On Tuesday President Obama announced that the U.S. government will step up its efforts to help fight Ebola in West Africa. Coming six months into the crisis, and more than a month after the World Health Organization said that the outbreak was getting out of control, this major commitment of supplies and personnel by the world’s wealthiest country is long past due.
The biomedical community also seems to be lagging. Ebola vaccines and drugs exist but are only available in limited quantities thanks to their experimental state. Reading the headlines, it sounds like the researchers and regulators have moved too slowly. The drugs are "still stuck in the lab." There is a new way to quickly make enough drugs to halt the outbreak, "if only the U.S. had the boldness to try it." The most promising vaccine was recently put on an accelerated testing schedule, but it's too little too late.
That we developed Ebola vaccines and drugs, but didn't have them ready to deploy in West Africa, sounds suspicious. We have the scientific know-how to cure Ebola, but we haven’t bothered to make that cure available? Is this really true?
Despite the hope that we can soon defeat Ebola with new drugs and vaccines, the reality is that it won’t be solved with a biomedical silver bullet.
At first glance, it seems to be. When we’ve had the political will to bring medical science to bear on a major health problem in Africa, the results have often been impressive. Consider African meningitis, which has long been a major problem in sub-Saharan Africa. During a 2009 epidemic, there were nearly 90,000 suspected cases, and over 5,000 people died. But thanks to a partnership of government agencies, NGOs, and pharmaceutical companies, a cheap and effective meningitis vaccine became available in 2010, and it has nearly eliminated the disease in the countries where it has been used.
So why haven't we defeated Ebola with the same strategy? Because Ebola is different. It's unusually deadly and extremely rare. That combination makes it difficult to develop and test safe and effective treatments. That there are even experimental Ebola drugs available during this current, record-breaking outbreak is a lucky coincidence; researchers have worked on their development for decades, despite Ebola’s historically small threat.
In fast, scientists have been interested in treatments for Ebola since it was first discovered in 1976. But because Ebola is so rare, and conventional methods to control it are generally effective, the virus is easily overshadowed by much larger public health threats in Africa. Between 1976 and 2012, there were fewer than 3,000 cases and 1,600 deaths caused by Ebola outbreaks. Compare this with the 5,000 deaths caused by African meningitis in just one year, the half-million or more malaria deaths annually, or the nearly 25 million Africans infected by HIV, and Ebola seems much less threatening. If we care about saving lives, then medical research to develop effective vaccines for HIV and meningitis or to combat the difficult problem of drug-resistant malaria should clearly take higher priority than Ebola treatments.
On the other hand, as we're seeing now, Ebola outbreaks can quickly get out of control and wreak havoc on fragile economies and social institutions in developing countries. Without an effective response, the number of cases could swell to tens of thousands within a month. Because of Ebola’s pandemic potential, the U.S. boosted funding for research on the virus in 2002 as part of its effort to prepare for bioterrorism. With this funding, researchers have developed several candidate drugs and vaccines over the past decade, but these are only just now reaching the point where human clinical trials can even be considered. The most promising drug, the ZMapp antibody cocktail, was just recently shown to be effective in monkeys. ZMapp is the latest version of a drug that has been in development for years; previous versions weren't nearly as effective as the current one.
Even with experimental vaccine and drugs on hand, it’s challenging to test whether they are effective in humans. Because Ebola outbreaks are rare and dangerous, it’s tough to complete the controlled clinical trials that are the gold standard in medicine. A vaccine or drug trial would have to be initiated quickly, as soon an outbreak is detected, often in a remote location with poor infrastructure. Such a trial would actually have to compete with the current best approach to fighting Ebola—in the past, standard infection-control methods have managed to end Ebola outbreaks quickly, before a trial could really get underway. Plus, given Ebola's high fatality rate, a drug trial that randomly assigns some patients to receive a placebo instead of a promising drug would be unethical. Yet without a well-designed study, it is hard to know if the new drug actually works.
Despite the hope that we can soon defeat Ebola with new drugs and vaccines, the reality is that it won’t be solved with a biomedical silver bullet. Our best tools to fight pandemic viruses are social institutions: hospitals, governments, and health organizations that supply the trained personnel and equipment to carry out the disease control measures that we know are effective. In a 2006 report, leaders from major health organizations argued that the success of new drugs and vaccines "will require the development of physical infrastructure, human resources, and logistical and legal frameworks." Communications experts should be included in every response team; otherwise, misunderstandings between frightened local communities and foreign health workers dressed in hazmat suits will undermine the effort to end the outbreak.
Effective Ebola vaccines and drugs will some day be a huge advantage, but these scientific solutions won’t be effective unless we solve the social problems, too.