfizer held the patent had some of the largest impacts, while Eli Lilly, Kyorin and Bayer’s drugs had the smallest impacts. </p>
<p>Companies are paying attention to the index because it can <a href="http://www.marketplace.org/2015/01/23/health-care/new-effort-ranks-drugmakers-impact">affect brand perception</a>. </p>
<p>As Sanofi executive François Bompart <a href="http://www.marketplace.org/2015/01/23/health-care/new-effort-ranks-drugmakers-impact">says</a>, the Global Health Impact Index is “a good way for people to compare their performance, and… [it gives them] an incentive to do better and be more creative.” The index creates a stronger incentive for companies <a href="http://www.marketplace.org/2015/01/23/health-care/new-effort-ranks-drugmakers-impact">to be better corporate citizens</a>.</p>
<p>We plan to expand the Global Health Impact Index beyond malaria, tuberculosis and HIV/AIDS to help provide an incentive for companies to develop medicines for other neglected tropical diseases such as worms and schistosomiasis.</p>
<p>Future iterations of the Global Health Impact Index, in conjunction with other measures of corporate social responsibility like the <a href="http://www.accesstomedicineindex.org/">Access to Medicines Index</a>, might be the basis for boycotts of poorly rated companies or socially responsible investments. People could lobby insurance companies to include products from companies that perform well on the Global Health Impact Index in their formularies. </p>
<p>In the future, we envision a Global Health Impact label, like a Fair Trade label, for companies to use on all of the over-the-counter products they make – everything from pet vitamins to painkillers. The hope is that consumers in developed countries will prefer to purchase everyday medicines from companies with better rankings on the Global Health Impact Index. Similar ethical labels like “Fair Trade” have had a <a href="http://www.wageningenacademic.com/doi/book/10.3920/978-90-8686-647-2">large impact</a> in some places. </p>
<p>Millions of people suffer from devastating diseases in developing countries. By using data about what companies are doing for global health, we all might be able to push them to live up their obligations.</p><img src="https://counter.theconversation.com/content/62888/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Hassoun does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the future, consumers in the developed world could choose to purchase products from the companies that do the most to promote global health.Nicole Hassoun, Associate Professor of Philosophy, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/493292015-10-22T16:24:45Z2015-10-22T16:24:45ZStaying alive is just step one for West Africa’s Ebola survivors<p>The West African countries of Guinea, Sierra Leone and Liberia have now been battling an Ebola epidemic for almost two years. Although new cases have been <a href="http://www.theguardian.com/world/2015/jan/22/drop-in-ebola-cases-signals-turning-point">falling for some time</a>, it is only recently that a possible vaccine has been <a href="http://bit.ly/1HETAIF">found successful</a> and the epidemic now finally seems to be coming under control.</p>
<p>To date, in West Africa, over <a href="http://apps.who.int/ebola/current-situation/ebola-situation-report-7-october-2015">28,000 people</a> have been affected. Over a third of those people have died but almost two thirds have survived. While most research has so far rightly concentrated on containing and curing the disease, we should now turn to rebuilding public health systems and planning the long-term care needs of survivors – and all West Africans.</p>
<h2>From surviving Ebola to living with it</h2>
<p>We know from previous outbreaks of Ebola – for example, in the <a href="http://jid.oxfordjournals.org/content/179/Supplement_1/S1.long">Democratic Republic of Congo</a> – that survivors can <a href="http://jid.oxfordjournals.org/contloss79/Supplement_1/S13.long">suffer problems</a> with their vision, hearing or joint pain. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25%20e637">Some studies</a> have shown these issues can last for at least two years after a patient is diagnosed with the disease and that they can also develop cognitive problems such as memory loss.</p>
<p>Evidence <a href="http://time.com/3850998/ebola-eye-virus-ian-crozier">also indicates</a> that the Ebola virus can remain in vital organs such as the eyes for months, even when no other symptoms are present, potentially leading to a <a href="https://theconversation.com/how-can-cured-ebola-patients-fall-sick-again-months-after-recovery-48915">re-emergence of the disease</a>. And survivors are <a href="http://rsx.sag%20epub.com/content/early/2014/12/15/1933719114563733.extract">currently advised</a> to use condoms until doctors can be sure the virus is gone. Research evidence is unclear how long this can take.</p>
<p>The problem is healthcare provision for Ebola survivors in affected countries <a href="http://bit.ly/1RXXN1I">currently focuses</a> on short-term clinical treatment rather than long-term planning for a chronic condition. <a href="http://www.sciencedirect.com/science/article/pii/S1473309915701520">Survivors need</a> access to specialist visual, hearing, mental and reproductive healthcare services and professionals. But the needs of Ebola survivors stretch far beyond immediate medical treatment, <a href="http://www.sciencedirect.com/science/article/pii/S1473309915701659">encompasssing</a> long-term monitoring and access to rehabilitation and culturally sensitive mental health services.</p>
<p>We don’t yet understand what the full lifetime effects will be on young children who survive the disease, especially those that <a href="https://theconversation.com/better-policies-are-needed-to-support-local-adoptions-for-children-orphaned-by-ebola-45412">have been orphaned</a> or are living in poverty. But we do know that some of the physical effects of the disease can create long-term disabilities as such as vision loss. The consequences for people who lose <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003706">family members and social networks</a> can also <a href="https://theconversation.com/as-sierra-leone-waits-for-ebola-all-clear-its-emotional-scars-will-take-longer-to-heal-46421">be profound</a> and lead to psychological problems such as emotional anxiety and depression, and even survivor guilt.</p>
<p>More widely, there are major <a href="http://sa.au.int/en/sites/default/files/THE%20SOCIAL%20IMPACT%20OF%20EBOLA%20-English.pdf">social and economic consequences</a> for Ebola survivors, who <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6350a6.htm">may have lost</a> their support networks, employment and even their possessions during the infection control process. We also know that people suffer the effects of a global and local stigma towards Ebola and may be shunned by their communities, unable to even enter shops to replace their lost belongings.</p>
