An outbreak of an infectious disease creates a crucible in which forces are melded in an intense, high-stakes, pressure-filled environment. The situation is volatile, oftentimes unclear and rapidly evolving, and the pathogen may be life-threatening. The scenario is a test of humanity and our response to unpredictability. We often fail.
In 2015, as the Ebola outbreak in West Africa had begun to slow down, we conducted an anonymous survey of more than 200 local and foreign Ebola responders about their experiences during the height of the epidemic. Nearly all of those surveyed mentioned that political and interpersonal challenges at times slowed their responses. Many said they feared the politics more than the virus. More than a quarter reported either witnessing, hearing about, or falling victim to illegal or unethical tactics while responding to the outbreak.
Among the tactics they reported: money and other forms of aid disappearing before it reached its intended recipients; knowingly defective personal protective equipment sent to health workers treating Ebola patients; harmful competitive practices among research groups, like intimidation and data hoarding, to prevent others from conducting field research.
These findings, which appear in our new book, “Outbreak Culture,” saddened but didn’t surprise us. It confirmed the experiences of individuals working in the lab that one of us (P.S.) heads at Harvard University, as well as firsthand accounts from health officials and responders uncovered through reporting done by the other (L.S.). Our survey findings, supplemented by interviews and previously published reports, suggested that the problem was more pervasive than a few serious anecdotes.
Most of the experiences reported to us had little to do with the virus, but instead focused on the actions and reactions of individuals, groups, and organizations during the intense and at times chaotic responses to Ebola. This led us to believe that a culture can form in this environment, created by individual actors and larger agents, that has at times proven to be as lethal as the infectious agent itself.
The creation of what we call “outbreak culture” is driven by multiple factors, from political motivation and life-threatening fear to personal gain and isolation. Behaviors as a result of outbreak culture can lead to confusion, collusion, and culpability amid an already chaotic situation.
The toxicity that can emerge in outbreak culture isn’t limited to the response to Ebola. We’ve documented the same dysfunctions — and sometimes worse — during other large-scale epidemics. Outbreak culture fueled the stigmatization of groups of people susceptible to AIDS in the 1980s, led to the underreporting of initial cases of severe acute respiratory syndrome (SARS) in China in 2002, and delayed research into the 2006 avian flu outbreak in Indonesia. Outbreak culture also inhibited an adequate response to Zika.
The 2014-2016 Ebola outbreak in West Africa is the largest and most widespread Ebola outbreak to date. 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. The second-largest Ebola outbreak, now spreading through a war zone in the Democratic Republic of Congo, is creating a new crucible.
While some postmortem recommendations offered by response experts after the West Africa Ebola outbreak have been put in place in the DRC, we aren’t certain that systems are in place to address and shift outbreak culture.
Every epidemic has its own complexities, and the one in the DRC is no different. Ebola’s emergence in a war zone has led to unprecedented actions of rebel groups to undermine efforts of health care workers and responders. Even so, some of the same challenges during the West Africa Ebola outbreak apply. Local skepticism and distrust of government and foreign responders following years of conflict and a fragile health system created perfect storms in both settings. Though lessons were learned during the 2014-2016 epidemic, the culture of outbreak response doesn’t seem to have changed.
Countries that have the resources to provide an adequate response early on — including the United States — are instead citing safety concerns for disengaging at a time when tactful methods of community engagement and protection of responders is needed for global health security. Essential response efforts, including clinical research taking place on the ground in the midst of the outbreak, have been met by some with criticism rather than praise.
Parachuting in to assist in an outbreak, while not preferred, is still the method that governments and agencies are adopting, when they should be sowing seeds of trust and empowering local communities to lead the response. Limited supply of critical resources, such as case records to trace contacts, as well as personnel, equipment, and vaccines, is cause for worry.
These potentially fatal factors have little to do with the lethal Ebola virus, but are compounded by its presence.
In recognizing the many challenges of an outbreak, it should not be a surprise that outbreak culture exists and is damaging to global society. The outbreak in the DRC is destined to grow worse, and the current policies and response trends that have been shaped by our mindsets to approaching outbreaks are only increasing the risk for another large-scale devastation.
Outbreak culture can be changed. But that requires a deliberate choice that is thoughtfully implemented, governed by core principles, and guided by realism, honesty, transparency, and accountability. It requires eliminating the man-made and sometimes intentional barriers that impede the organization and collaboration needed to quell an outbreak.
Shifting outbreak culture to a collective mindset, aligned incentives, and practices that favor collaboration will determine the strength of our ability to respond as threats increase from natural outbreaks, drug-resistant infections, and bioterrorism.
Effective and sustained action requires a global understanding that viral sovereignty — the idea that a virus or other disease-causing organism is the sovereign property of a country — is a misunderstanding of the reach of these organisms. So is the idea an infectious microbe can be contained to a region. Pathogens don’t distinguish between nationalities, religions, or political beliefs, nor do they respect borders. It is a collective problem that needs to be solved globally.
There is no watchful waiting in outbreaks. Leading agencies and countries, including the U.S., must enter the arena early and remain steadfast in their responses, even if the number of cases appears to dwindle. In the West Africa outbreak, some agencies withdrew in 2014 as the outbreak seemed to wane, only to find the virus re-emerge, deadlier than before. Recommitment turned costly.
There’s no doubt that melding multiple agencies and actors in an outbreak response creates a piecemeal patchwork of aid, though with intentions of a comprehensive and collaborative response. Limited measures are in place to ensure accountability in the midst of a volatile and unpredictable situation. Countering outbreak culture requires working toward organizational justice as well as establishing guidelines and incentives for transparency, meritocracy, and collaboration so all actors feel supported. In addition, all agencies must work to create common goals in support of efforts on the ground, including ongoing data collection, research, and community engagement. These principles are just a few of those we discuss in our book.
It is too late to commit to such principles in the midst of the DRC outbreak — though a swift and sold response is still imperative.
Subsequent epidemics should be met with readiness perpetuated by universal guiding principles and a global governing structure. If the global mindset does not change to favor readiness over response, dysfunction will persist. Organizations tasked to respond to outbreaks have much to learn from the military and its perpetual readiness. The world is in need of a centralized governing structure dedicated to global health security that mirrors the military-style approach in both readiness and response. The DRC serves as a case example of the need for stronger and expanded military-like missions with a clear objective to prevent the outbreak’s worsening and spread.
As we close out the year marking the 100th anniversary of the deadliest influenza pandemic in history, which is estimated to have killed 25 million people in 25 weeks, we must acknowledge that such devastation can and will happen again unless everyone involved in global health security strives to form a new — and positive — outbreak culture.
Lara Salahi is a journalist and assistant professor of broadcast and digital journalism at Endicott College. Pardis Sabeti is professor of immunology, infectious diseases, and evolutionary biology at Harvard University. They are co-authors of “Outbreak Culture: The Ebola Crisis and the Next Epidemic” (Harvard University Press, November 2018).