The Ebola epidemic has killed more than 4,000 people in West Africa, and World Health Organization Director-General Margaret Chan warns that panic “spreading faster than the virus” will harm peace and security in the region. Public health experts counsel that the best way to prevent the virus from spreading in the United States is to slow its progress in West Africa by improving heath care institutions there. While the situation in Africa is dire, the United States is also susceptible to fear, distrust of authority, and sloppy medical sanitation practices.The domestic response to Ebola will require coordinated efforts by trusted institutions such as doctors, state and local departments of public health, and the Centers for Disease Control to track the spread of the virus and triple-check that safety protocols are followed. Epidemic disease requires more intensive safety measures, monitoring, and efforts to assuage fears than the fires, floods, and hurricanes that emergency and crisis managers usually prepare for. Other slow-onset disasters such as heat waves or droughts can develop over months or years, but these rarely alarm the public to the same degree that a disease feeds public fears. Pop culture tales of a virus spreading out of control are both a symptom and a cause of the deep-seated fear of pandemic disease.Despite the virulence of Ebola, it poses a relatively low threat to the United States in the short term compared to the possibility of large numbers of deaths and failed states in places without a robust health care system and modern sanitation practices. The reproduction number (R0) of Ebola is estimated to be no more than 2, which is the number of infections that one case generates over the span of its infectious period. Ebola’s reproduction number is less than that of HIV (4), measles (18), and other infections that threaten public health. Still, the most hysterical blogs and media outlets criticize the CDC for lowballing R0 estimates, adding to the distrust of public institutions. The R0 number captured public imagination in the movie Contagion, in which Kate Winslet stands up and writes the reproduction number on a whiteboard as a way to convince public health officials of the pandemic potential of a new virus.Globally, the most important factors contributing to Ebola’s deadly spread are poverty and the attendant lack of trust in public institutions and in health messages about the best ways to prevent the disease from spreading. Many Liberians believe that warnings about Ebola are either Western propaganda or plots by their own government to secure aid from international donors. The institutional gaps in poor countries for responding to the disease are more severe than in the United States. In the affected West African states, the relative weakness of the state means that local tribal or community-based structures are more able to institute practices that can limit the spread of disease. These would include uprooting deeply ingrained cultural practices, such as the laying of hands on the deceased (particularly fatal in the case of Ebola) and limiting the consumption of potentially infectious bush meat.Despite its comparative wealth, the United States has its own difficulties in mounting a national effort against Ebola. The conventional wisdom is that the virus is easily contained by modern medical facilities, but in fact American hospitals have little if any experience with viral hemorrhagic fever.1 Many of the people treating the five U.S. cases probably learned most of what they know about Ebola in the past month. There is widespread public attention and fear, but also ignorance and uncertainty about the disease. Nowhere is this more apparent than the underreported public confusion between “Ebola” and the similar-sounding and far more common “E. coli” (Escherichia coli), a naturally occurring intestinal bacterium sometimes reported as a cause of food poisoning. The exotic nature of Ebola means that even health care professionals are not immune to such confusion.The health care system also lacks data on how doctors and nurses will react to the virus. After a nurse in Spain became infected with the virus, some health care workers there refused to work and others resigned from their posts until safety measures improved. The hospital’s protocols and protective equipment, including latex gloves sealed with simple adhesive tape, were only marginally better than what might be found in a school nurse’s office. Disaster and public health researchers in the United States have found that roughly half the local public health workers who responded to various surveys would not report to duty during an influenza or SARS pandemic.2 Other research in emergency management shows that response plans need to account for the safety of the families of first responders since the primary reason responders abandon their posts is out of concern for the safety of their families.Underscoring the difficulties faced by CDC and other state and local agencies to contain the threat of Ebola is the largely reactive, rather than anticipatory, nature of the public health measures taken, such as screenings at a small number of ports of entry. The case of Thomas Duncan, the disease’s first victim in the United States, has undermined confidence in self-reporting by travelers as an effective measure. Further, it appears that the government is having a difficult time persuading citizens to follow the public health protocols most likely to save lives. Contacts of Thomas