<h2>Meeting community needs</h2>
<p>Governments, donors and voluntary organisations have all taken steps to help reintegrate Ebola survivors into their communities. <a href="http://www.cdc.gov/mmwr/preview/mmwrhtmhttp://www.who.int/features/2014/post-ebola-syndrome/en/a6.htm">For example</a>, they have provided packages of clothes and other everyday items, worked with community leaders to address stigma and encouraged survivors to take a role in providing support to help restore their dignity. Psycho-social care has <a href="http://www.who.int/features/2014/post-ebola-syndrome/en/">so far focused</a> largely on creating support groups and social protection schemes. Getting the different groups involved to <a href="http://www.who.int/features/2015/ebola-survivors-clinic/en/">provide specialist care</a> but also to monitor and support each other would seem like another step in the reintegration process.</p>
<p>But what is really needed is a response that benefits the whole community, one that is also aware of how health inequalities affect women, children and disabled people. This would begin by asking patients, their families and local communities about their public health needs, using community meetings to better understand the barriers to accessing care. In turn, this would open the debate up to improving the health of everyone and not just the health system.</p>
<p>In poor countries that have experienced recent conflict, such as Sierra Leone and Liberia, global and local health policy has neglected these issues of equality and democracy. <a href="http://eprints.whiterose.ac.uk/90600/">As a result</a>, health systems don’t adequately reflect local needs and leadership isn’t held accountable. More also needs to be done to link social care and specialised health services while rebuilding local capacity.</p>
<p>Instead of trying to impose <a href="http://link.springer.com/article/10.1007/s10198-015-0710-0">public health policies</a> and structures on communities, organisations need to make sure local people and governments have more of a bottom-up democratic role in creating their own health systems. Public health work becomes more sustainable when it reflects specific local health needs and <a href="http://www.sciencedirect.com/science/article/pii/016885109500737D">prioritises investment</a> and <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301102">payment of healthcare workers</a>. Rebuilding is also about the entire public health system including linked transport, education, housing and sanitation infrastructure.</p>
<p>People with chronic health issues, such as the long-term effects of Ebola, will need a variety of services to help them rebuild and carry on with their lives. For this to work, all health and social care services have to become used to dealing with disabled patients as a matter of routine. This urgently needs to become a mainstream reality in all policy and practice.</p><img src="https://counter.theconversation.com/content/49329/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maria Berghs does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Recovering from Ebola can mean disability, stigma and the threat of the disease returning – but authorities are starting to act.Maria Berghs, Research Fellow, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/454122015-08-13T05:56:15Z2015-08-13T05:56:15ZBetter policies are needed to support local adoptions for children orphaned by Ebola<figure><img src="https://images.theconversation.com/files/91103/original/image-20150807-9923-1qqvlu9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Better policies could do a lot to help children orphaned by Ebola.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unicefguinea/15463546618/in/photolist-pysHEJ-pQYZTJ-r5ndGw-oerhxP-rwjPiC-ryvKVC-sxxkhj-sQ8odZ-rTmqpZ-rT8Lto-sxFrin-sxzCX7-rT9CT1-sxxHwE-sPXwLS-rTm4wX-sxGSLV-sPWrsY-sQa1jP-sxF3Gk-sxysQq-sQ9qoD-rTkDaa-rTkcJR-sMQPCh-rTk88M-sPWYAQ-rT8bFU-pzfgiA-ocvwnC-oeri1x-ocAdRU-ocEnhB-oaC3rY-nVaX1B-oaC4wJ-oaC3YE-ocEmMt-nVbPzR-rJN9R3-pJhysz-nVazSf-rqyqtk-rqqYhq-roGdBZ">UNICEF Guinea</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>While the worst of the Ebola epidemic has passed, its impact is far from over for the orphans left behind. In Sierra Leone alone, a country of just over six million people, the Ebola epidemic has orphaned more than 12,000 children who have lost one or both family members, according to <a href="http://www.street-child.co.uk/ebola-orphan-report">Street Child</a>, a British charity.</p>
<p>It might seems like adoption is the most obvious solution to help these orphaned children. But adoption in this scenario, whether to relatives nearby or prospective parents overseas, is difficult. Instead, governments in West Africa and international aid agencies should help facilitate adoptions locally and provide better health care and education to support entire communities.</p>
<h2>Family adoption isn’t always easy</h2>
<p>I first went to Sierra Leone in 2005 as a Fulbright Scholar to research the impact of humanitarian aid on children and other vulnerable groups. The orphans I encountered faced many health and educational challenges, but they usually were not homeless. Instead, relatives within an extended family group cared for them.</p>
<p>Traditional adoption, however, is unlikely to help all Ebola orphans throughout West Africa. These orphans are often stigmatized by their association with the disease. In some cases, the orphans are also the only member of their extended family to survive. And the children who endured the disease often need additional medical attention for lingering health problems, such as poor eyesight and joint pain, which few families can cope with alone.</p>
<p>Arranging family adoption is also problematic, as Ebola orphans are clustered in separate communities. Francis Mason, director of the Conforti Community Aid Children Organization (CCACO) of Freetown, emphasized in an interview with me that:</p>
<blockquote>
<p>The problem is not so much of individual orphans but of groups of orphans in communities where whole families are missing. </p>
</blockquote>
<p>In the village of Romeni, located in Port Loko province, community members now struggle to care for 522 officially registered orphans. While Romeni, which had a pre-Ebola population of over 2,000, accepts responsibility for the children, the sheer numbers add to the economic stress caused by the epidemic. Food shortages are common, and even clothing the children is a problem. Many have only rags to wear. </p>
<p>In other cases, orphans have moved multiple times, having been taken from their home village to a distant Ebola Treatment Center, and then returned, only to be passed between relatives. Some are unable to be reunited with family members. </p>
