Responding to Ebola’s Long-Term Threat to Development

On December 5, the United Nations’ Economic and Social Council (ECOSOC) hosted its first meeting on the Ebola epidemic’s long-run implications on development in the affected countries.  

The meeting agenda was overstuffed with speakers. UN Secretary-General Ban Ki-Moon and WHO Director-General Dr. Margaret Chan both gave strong presentations detailing the Ebola threat and progress on the response. However, neither speech contained information that would be new to those reading newspaper accounts of the epidemic or following blogs like ours. The most compelling presentations came by video from the ministers of finance of Guinea, Sierra Leone, Liberia, and Mali, the four countries currently managing the active spread of Ebola. They provided a litany of examples of economic breakdown, which I and others at the World Bank forecasted here and more recently here.

As a panelist, I fielded two questions from Dr. Paul Farmer, Special Adviser to the Secretary-General on Community-Based Medicine and Lessons from Haiti. The first was on how the West African economies will be impacted by Ebola. I explained fear—or more precisely “aversion behavior”—not the disease itself, will have the greatest effect on the countries battling the epidemic. (Read more about the impact of aversion behavior here.) 

The second question was on how to mitigate aversion behavior after the epidemic is under control.  Unfortunately, because of continued aversion behavior, economic growth may not resume at the same pace on its own. Rapid abatement of observed aversion behavior will require that people everywhere perceive all African countries as safe places to live, work, and visit. In order to have the confidence to resume trade and travel, people need to be assured another disease outbreak like Ebola is not imminent.

One possible answer mentioned by other participants is “strengthening African health systems,” but this phrase doesn’t specify how “strong” the systems need to be or how governments and donors can bring about the desired “strengthening.” Do African health systems need to be as strong as European or American ones, which limited the Ebola outbreak to individual cases? Or only as strong as the Nigerian and Senegalese systems which have so far seemed capable of containing the disease? Still, Liberia had only 50 physicians for the whole country before the epidemic, so even bringing the country’s health care up to Nigerian standards would require more money and health providers than available.

I advocated for a more cost-effective approach that has the added advantage of versatility: active case detection. This strategy refers to the deployment of mobile workers to test everybody in the population several times a year at their places of residence. With simple diagnostic kits, disease surveillance could be added to the tasks of other mobile teams, such as vaccination workers and even agricultural extension workers.  The practice is the opposite of “passive case detection,” which is building health centers and waiting for sick people to come, be tested, and sometimes declared infected with the disease.  In contrast to a passive approach, active case detection would act as an “early warning system,” so diseases are discovered and contained before health systems are damaged or infections spread to urban areas.

Health systems advocates are not going to like the suggestion that active case detection will achieve cost-effective disease surveillance, because it suggests one could graft a disease surveillance strategy onto an otherwise weak health system. But I’m not sure their objection is justified. For me, it’s an open question whether any African health system, no matter how comprehensively it is strengthened, could withstand an Ebola (or similar) outbreak unless it has forewarning from an active case detection system and benefits from a rapid deployment outbreak response team mobilized by such a system.

If we are to reassure workers, parents, investors, and tourists that a future outbreak is unlikely (or would be immediately contained) in West Africa, while protecting the world from future zoonotic disease outbreaks, we need to improve the response time of outbreak response units.  Active case detection may be the quickest and most cost-effective path to this objective.