Duncan are reported to have resisted public health officials’ recommendations to self-quarantine. The nurse who treated Duncan also contracted the disease because of a breach in protocol. Asking people to avoid contact with others for as long as three weeks, the disease’s incubation period, is a tall order, especially since relatively few of the people asked to quarantine will actually have the disease. The public may also be confused by the seemingly contradictory nature of the simplest caricatures of public health messages: On the one hand, Ebola is difficult to contract, so don’t worry; On the other hand, if you are suspected to have been exposed to the virus, you could be placed under house arrest for three weeks.In New Jersey, an NBC news crew who worked with an afflicted cameraman violated a New Jersey Health Department quarantine. The network’s chief medical correspondent, Dr. Nancy Snyderman, was spotted in public ordering takeout food at a restaurant. If public health officials cannot expect a physician in the media spotlight to forego a trip to a restaurant known for its delicious chowder, can they expect less well-informed people to obey quarantine orders? Individuals involved in the few cases of Ebola in the United States have shown some of the same resistance to state control and medical protocols that have exacerbated the problem in Africa.What is clear is that the Ebola virus is not a brief, harmful event with a longer recovery period, such as a hurricane or an earthquake. For most disasters, public agencies plan for a surge capacity to meet the threat for a short time and then return to normal staffing levels. Ebola, however, requires sustained planning and coordination over a long period of time. Arguably many hazards and disasters could benefit from a long-term planning and recovery process, but in the case of Ebola, a long-term view is critical to preventing the crisis from worsening.Containing Ebola will require the help of emergency managers, police, and emergency services in addition to hospitals, but the virus is distinct from other hazards and disasters that first responders usually face. Preparing for the virus may have more in common with the civil defense tradition of preparing for nuclear war than experience in preparing for natural disasters. The Cold War threat of nuclear attack stoked fears of mushroom clouds and the barren world that would follow nuclear war, just as Ebola stokes deep-seated but not unreasonable fear. At the same time, backyard shelters and sham “duck and cover” defenses could do little to prevent nuclear catastrophe. Cold War civil defense is usually ridiculed for being ineffective, but at their best, civil defense government agencies directed people to take actions to prepare for nuclear war that could also protect them against a range of hazards, from fires, to floods and hurricanes. Civil defenders organized neighborhood watches, stocked sandbags, cleaned out chimneys, and identified shelters that provided little protection from nuclear attack but were safe harbors from tornados. They also engaged in imaginative anticipatory thinking to plan for and rehearse scenarios well in advance of a critical event.Public health authorities should learn from the civil defense legacy by harnessing public attention to the threat of Ebola to build institutions that can prepare for a range of hazards and disasters, from clinics with surge capacity to treat the sick during flu outbreaks to better public health communication; evacuation and shelter planning; and improved plans allowing responders to focus on their duties and not worry about the safety of their families. The Ebola crisis could also focus attention on foreign aid, and particularly aid programs that strengthen social institutions in poor countries rather than provide more narrowly targeted “Band-Aid” solutions.The United States faces a crisis of trust in government less severe than in Liberia, but it is still important to address this problem if we are to be prepared for pandemics. A Pew Research Center survey shows that trust in government is near its all time low. Other major institutions, from schools to unions to business and religion, do not fare much better. Specific federal agencies, however, such as the CDC and even the Department of Homeland Security, show much more favorable views among the public. Just as Americans hate Congress but love their congressmen and women, Americans distrust government to do the right thing most of the time, but they have more faith in some specific agencies to get the job done. If these agencies work with state and local counterparts, they can build public trust in plans to prepare for and respond to pandemics. At its best, civil defense was a very thin federal government program, but it provided expertise and authority to state and local offices that had the capacity and local knowledge to train people in their geographic regions to prepare for a range of hazards and disasters. If the history of civil defense is any guide, state and local officials and not just the DHS will be important partners in directing attention to the most productive efforts to prepare for disaster.
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Fear and distrust of government are major problems when it comes to controlling Ebola in West Africa, but the United States has its own problems along these lines as well. America’s public health authorities should look to the civil defense legacy for lessons on preparing for pandemics.