<p>While on a recent visit to Port Loko, I learned of one small boy, age six, who became stranded in a care center in Bo, a city far away from his original home. While the boy knew his name, he was uncertain of his home. Despite repeated attempts to find relatives, his village has yet to be located, leaving him for an indefinite time in the care center, separated from family members.</p>
<h2>International adoption won’t help many children</h2>
<p>In past responses to epidemics, international adoption has helped to supplement local solutions. But in this case, foreign adoption is unlikely to be widely used. The policies of both national governments and international organizations make this process complex and lengthy. </p>
<p>In addition, <a>regional norms</a>, developed by the African Child Policy Forum (<a href="http://www.africanchildforum.org/en/index.php/en/">ACPF</a>), actively discourage adoption of Africans by foreigners. </p>
<p>According to Mark Montgomery, professor of economics at Grinnell College and an expert on international adoption, “Very few African countries allow more than a trickle of children to be adopted abroad.”</p>
<p>Although Sierra Leone does not officially prohibit adoption, prospective parents must fulfill a six-month residency requirement. The entire adoption process can take up to two years and includes mandatory field investigations by the US Department of State. </p>
<p>According to the State Department, only <a href="http://travel.state.gov/content/adoptionsabroad/en/country-information/learn-about-a-country/sierra-leone.html">33 children</a> from Sierra Leone were adopted by Americans in 2013.</p>
<h2>Policies to support orphans within their communities</h2>
<p>Adoption alone is unlikely to meet the needs of Ebola orphans. But an integrated approach that enhances traditional solutions with special measures for orphans, their families and their wider communities could do that.</p>
<p>A starting point for this strategy is to establish the legal status of orphans and secure their position with a family member or other caregiver. This may require outside intervention from international humanitarian agencies. It may be necessary to search for surviving relatives in another community or bring children from a distant treatment center back to their village. </p>
<p>In Sierra Leone, <a href="http://www.unicef.org/appeals/files/UNICEF_Sierra_Leone_EVD_Weekly_SitRep_15_July_2015.pdf">UNICEF</a>, in conjunction with the national <a href="http://mswgca.gov.sl/Ebola/index.html">Ministry of Social Welfare, Gender and Children’s Affairs</a>, supports civil society groups that reunite Ebola orphans with family members and help to establish guardianship. Children may be moved from one home to another if their current family setting is unsuitable.</p>
<p>Orphans also need to be protected from the danger of illegal activities. “Ebola has put children more at risk for child trafficking, child abuse, and child labor,” says Haley Clark, Child Protection Officer at <a href="http://www.worldhope.org/locations/africa">World Hope International</a>, an American humanitarian organization, who spoke with me in Freetown. She says that there needs to be more coordination between aid and support services to address human trafficking and child labor in both rural and urban settings. </p>
<p>Most importantly, support for individual orphans could be combined with broader community development efforts that address education, health care, food security and housing. This approach would supplement major initiatives undertaken by the <a href="http://www.worldbank.org/en/news/press-release/2014/09/25/world-bank-group-nearly-double-funding-ebola-crisis-400-million">World Bank</a> to improve medical care in Guinea, Liberia and Sierra Leone. In addition, orphans need targeted support efforts in places that are former Ebola hot-spots.</p>
<p>For instance, support for local schools in villages hard-hit by Ebola will help not only orphans but also other children as well. Greater attention to clean water and adequate sanitation in both urban and rural areas is especially important, as improvements in these areas can help to prevent the outbreak of future epidemics.</p>
<p>Greater integration between programs targeted at individual orphans and those designed to help their wider community can help heal the ravages of the Ebola epidemic.</p><img src="https://counter.theconversation.com/content/45412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claudena Skran received funding from the US government - Fulbright Fellowship (2005-06) and UNHCR - consultant (2011-12) to conduct research on aid projects in Sierra Leone. She is affiliated with the Kidsgive - Sierra Leone scholarship program, supported by Lawrence University and private donors..</span></em></p>Governments in West Africa and international aid agencies should help facilitate adoptions locally and provide better health care and education to support entire communities.Claudena Skran, Professor of Government and West Professor of Economics and Social Science, Lawrence UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/458012015-08-11T10:43:09Z2015-08-11T10:43:09ZNews about the success of a new Ebola vaccine may be too good to be true<p>Ebola is on the run: the number of cases <a href="http://abcnews.go.com/Health/wireStory/ebola-cases-single-digits-2nd-week-32901959">dipped below 10 a week</a> recently, and a few days ago investigators <a href="http://dx.doi.org/10.1016/S0140-6736(15)61117-5">announced in the prestigious journal The Lancet</a> that a new Ebola vaccine was “100% effective.”</p>
<p>In response, global health authorities are starting to sound a little giddy. “We believe that the world is on the verge of an efficacious Ebola vaccine,” <a href="http://www.reuters.com/article/2015/07/31/us-health-ebola-vaccine-idUSKCN0Q51FP20150731">said</a> Marie Paule Kieny, the World Health Organization’s (WHO) assistant director-general for health systems and innovation (and an author on the study). “It could be a <a href="http://www.bbc.com/news/health-33733711">game changer</a>.”</p>
<p>She’s right: this is wonderful news, and a great testament to human ingenuity. A <a href="http://www.nature.com/news/how-ebola-vaccine-success-could-reshape-clinical-trial-policy-1.18121?WT.mc_id=TWT_NatureNews">genetically engineered hybrid</a> of the benign vesicular stomatitis virus and the Zaire strain of Ebola, together called rVSV-ZEBOV, was tested in a multi-site clinical trial conducted amid a massive aid response in Guinea, one of the poorest countries in Africa. The scientific and logistical acrobatics required to pull this off boggle the mind.</p>
