Professor of Epidemiology Abdul El-Sayed: Ebola in America

Until Thomas Eric Duncan brought Ebola into the United States, the disease was largely dismissed as an exotic pestilence of concern mainly to impoverished West Africa, and those who dared to volunteer there. And its transmission to two nurses responsible for Duncan’s care – likely resulting from several breaches of medical protocol – has focused intense scrutiny on US preparedness for a possible outbreak. President Barack Obama even announced last week the appointment of an “Ebola Czar” to manage the detection, isolation, and control of the virus in the US.

Medical and public health experts had been assuring the public that there was little cause for fear. The Centers for Disease Control and Prevention (CDC) and other health agencies were working behind the scenes, painstakingly tracing anyone who may have come into contact with Duncan and quarantining those who might transmit the disease. Transmission in the US was nearly impossible, owing to the strength of the US health system, it was thought.

But, as recent events have illustrated, robust health agencies should not be taken for granted. In fact, over the past decade, the government has slashed budgets at several top health agencies, including the CDC, the National Institutes of Health (NIH), and state and local health departments. Between 2005 and 2012, for example, the CDC lost 17% of its funding, and officials recently reported that funding allocated for Ebola-type health emergencies is $1 billion less than it was in 2003.

The challenges faced at the state and local levels may be even greater. Some 23% of local health departments reported that public health preparedness programs were reduced or even eliminated in 2011, while a further 15% reported similar cuts in 2012. In 2014 alone, the Hospital Preparedness Program, which links regional hospitals with local health departments to prepare for potential public health emergencies, suffered$100 million in budget cuts.

These reductions have already left their mark. The Hospital Preparedness Program was designed specifically to train health personnel on disease containment in the setting of unforeseen epidemics, such as Ebola. Had it been adequately funded, perhaps the two nurses now infected would still be healthy.

The NIH, which funds important advances in our understanding and treatment of diseases like Ebola, has also suffered cutbacks. Its budget has stagnated for most of the past decade, except for years when it was dramatically reduced, such as in 2013. This has forced productive research laboratories to close, putting potentially life-saving research – like that on an Ebola vaccine – on the back burner.

One explanation for the drastic budget cuts of recent years is that public health institutions usually operate with little fanfare and out of the public eye. At their best, they prevent disease without a trace, leaving little visible evidence of their crucial function. Hence, funding for public health has been a tough sell in good economic times, and is one of the first targets for retrenchment.

But global health emergencies like the current Ebola epidemic highlight the folly of these fiscal priorities. Though we may not lean too heavily on our health infrastructure typically, its importance becomes all too apparent when disease and death come knocking at our door.

Indeed, though the threat of a serious Ebola outbreak in the US remains minimal, that is no reason for complacency. As the number of cases in West Africa rises, so does the potential for outbreaks outside of that context. And when members of the international community cannot contain the epidemic, the richest and most powerful actor, namely the US, has an obligation to step in and try to do so.

But budget cuts have damaged America’s ability to fulfill this obligation, and thus may cost more than policymakers bargained for. In late September, Obama committed $88 million and 3, 000 troops to support the fight against Ebola in Liberia. But his decision came only after the epidemic had been smoldering for many months, with 6, 000 Ebola cases confirmed and many more believed to be undetected. Had CDC funding been at an appropriate level, US support – in the form of highly trained public health professionals, rather than ground troops – might have been deployed much earlier and been more effective.

Ironically, the CDC and its leadership have come under intense scrutiny over the mishandling of Duncan’s care and the Ebola transmissions that resulted from it. However, had the same lawmakers who are now deriding the CDC listened to pleas for more support and warnings of the consequences of poor funding over the past several years, perhaps the US would not be in the situation in which it finds itself today.

The guiding principle of public health is to prevent disease before it strikes, and this requires long-term investment in institutions that can protect us. Our collective health and wellbeing are evidence of such institutions’ effectiveness.

Fortunately, the Ebola outbreak is unlikely to expose Americans fully to the poor fiscal choices of the past decade. But the disease’s sudden appearance on the global scene serves as a stark reminder of what can happen if we do not remain vigilant. The next epidemic could be just around the corner. We must ensure that we are fully prepared.