A tale of two viruses

Epidemics invariably generate calls for technical solutions such as drugs and vaccines, but gaining trust of communities, understanding and allaying their concerns, and forging effective coalitions between local and outside responders are first essentials. Many have expressed surprise at the ongoing outbreak of Ebola in West Africa, which, by mid-March 2015, had caused close to 25 000 reported cases and more than 10 000 registered deaths. Secondary spread in other West African countries, Europe, and the United States contributed to the alarm, and the epidemic has shaken the very foundations of global health and its institutions. Yet, it was a quarter century ago that the Institute of Medicine published its landmark report on emerging infections that discussed infectious disease spread in an increasingly interconnected world [1]. Albert Camus, in his epic ‘The Plague’, observed that wars and pestilences always take people equally by surprise. Although several other newly recognized conditions such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) demonstrate the challenge of microbial threats in a globalized world, no event better exemplifies the challenge of infectious disease emergence than the global HIV/AIDS epidemic. Many books and reports will likely be written about how Ebola escaped control in Guinea, Liberia, and Sierra Leone. Our purpose here is to highlight similarities between the epidemics of HIV and Ebola, despite differences in their biology and control, and to draw conclusions from the experience of HIV/AIDS service scale-up relevant to any future epidemic response. When AIDS was recognized, stigma, discrimination, denial, fear, and emotional reactions contrary to scientific understanding were widespread. So it has been with Ebola, and not only in West Africa. In October 2014, health authorities in Spain euthanized the dog of an Ebola-infected Spanish nurse, despite there being no evidence the animal posed a risk. In the United States, there have been examples of unnecessary restrictions on people's movement, including barring prospective attendees from West Africa from a major meeting on tropical medicine, and frank acts of discrimination such as denial of access to services or schools, all incompatible with guidance from public health authorities. Denial and anger have sometimes turned violent against healthcare workers in the West African field, whereas at the same time, public health responders have been insensitive to community norms. Behavior and attitudes are important in the spread and control of both HIV and Ebola, be it sexual behavior and childbearing aspirations in the context of HIV, or burial practices deeply ingrained in West African culture that promote the spread of Ebola. An insight from Liberia was that attitudes and beliefs around death and the afterlife were such that the suffering of families was as great from enforced cremation as from the loss itself of loved ones. The critical need to engage with those affected and at risk is now taken as self-evident in the world of HIV/AIDS, but still the tendency persists for public health to instruct rather than involve communities to promote their own solutions; this may explain in part why unsafe burials remain a risk factor for Ebola this far into the epidemic. The term ‘interventional anthropology’ captures the needs and opportunities for understanding communities’ perceptions and structures, facilitating the early crafting of acceptable communications and responses. As with HIV/AIDS in the early days, the severity and impact of the current Ebola epidemic were underestimated or minimized by authorities not situated in West Africa. The humanitarian organization ‘Médecins Sans Frontières’ repeatedly issued warnings, but was ignored or dismissed as alarmist. Experienced field workers who witnessed the devastation were assumed to be exaggerating. As with HIV/AIDS early in that epidemic, the disease had to be seen in its African environment for the magnitude of the challenge to be grasped, and for acknowledgement that this emergency needed prioritization above other health concerns. Additional attitudes suggested that this was someone else's problem or that the crisis would ‘burn out’ if we waited long enough. And as with HIV/AIDS, politicization of technical matters, combined with individual and organizational rivalries, was impediment to a synergistic response. For both epidemics, historians will ask what could have been done earlier, and by whom, to investigate and contain the outbreak. Weak systems across the board are characteristic of fragile states. Fundamental to understanding the uncontrolled spread of Ebola has been the lack of effective health systems. The three countries heavily affected by Ebola are amongst the weakest in the world in terms of economic and human development, lacking capacity to respond to a complex outbreak. Poorly functioning public health systems were quickly overrun by Ebola, whose biology exploited extensive population movement characteristic of West Africa and inadequate infection control measures in healthcare settings [2]. Ebola tracked along the fault lines of these societies, as noted by Jonathan Mann, when he commented on the HIV/AIDS pandemic years ago. The current reality in the West African countries with severe Ebola epidemics contrasts with the situation in countries heavily affected by HIV/AIDS, which have benefited from resources provided by the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). In West Africa, only Nigeria and Côte d’Ivoire have received substantial HIV/AIDS assistance, whereas most of the resources have flowed to East, Central, and southern Africa. Although the Ebola-affected countries fortunately escaped the worst of the HIV/AIDS epidemic, they also missed out on the many HIV-related investments that have had positive impact beyond HIV/AIDS. It is unlikely that Ebola would have spread so extensively in countries where substantial HIV/AIDS resources had been invested. In Nigeria's successful containment of secondary spread of Ebola introduced by an infected traveler from Liberia, the response was heavily reliant on the infrastructure and human capital investments for polio eradication, as well as HIV/AIDS [3]. Much has been written about the essentials of health systems strengthening, about vertical as opposed to horizontal approaches, and about the effects of disease-specific programs like PEPFAR and the Global Fund. Investment in global health requires focus on health capacity, health security, and health impact [4]. From a public health perspective, the health systems priorities include a trained healthcare workforce with necessary clinical and public health skills; surveillance and health information systems; adequate laboratory capacity; and the ability to collect, analyze, and use data for program evaluation and implementation [5]. These essentials underlie public health preparedness and practice, and support infrastructure such as national public health institutes and emergency operations centers. All of these elements were absent in the West African countries affected by Ebola. By the time substantial external assistance was delivered, the outbreak was so widespread that even the world's most experienced health organizations had difficulty providing adequate data management for real-time understanding of epidemic trends and enabling contact tracing, which have only been achieved as the number of cases has declined. One of the greatest achievements in PEPFAR partner countries has been the development of a cadre of public health professionals trained in field epidemiology, and the capacity of such countries to investigate and address their own disease outbreaks has been transformational. Recent trends in Ebola in West Africa have been encouraging. Yet, perhaps the greatest danger now is the risk of complacency or acceptance of a ‘new normal’ of low level Ebola transmission. In reality, today's situation concerning Ebola would have been unthinkable one year ago. The performance of the world's organizations has featured prominently in global discussions, their response and capacity debated, and the availability of standby resources and personnel proposed. More fundamental in our view is the need to address the weakness of health systems and preparedness in the affected countries; the poor health indicators in these fragile West African countries; and the extraordinary vulnerability across the African continent from lack of effective infection control in healthcare settings. Oscar Wilde said that to lose one parent may be regarded as a misfortune, to lose both looks like carelessness. Ignoring insights from HIV/AIDS relevant to other epidemic responses would be more than careless. Acknowledgements Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Conflicts of interest The authors have no conflict of interest to declare.