<p>Yet, for three reasons, we cannot know if the vaccine really worked, or how well. Those reasons are the lack of placebo comparison, the way the investigators diagnosed vaccine failure and the possibility of statistical flukes.</p>
<h2>Reason #1: There was no placebo to test the vaccine against</h2>
<p>In response to the <a href="http://www.wsj.com/articles/squabbles-over-testing-methods-hamper-search-for-ebola-vaccine-1428602404">challenging ethics</a> of Ebola vaccine research, investigators studying rVSV-ZEBOV opted not for the standard placebo-controlled trial with which most vaccines are tested but instead for an innovative approach called “ring-vaccination.” </p>
<p>In the clinical trial, the investigators drew a “ring” of vaccination around people with known exposures to Ebola. Groups of people who were exposed to a person with Ebola virus disease, or to someone who had been in contact with someone else with Ebola virus disease, were invited to participate in the study. Researchers recruited 7,651 people who fit that profile and randomized them to receive immediate vaccination with rVSV-ZEBOV or vaccination that was delayed by 21 days. </p>
<p>Afterwards, investigators followed all study participants for several weeks to see if they developed Ebola virus disease. In the immediate vaccination groups, no one developed Ebola virus disease more than 10 days after vaccination, whereas 16 patients in the delayed vaccination group did. Because the number of cases of Ebola virus disease was so much lower (ie, zero) in the immediate vaccination group, the investigators concluded the vaccine was 100% effective. </p>
<p>This conclusion was reasonable, but it also could be wrong. Without a placebo comparison, it’s easy to get fooled. Perhaps people with deferred vaccination were more likely to engage in risky Ebola exposures, or those who developed Ebola virus disease in the immediate vaccination group were less likely to stay in study follow-up. The investigators did as good a job as possible to avoid these problems, but without a placebo arm in the study, we just cannot be sure.</p>
<h2>Reason #2: The definition of vaccine failure isn’t failsafe</h2>
<p>No cases of Ebola developed in the immediate vaccination group 10 days after vaccine was given. But nine cases of Ebola developed in the immediate vaccination group <em>within</em> 10 days of vaccination. Since the incubation period for Ebola virus disease is typically longer than 10 days, the investigators concluded that the nine cases of Ebola virus disease that developed within 10 days of getting the vaccine resulted from pre-vaccine exposure. </p>
<p>Again, this was a defensible conclusion, but it could also be wrong. Sometimes Ebola develops in less than 10 days, which means some or all of the nine people in the immediate vaccination group could have been infected with Ebola after being vaccinated. That means sometimes the vaccine may have failed to provide protection against Ebola, and we do not know exactly how often.</p>
<h2>Reason #3: The possibility of statistical flukes</h2>
<p>When investigators were following study participants to see if the vaccine prevented Ebola, the total number of Ebola cases was shrinking rapidly. That is good news for people living in West Africa but problematic for the study. With such a small number of total cases, comparisons between immediate and delayed vaccinees become harder to make with confidence, because statistical flukes can occur. </p>
<p>How easily could a fluke event have thrown off the results? </p>
<p>Let’s go back to those nine cases of Ebola in the immediate vaccination group. Imagine if just a few of them were cases of vaccine failure, and in fact, were cases where Ebola virus disease developed after vaccination. Further, what if a few immediate vaccinees lived in communities where infection control measures were better, coincidentally, than in communities where vaccination was delayed? Perhaps immediate vaccinees were less likely to encounter Ebola because burial practices were less risky in their communities, by chance, or there was a better supply of gloves and other protective equipment. If both easily imaginable circumstances occurred in just a few cases, vaccine efficacy could be much lower than 100% and our public health messaging would be considerably more muted.</p>
<p>The study investigators took meticulous steps to prevent each of these problems, and they argue persuasively that it is unlikely the protection they saw from rVSV-ZEBOV was entirely due to chance. I agree. The point is that it is easy to imagine ways the vaccine is far less than 100% effective, and even possible (if unlikely) the vaccine provided no protection whatsoever. The reasonable doubt that remains is why most vaccines are tested and then retested in placebo-controlled clinical trials so that the public can trust us when we say vaccines work.</p>
<h2>Despite need for more info, we aren’t likely to get it</h2>
<p>In response to this uncertainty, Lancet editorialists were properly <a href="http://www.thelancet.com/pb/assets/raw/Lancet/pdfs/S0140673615611771.pdf">guarded</a> about the vaccine. They wrote, “More data on efficacy are needed before it can be widely deployed.” </p>
<p>More data are needed – but we will probably never get more data. Ebola is burning out in western Africa. That means it is becoming increasingly impossible to test the efficacy of any intervention against Ebola. This is one reason that the clinical trial results for the rVSV-ZEBOV vaccine were released earlier than expected: the data safety and monitoring board for the trial recognized that with so few cases of Ebola, the trial could no longer acquire meaningful efficacy data. That means the Guinea rVSV-ZEBOV vaccine trial is likely to remain the best evidence we have for an effective Ebola vaccine for a long time.</p>
<p>Ordinarily, the next step would be to prove vaccine efficacy beyond a shadow of a doubt by comparing the vaccine to placebo in a large randomized clinical trial. To get this done, we would need to wait for the next time Ebola emerges in some remote village in Guinea or a neighboring country, and then mount the mother of all Ebola vaccine trials designed to prove that the magic bullet we seek is really in hand. </p>
<p>We will probably never take this step. Just as many scientists <a href="http://www.theguardian.com/world/2014/oct/10/ebola-vaccine-placebo-trials-unethical-scientists-say">decried placebo-controlled studies</a> amid the present Ebola epidemic, surely any future resurgence of Ebola cases will be accompanied by a similar hew and cry. In fact, the critique will be even more vehement: with a vaccine already touted as “100% effective,” how can we possibly deny it to people at risk of death in days? As a harbinger of this conversation to come, upon release of the rVSV-ZEBOV study results, the study data safety and monitoring board recommended and ultimately Guinean ethics authorities approved of immediate rVSV-ZEBOV vaccination for all people in the study region who were newly exposed to Ebola. </p>
