Public Health in the Age of Ebola in West Africa

The world is witnessing the unprecedented unfolding of the West African Ebola epidemic.The epidemic could have major ramifications for global public health in ways that no other modern infectious disease has, perhaps including AIDS, and can be viewed as a "Black Swan" event.Nassim Nicholas Taleb, the Lebanese-American author and scholar, introduced the metaphor of the black swan, a bird that was once thought not to exist, to explain financial events.Subsequently, Taleb extended the Black Swan concept, in his 2007 book of the same name, beyond finance to explain high-profile, difficult-to-predict, and rare events in history and the present 1(ppxxi-xxii) :What we call here a Black Swan (and capitalize it) is an event with the following three attributes.First, it is an outlier, as it lies outside the realm of regular expectations, because nothing in the past can convincingly point to its possibility.Second, it carries an extreme "impact."Third, in spite of its outlier status, human nature makes us concoct explanations for its occurrence after the fact, making it explainable and predictable.The West African Ebola epidemic has all the makings of a Black Swan event with one exception-the global public health community will be working to contain it for months, or years, to come.As of October 2014, there is no evidence that this devastating epidemic is anywhere near under control.If the number of new cases of Ebola virus disease projected by the World Health Organization (WHO) (20 000 cases by early November 2014) 2 and the Centers for Disease Control and Prevention (1.4 million cases in Liberia and Sierra Leone by the middle of January 2015 if there are no or unsuccessful interventions) 3 materialize in West Africa over the next several months, it is difficult to imagine that the virus will not make its way into other African countries, particularly densely populated cities such as Dakar, Senegal; Abidjan, Ivory Coast; Lagos, Nigeria; Kinshasa, Democratic Republic of the Congo; or Nairobi, Kenya.Newly infected, but not ill or only mildly ill, persons could leave the affected countries by foot, automobiles, trains, and even planes that move across the continent.With millions of Africans living in crowded, squalid conditions of poverty in the large slums of major urban centers, circumstances are ripe for an even larger Ebola epidemic throughout continental Africa.What can be learned from the first phases of the unfolding Ebola epidemic in West Africa?Already, we have learned that Ebola in urban Africa creates a much different situation than Ebola in rural Africa, that early rapid interventions are needed to prevent Ebola from spiraling out of control, and that quarantine efforts are more likely to backfire than to curtail the spread of disease.Two lessons, however, have changed our thinking about infectious disease threats and their potential effects on international and regional security, economic stability, and overarching public health governance.