There is no avoiding stating the obvious that discussing a high mortality disease which leads to a very horrible death is scary and unpleasant. If you have a low threshold for the unpleasant then skip this post now. Ebola meets the criteria of a ‘dread risk’. That is a risk that “has judgments to be made on scales of uncontrollability, dread (or fear), involuntariness of exposure and inequitable distribution of risk” (this definition is from the Royal Society Report on Risk).
Despite this being an awful story and one with deep negatives, there are positives of heroic deeds and rays of light coming out of the situation. Compassion, bravely, courage and man’s ingenuity to apply science do shine through. However, the threat of death by Ebola strikes home to the very heart of our psyche, challenges our normal customs and it raises many ethical and intellectual issues for those who have to plan for and deal with this crisis. This is made worse by lack of science attention on this disease unlike well researched pathogens such as plague, where there is vaccine available.
This is two part blog post (Part I and Part II). Part I is about the context of the Ebola outbreak. In Part II I have tried to define some of the issues which would be of interest to the crisis, business continuity or security leader. My goal is to open the discussion on what we in the resilience business could learn from it and for future outbreaks. This of course is a massive topic and doing succinct analysis is a challenge. I think it is worth noting that in my 30+ years of risk management experience (including planning for higher mortality biological warfare pathogens and other dread risks such as nuclear, radiation, toxins, chemical to name a few!) I have found that these sort of risks bring some of the most difficult ethical and technical challenges. This is not least in complexity of issues and of understanding, and having to translate science and medical ‘speak’ to user language. So this is not a neat and easy to package area, you can expect this to be a difficult topic with much residual uncertainty.
My motive for writing this post is to share some current observations that are relevant to business continuity (and maybe for the resilient society). Unfortunately, these may also be relevant to biological weapons or a terrorism event causing infectious disease outbreaks. For example a defector from the former USSR bioweapons programme stated that Marberg was seriously considered in the programme (see Ken Alibek’s book: Biohazard). There are connections to pandemic planning, as the crisis illustrates reactive government and international bodies’ response. These might have direct ‘read-across’ to BCM. These observations may also be very relevant to your exercises or global incident response and health incident planning.
So here goes: Initially I have mapped out the coverage in the UK Daily Telegraph as a UK broadsheet example and articles drawn from the Economist. I have then also reviewed the more obvious main web resources (WHO, CDC, DoH etc). The information in this blog is drawn from only publically available information so is not all encompassing, nor is it technical.
Context: this outbreak proliferates from a very small base in early 2014 and control was not gained in Guinea, Liberia and Sierra Leone. Then some cases spread to Nigeria. Returning or repatriated heath care workers arrive back home to Spain UK and USA and a few African countries. A case turns up in Mali. A clear timeline diagramme is on the WHO site [Ebola story] This disease has appeared in Africa many times before. David Quammen in his book ‘Ebola’ (he also covers Ebola relative ‘Marburg’ outbreaks in Angola in 2005 and DR Congo in 1998) outlines many previous outbreaks. The perception was that Ebola was a one way ticket, since the villages found in Africa were often full of dead people. I think this illustrates that fact that ‘event aetiology’ (the way an event/causation/reason unfolds) for Ebola became the accepted norm i.e. very low chance of recovery, perhaps 10 to 20%? However, infectious diseases have very high uncertainty factors and this thinking has a way of proving us wrong as each set of circumstances varies.
In looking at the macro effects – the case for early intervention is so strong when you look at the effort required to halt a diseases advance when it starts to burn out of control (and reignites like in Guinea at present). Intervention must be swift if we are to stand some chance of stopping the ‘fire’ spreading and it must be prosecuted until burn-out. The WEF Risk Report for 2015 discusses Ebola in the context of health in cities and makes it clear that Ebola illustrates some significant weaknesses. Some of the issues are shown in the box below:
One can’t help thinking that WHO surveillance and membership is designed to do most of the above list, however, in less developed countries with massively poor infrastructure the expectation that countries will act swiftly is not reasonable. People in the bush do not pop-in to see their GP who then reports on significant diseases. The global capability to intervene effectively in any future health crisis also rests on the world capability to design, develop and produce vaccine in quantity. For countries without the means of production (or the financial resources as it is extremely expensive) this is a serious issue as they will need to rely on their alliances and a developed benefactor. The current tragedy is that even before Ebola the current life expectancy in some countries is abysmally low (The Economist 3 January 2015 quotes “No county for old men” as life expectancy in Guinea is 56, Liberia 60, Sierra Leone 45! and in Sub Sahara Africa 56 years). I mentioned deep negatives and this awful list has got to be one of them.
The economic impact of an outbreak of a disease that disrupts all normal activity is a serious event for a country. Worse is the impact on a region, and the collapse of reputation for a safe and amazing destination in the holiday business is fundamental to growth plans. According to the Economist, tourism in Africa is worth about $170 billion a year. Now no-one is travelling to Africa full-stop (not sure where they are going instead – the winners?). Other impacts are the exodus of the rich, skilled and expats. Disrupted international flights, cocoa price volatility, exchange rate volatility, and impact on democracy – as leaders impose quarantine measures are apparent. Emergency measures get imposed and they shape the political landscape for a long time afterwards and some remain in place, some are mis-used or not ever lifted. There are of course increases in some areas, such as e-commerce, mobile phones and hygiene products. The full impact of such an outbreak will be felt long in the future as getting children back to school will take time when it was already on a slow upward curve. The future of a large number of orphans provides another negative issue as young minds are altered by seeing their family environment destroyed. Extractive industries output and future investment and development will also suffer.
There are some new and novel issues emerging such as the development of ‘short cut’ ethics processes to use of drugs and trials with patients willing to take an option when seemingly there is non. Perhaps this is not novel? The use of mobile phone traffic as an epidemiologists’ tool is being pioneered and there is more to come here, but there are limitations as the take-up of phones in the affected countries is low. The rapid development of quick diagnostics kits is taking place and this will aid the decision making and limiting the spread (if administered). This all sounds excellent but the reality of the problems of reaching a remote settlement in Guinea in the rainy season is hard to comprehend in a country where access is taken for granted.
I think the key issue in this and future outbreaks (after detection and intervention) is effective contamination control to limit reproduction and slow the spread of any disease. This will be difficult if people do not get communication, understand it or think communication is credible as they will continue to do what they always do. The rule is that culture will continue to trump science/medicine. Although classed as a low transmissible disease, the Economist quoted (18 October 2014) that a patient in the later stages pushes some 10 litres of highly infective fluid out of the body. Even the health workers who had splash and fluid protection have still contracted the disease. This shows the difficulty of contamination control even in trained persons. See the Ro number (blog post 20 November 2014 – the difference uncertainty makes in crisis management).
Part II of this post is more structured and outlines some of the issues raised and observation relevant to BCM, crisis, risk and security practioners.
• We cannot separate national emergency response and resilience from politics and the interconnectedness of the world is demonstrated.
• Reputation of something happening in a region may impact perceptions beyond the reality – nothing new here. Facts should be assessed with added expertise free of the ‘dread’ risk slant.
• When something is new (like Ebola in the West) it will take time to define and get the medical and science systems moving.
• Contamination control is difficult but early and effective intervention limits the need for radical and high risk interventions.
• In planning any contingency or response the part played by culture and customs cannot be underplayed, as assumption is that your human capital will react and behave as it always has unless there is incentive or sanction to change behavior.