<h2>Are we lowering our standards for vaccines in the developing world?</h2>
<p>In a time when we benefit from a <a href="http://www.cdc.gov/vaccines/hcp/acip-recs/index.html">panoply of effective vaccines</a>, it is easy to assume all vaccines work well. Yet many vaccine candidates have failed. To list a few, there are failed vaccines against <a href="http://www.sciencemag.org/content/330/6002/304">herpes simplex virus</a> and <a href="http://jama.jamanetwork.com/article.aspx?articleid=1674236"><em>Staphylococcus aureus</em></a> and even two HIV vaccines that <a href="http://www.nature.com/news/hiv-vaccine-raised-infection-risk-1.13971">seemed to increase</a> the risk of HIV infection. The reason we test vaccines in rigorous placebo-controlled trials is to avoid exposing the public to vaccine duds, or worse. </p>
<p>Does our well-founded fear of Ebola, and our equally <a href="http://www.nejm.org/doi/full/10.1056/NEJM199710023371411">legitimate</a> fear of unethical placebo research in Africa, convince us that people in West Africa should be given a vaccine that hasn’t been proven effective using the same standards as vaccines given in the rich countries of the world?</p>
<p>It might be politically easier, and logistically expedient in the short term, to answer “yes.” But, in the long run, I fear saying “yes” will make it harder to deliver to low- and middle-income countries vaccines of the same quality as are used in rich countries. </p>
<p>That is why it is so important to know whether the Ebola vaccine was 100% effective, or 100% lucky. The good money is on a percentage somewhere in between, but in truth, I doubt we will ever know.</p><img src="https://counter.theconversation.com/content/45801/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Previously Timothy P Lahey received funding from the NIH and private funders for research related to HIV immunology, and TB vaccines. None present a conflict of interest with the current article. </span></em></p>Was the Ebola vaccine 100% effective, or 100% lucky? The good money is on a percentage somewhere in between, but in truth, we will never know.Timothy P Lahey, Associate Professor of Medicine, Dartmouth CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/408852015-05-22T16:40:00Z2015-05-22T16:40:00ZThe Ebola outbreak highlights shortcomings in disease surveillance and response – and where we can do better<figure><img src="https://images.theconversation.com/files/82440/original/image-20150520-11450-mgtxg3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two women walk in front of a billboard, which says "Ebola must go. Stopping Ebola is Everybody's Business" in Monrovia, Liberia, January 15 2015.
</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unmeer/16130327748/in/photolist-qzo9t7-oSscns-pg72Le-mZyb4f-mZyaVE-oHimQn-oCVKH6-op34XZ-oHgPqn-oDu5N9-pR4ewF-rdq1T3-q6bu3C-pQZWrR-purTDK-ocA6u9-oFukiA-oFipFC-sd4xMc-ozymNw-ovHMjj-oxFbgp-oxEVMp-ovCUoB-r5ndGw-qNKeMF-q6bRs1-r617Uh-pyBaz3-pBoeo6-oUu2Gt-piU225-qoCKXE-p58esM-qwihUe-piag7D-oXcJW5-mZyaYW-pxUe6Y-qTfRRp-qTLM78-pvTEb5-pzBsRW-oYBRVh-qN1o9r-oZ1QmQ-oMEPC8-oer9yg-pQTq2G-r3TCGn">UNMEER/Emmanuel Tobey</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>Right now the World Health Organization (WHO) is holding its annual <a href="http://www.who.int/mediacentre/events/2015/wha68/en/">World Health Assembly (WHA)</a>. At this time last year, Ebola Virus Disease (EVD) was rapidly spreading through West Africa, and the outbreak is rightly a major item on this year’s assembly agenda. Attention will be paid to the decisions made in response to the outbreak and what this tells us about how best to respond to the next one, including for advance preparation and early warning.</p>
<p>WHO Director-General Margaret Chan has already outlined her plans for a US$100 million <a href="http://www.who.int/dg/speeches/2015/68th-wha/en/">contingency fund</a> to support emergency response capacity in future outbreaks. This is welcome news. </p>
<p>The EVD outbreak in West Africa demonstrates how important the interaction between human and animal health is. It is a zoonotic infection, which means it originated in animals (bats, in this case) before spreading into humans. So, alongside better strategies to respond to outbreaks in human populations, we also need to have a stronger focus on disease surveillance in animals to identify infectious diseases before they pose a risk to human health. </p>
<p><a href="http://www.onehealthinitiative.com">One Health</a>, a discipline through which we examine how the interactions of humans, animals and the environment come together to allow an infectious threat to arise, develop and become a sustained outbreak, could have informed a better preemptive response to the virus.</p>
<h2>How did Ebola become a major outbreak?</h2>
<p>Ebola causes harmless, asymptomatic infection in bats. It took one encounter (or entry cause) for the virus to spill into humans. After that initial encounter, the disease was able to spread through communities in West Africa because of <a href="http://www.who.int/csr/disease/ebola/one-year-report/factors/en/">limited public health infrastructure</a>. The regional population is <a href="http://currents.plos.org/outbreaks/article/containing-the-ebola-outbreak-the-potential-and-challenge-of-mobile-network-data">highly connected</a>, which led to an exponential increases in cases. There was also a lack of diagnostics for other <a href="http://www.who.int/csr/disease/ebola/one-year-report/factors/en/">infectious diseases</a>. Unfortunately, the global community was slow to take action.</p>
<p>In the affected areas, there was a <a href="http://www.dw.de/ebola-fight-hindered-by-lack-of-awareness/a-17858448">lack of awareness</a> about EVD and its transmission, which allowed the spread of disease. This emphasizes the need for education and communication in the community that involve local leaders as well.</p>
<h2>Responding to the outbreak</h2>
<p>When it became clear that EVD had the potential to go from a severe regional outbreak to a <a href="http://www.sciencedirect.com/science/article/pii/S1201971214016178">pandemic</a>, interdisciplinary teams arrived to help the overwhelmed domestic healthcare system control the epidemic.</p>
<p><a href="http://www.msf.org/article/guinea-mobilisation-against-unprecedented-ebola-epidemic">Doctors Without Borders</a> (MSF) was the first to highlight that this was an unprecedented outbreak, as early as March 2014, following the first reporting of the outbreak. Local development partners such as King’s Sierra Leone Partnership, an international health link through King’s College London, took on leadership roles in <a href="http://kslp.org.uk/about-kings-sierra-leone-partnership/ebola/">outbreak control</a> in partnership with national government response. </p>
<p>But it was only in the latter part of the outbreak that epidemiologists and wildlife scientists began assisting in identifying the potential <a href="http://www.embo.org/news/research-news/research-news-2014/bats-possible-source-of-ebola-virus">source</a> of the outbreak – possibly bats roosting inside a hollow tree in Meliandou, Guinea. </p>
<p>One Health wasn’t applied in the early stages of the outbreak to assess the likelihood of multiple entry points into the human population, and no pre-outbreak surveillance had been undertaken in West Africa.</p>
<h2>The social context of the Ebola outbreak</h2>
<p>The cultural setting of West Africa has been much <a href="http://www.theguardian.com/global-development/poverty-matters/2014/aug/13/ebola-epidemic-poor-facilities-distrust-healthcare">discussed</a>, but <a href="http://www.ghjournal.org/ebola-emerging-the-limitations-of-culturalist-discourses-in-epidemiology/">hinders</a> the understanding of this outbreak by ignoring the political and economic global forces that left West Africa vulnerable. </p>
<p>Long-standing <a href="http://news.nationalgeographic.com/2015/01/150130-ebola-virus-outbreak-epidemic-sierra-leone-funerals/">cultural practices</a>, such as washing deceased relatives, further spread the disease. Early and targeted engagement with local community leaders about infection control should be a key component of future outbreak control. </p>
<p>However, simply focusing on human public health isn’t enough when it comes to a zoonotic infection. We also need to focus on how an outbreak like this can affect animal populations. The debate on the Ebola response has focused nearly entirely on human fatalities, ignoring the potentially far-reaching and largely undocumented <a href="http://www.voanews.com/content/ebola-great-apes-24sept14/2460717.html">impact on nonhuman primates</a>. </p>
<p>And discussions focused on banning <a href="http://www.washingtonpost.com/news/morning-mix/wp/2014/08/05/why-west-africans-keep-hunting-and-eating-bush-meat-despite-ebola-concerns/">bushmeat</a> ignore human economic concerns and the critically endangered nature of at-risk animal populations being <a href="http://www.thedailybeast.com/articles/2015/01/22/ebola-is-wiping-out-the-world-s-gorillas.html">further decimated by EVD in West Africa</a>. </p>
<h2>Prediction and surveillance</h2>
<p>Prediction, or at the very least understanding, of possible threats should be a key goal of future risk reduction strategies, to ensure we prevent another “<a href="http://archinte.jamanetwork.com/article.aspx?articleid=1916610">Black Swan</a>”: an unexpected major event that comes as a complete surprise, “<a href="http://en.m.wikipedia.org/wiki/Black_swan_theory">"rationalized after the fact with the benefit of hindsight</a>.” </p>
<p>For infectious diseases, prediction rests on strong disease surveillance in both human and animal populations. We could have predicted West Africa was susceptible to <a href="http://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.0030371">EVD</a>, but such surveillance doesn’t currently form any of the decision-making processes that are used globally. </p>
<p>The main international treaty underpinning health security, the <a href="http://www.who.int/topics/international_health_regulations/en/">International Health Regulations (2005)</a> (IHR 2005), requires the 195 member states of the WHO to have in place “core capacity requirements for surveillance and response to events.” </p>
<p>By the initial deadline of 2012, <a href="http://www.who.int/entity/ihr/qa-ihr-rc-11nov.pdf">only 42 countries</a> had met their core capacity requirements. By the end of June 2014, four months into the Ebola outbreak, only a further 21 met these requirements. Fewer than one-third of the WHO member states have declared their compliance with IHR 2005. Efforts to help poorer nations to achieve this have not been forthcoming. This means that the majority of member states still lack adequate human disease surveillance. </p>
<p>However, complying with IHR 2005 does not guarantee that countries are able to detect emerging zoonotic diseases. The checklist for monitoring progress toward IHR core capacities does not include animal or wildlife disease surveillance. </p>
<p>The WHA 2015 has focused on renewed calls to strengthen human disease surveillance. But as an international community, we need to consider early combined surveillance of both humans and animals. There should no longer be a complete division between ministries of health and wildlife agencies. </p>
<p>The goals of the WHO in curbing the spread of the infectious disease must align with those of the <a href="http://www.oie.int">World Organization for Animal Health</a> and <a href="http://www.fao.org">Food and Agriculture Organization of the United Nations</a> to ensure that infectious disease threats are targeted from their transmission from animals to humans through to managing their quarantine and public health control. </p>
<p>The $100 million contingency fund is a welcome step in the right direction. But now international aid needs to focus on developing public health systems that are robust, effective and cross-species. Disregard of animal well-being comes at our own cost.</p><img src="https://counter.theconversation.com/content/40885/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arinjay Banerjee receives funding from Integrated training program in Infectious Diseases, Food safety and Public policy, University of Saskatchewan and Natural Sciences and Engineering Research Council of Canada.</span></em></p><p class="fine-print"><em><span>Colin Brown and Grant Hill-Cawthorne do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Along with better strategies to respond to outbreaks in human populations, we need a stronger focus on surveillance in animals to identify infectious diseases before they pose a risk to human health.Arinjay Banerjee, PhD Student in Veterinary Microbiology, University of SaskatchewanColin Brown, Infectious Diseases Lead, King's Sierra Leone Partnership, King's College LondonGrant Hill-Cawthorne, Lecturer in Communicable Disease Epidemiology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/331912014-11-13T04:44:32Z2014-11-13T04:44:32ZEbola’s ‘other’ victims: how the outbreak affects those left behind<p>Media coverage of the growing Ebola epidemic in Guinea, Sierra Leone and Liberia has presented world audiences with apocalyptic predictions of ultimate death tolls and grisly imaginings of its spread to other shores. But we’ve heard little about the people left behind. What impacts has the epidemic had on their livelihoods? </p>
<p>Consider this story of an <a href="http://www.economist.com/node/12775514">okada</a> (motorcycle taxi) driver in the Sierra Leonean city of Makeni. Following the Ebola-related deaths of a number of this man’s relatives, the Sierra Leonean government – not unreasonably – placed him under quarantine for 21 days. When he emerged with clear test results he found that the government had <a href="http://observers.france24.com/content/20141016-taxi-drivers-collateral-victims-sierra-leone-efforts-stamp-out-ebola?page=52">banned okadas from operating</a>, in an attempt to contain the spread of infection. </p>
<p>Despite avoiding infection, the driver was unable to make a living. He later doused himself in petrol (gasoline) to <a href="https://m.facebook.com/photo.php?fbid=4633155843186&id=1721629258&set=a.3404998540021.1073741851.1721629258&source=57">end his life</a>. For this young man and many others among the 25 million people of Guinea, Sierra Leone and Liberia, Ebola is not just an epidemiological terror, it is also a socioeconomic disaster.</p>
<p>Before the epidemic, these three countries were already among the world’s poorest. They ranked within the bottom 5% of the <a href="http://hdr.undp.org/en/content/table-1-human-development-index-and-its-components">Human Development Index</a>. Five million of their combined population is considered <a href="http://www.fao.org/3/a-i4030e.pdf">undernourished</a>. </p>
<p>Though the causes are longstanding and complex, one reason for this poverty is the region is still recovering from another disaster, the Mano River Wars (including the Civil Wars of Sierra Leone from 1991 to 2001 and Liberia from 1989 to 1997 and 1999 to 2003). These wars <a href="http://reliefweb.int/report/guinea/uscr-country-report-sierra-leone-statistics-refugees-and-other-uprooted-people-jun">displaced millions</a>, destroyed infrastructure and ruined countless livelihoods.</p>
<p>An important effect of wartime displacement was the meteoric growth of urban centres such as Freetown. In the post-conflict context, many recovering households have become dependent on incomes from serving the needs of new and expanded urban markets. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/62766/original/f5bh2cg3-1414295378.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fuelwood is harvested in rural villages, before being transported and sold in nearby urban centres.</span>
<span class="attribution"><a class="source" href="http://www.energyforopportunity.org">Photograph provided by Energy For Opportunity</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In Sierra Leone, for example, there is a <a href="http://www.energyforopportunity.org/site_media/media/files/documents/final_report_-_fuelwood_and_timber_trade_in_sierra_leone.pdf">thriving trade</a> in forest products including construction timber, firewood and charcoal. </p>
<p>Harvested in rural villages, these commodities move through complex transport and trading systems for final sale by thousands of urban vendors. This provides incomes for large numbers in every corner of the country. </p>
<p>The functioning of these economic networks and most others in the region, however, depends critically on both mobility and public assembly. Both of these have been severely constrained by necessary Ebola counter-measures such as quarantines (often of entire cities), highway closures and urban lockdowns. Given the widespread poverty in the region, with people living hand to mouth, this is undoubtedly causing severe impacts on already vulnerable households.</p>
<p>Compounding this issue, <a href="http://www.theguardian.com/commentisfree/2014/sep/15/as-ebola-closes-schools-in-africa-how-do-we-help-children-lear">schools are closed</a> in all three countries, and are likely to remain so well into next year. This is a major concern for a region with low rates of adult literacy: <a href="http://hdr.undp.org/en/countries/profiles/SLE">Sierra Leone 43.3%</a>; <a href="http://hdr.undp.org/en/countries/profiles/LBR">Liberia 42.9%</a>; and <a href="http://hdr.undp.org/en/countries/profiles/GIN">Guinea 25.3%</a>.</p>
<p>The myriad impacts on already weak health sector systems are also serious. Before the outbreak, Sierra Leone was estimated to have around <a href="http://www.theguardian.com/world/2014/oct/08/-sp-ebola-west-africa-health-workers">120 physicians</a> serving its population of 6 million. This equates to around two doctors per 100,000 people. For a comparison, Australia has around <a href="http://data.worldbank.org/indicator/SH.MED.PHYS.ZS">390 physicians per 100,000</a>. </p>
<p>So far <a href="http://abcnews.go.com/Health/wireStory/sierra-leone-doctor-dies-ebola-26649996">five Sierra Leone doctors</a> have already died from Ebola infection (nearly 5% of the physician population in the country), with more currently suffering from Ebola infections. This not only limits the country’s capacity to tackle the Ebola crisis, but will also have a debilitating impact on the country’s health sector, now and in the future. Many people have <a href="http://www.junglelightspeed.com/the-silent-victims-of-ebola/">already died</a> in the region after avoiding medical care for fear of contracting Ebola. </p>
<p>Similarly, development programs have been halted or cancelled due to health risks to international staff. Despite recent good progress, all three countries were already struggling to meet their <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a>. The Ebola crisis has almost completely ensured <a href="http://www.sl.undp.org/content/sierraleone/en/home/presscenter/articles/2014/08/07/ebola-could-set-back-development-says-un-.html">they will not be reached</a>. </p>
<p>Ultimately, however, it’s clear that dealing with setbacks in achieving regional development priorities is both secondary to, and dependent upon, coping with the immediate effects of near-total economic shutdown.</p>
<p>The Ebola crisis presents a cruel paradox. Efforts desperately needed to contain the infection of thousands are simultaneously causing major, and in some cases severe, economic hardship for a population of millions. The international Ebola response will need to continue well after the crisis has faded from world news reports.</p><img src="https://counter.theconversation.com/content/33191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Media coverage of the growing Ebola epidemic in Guinea, Sierra Leone and Liberia has presented world audiences with apocalyptic predictions of ultimate death tolls and grisly imaginings of its spread to…Paul Munro, Lecturer in Environmental Humanities, UNSW SydneyGreg van der Horst, PhD Candidate in Resource Management and Geography, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/335312014-10-28T19:07:48Z2014-10-28T19:07:48ZMandatory Ebola quarantine is about politics, not public health<p>Governments have a duty to protect their citizens but the plan to impose mandatory detention on health-care workers being suggested by some Australian states is excessive and unwarranted.</p>
<p>On Monday, the media reported the Australian government has cancelled all temporary visas from the three worst-affected countries of Guinea, Sierra Leone, and Liberia. In a bizarre world first, this includes <a href="http://www.news.com.au/national/australia-closes-door-on-ebolaaffected-nations/story-fncynjr2-1227103990304">humanitarian visas</a>.</p>
<p>So it should not have come as a surprise that on Tuesday <a href="http://www.theaustralian.com.au/in-depth/ebola-crisis/mandatory-detention-considered-for-arriving-ebola-suspects/story-fnpqlos3-1227104066666">The Australian reported</a> that some state health authorities were looking into the possibility of requiring mandatory detention of returning health-care workers if they refuse voluntary home quarantine. </p>
<p>Admittedly, this is not a Commonwealth-led initiative and Australian states are not the first to consider mandatory quarantine. New York, New Jersey and Illinois have hurriedly rush through similar policies in <a href="http://www.washingtonpost.com/national/health-science/ny-nj-governors-impose-new-ebola-quarantine-rules/2014/10/24/8096e43e-5bac-11e4-8264-deed989ae9a2_story.html">the last few days</a>. </p>
<p>It does, however, contribute to an overall picture of Australia’s response to the Ebola epidemic - one that appears increasingly, and unnecessarily, mean-spirited. </p>
<h2>Can we legally quarantine people?</h2>
<p>Mandatory quarantine of health-care workers presents a number of ethical challenges, but it’s not without precedent. </p>
<p>The <a href="http://www.comlaw.gov.au/Series/C1908A00003">Quarantine Act 1908</a> allows for people to be quarantined if they’re infected with a quarantinable disease; if an appropriate inspector reasonably suspects they’re infected with such a disease; if they have been in contact with or exposed to infection from people subject to quarantine; or if they have been in a quarantine area within the last 21 days. </p>
<p>So there’s clearly a legal framework for it at the federal level, but does that mean it should be implemented? </p>
<p>During the 2003 SARS outbreak, some of Canada’s success in controlling the spread of the virus was attributed to mandatory quarantine of people suspected of carrying the disease. This notably included <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa032111">health-care workers</a>. </p>
<p>We now know these people not only suffered mental anguish over the separation from their families and loved ones, but the policy also made them feel like <a href="http://www.nejm.org/doi/full/10.1056/NEJMp038118">pariahs in their own communities</a>. Instead of being praised as the selfless heroes they were, these health-care workers were made to fear walking down their streets or wearing their uniforms. </p>
<h2>What is the actual risk?</h2>
<p>But governments do have a duty to protect their citizens, so what is the risk to the Australian community from doctors and nurses returning from Ebola-affected countries? </p>
<p>In contrast to SARS, which had an incubation period of just ten days, the Ebola virus can incubate for anywhere between two and 21 days. Unlike SARS, we know exactly what to look for with Ebola. We also have tests for rapid diagnosis. </p>
<p>Most importantly, even when people may have contracted the illness, they’re not infectious until they start displaying symptoms. Having a fever alone is not enough; you have to be producing large amounts of bodily fluids - and therefore very sick - before you can infect others. </p>
<p>What this means is that the current measure of asking health-care workers to self-isolate at home for 21 days and monitor their temperature twice a day is more than adequate to protect the Australian community. </p>
<p>But isolating people based on the possibility that they might be infected, even though they pose zero public health risk, is not just unethical. It ties up resources better spent - and arguably more needed - elsewhere. </p>
<h2>Not the time or place for politics</h2>
<p>Hysterical responses to health-care workers treating patients infected with Ebola are reminiscent of the initial treatment of <a href="http://www.amazon.com/Bioethics-A-Nursing-Perspective-5e/dp/0729538737">AIDS patients and their doctors and nurses</a>. </p>
<p>Yet fortunately, even as New Jersey governor <a href="http://www.reuters.com/article/2014/10/27/us-healthcare-ebola-usa-nurse-idUSKBN0IG2BO20141027">Chris Christie</a> defended the mandatory isolation of Medecins Sans Frontieres nurse Kaci Hickox, stating he had an “obligation … to protect the public health of all people”, federal US health officials strongly condemned the unwarranted measure. </p>
<p>The <a href="http://www.bbc.com/news/world-us-canada-29792776">UN Secretary-General</a> has also joined the fray, criticising enforced quarantine that needlessly penalises doctors and nurses who have willingly put themselves at risk to save others.</p>
<p>Political interference in public health is not helpful as a general rule, but political posturing in these types of events is particularly unhelpful. It breeds unwarranted fear and drowns out more important messages - messages about how Ebola is actually transmitted, the steps needed to contain this outbreak in West Africa, and what Western countries such as Australia and the United States can do to help. </p>
<p>Worse still, it actively discourages health and aid workers from travelling overseas to lend their expertise because they don’t know what political storm they will walk into upon their return.</p>
<p>Politics runs the risk of becoming policy whenever responsibility for public health exists within multiple layers of government. So when it comes to public health decisions, politicians need to rely on the informed opinions of their chief medical advisers. </p>
<p>While hollow debates about misguided measures not based in science take up media space, the increasingly dire situation in West Africa is forgotten.</p><img src="https://counter.theconversation.com/content/33531/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Kamradt-Scott has previously received funding from the European Research Council. He is also a member of the Liberal Party of Australia.</span></em></p><p class="fine-print"><em><span>Grant Hill-Cawthorne does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Governments have a duty to protect their citizens but the plan to impose mandatory detention on health-care workers being suggested by some Australian states is excessive and unwarranted. On Monday, the…Grant Hill-Cawthorne, Lecturer in Communicable Disease Epidemiology, University of SydneyAdam Kamradt-Scott, Senior Lecturer in International Security, University of SydneyLicensed as Creative Commons – attribution, no derivatives.