Pardis Sabeti - Outbreak Culture The Ebola Crisis and the Next Epidemic, With a New Preface

OUTBREAK CULTURE

The Ebola Crisis and the Next Epidemic

With a New Preface and Epilogue

PARDIS SABETILARA SALAHI

Cambridge, Massachusetts | London, England

Copyright 2018 by the President and Fellows of Harvard College

New Preface and Epilogue copyright 2021 by the President and Fellows of Harvard College

All rights reserved

First Harvard University Press hardcover edition, 2018

First Harvard University Press paperback edition, 2021

Cover design: Tim Jones

9780674269736 (EPUB)

9780674269750 (PDF)

Library of Congress Cataloging-in-Publication Data is available from loc.gov

ISBN 9780674260474 (pbk.)

THIS BOOK IS DEDICATED TO

Our families, for their support

Our colleagues, for their collaboration

All who are working to improve the culture of global emergency response

Dr. Sheik Humarr Khan, for all that he gave and all that we learned

The Ebola epidemic that ravaged West Africa from 2014 to 2016 devastated health systems and social systems in the region and tested the health security of the most developed countries in the world. It was widely known prior to the outbreak that the world was ill prepared to face a large-scale epidemic. Ebola reinforced those warnings. Less well understood was how much an outbreak environment affects the psyche and behavior of the actors involved in the response. That is not something one would likely know without experiencing a major outbreak response firsthand. It is in this contextPardis as a medical researcher who ended up sequencing Ebola, Lara as a journalistthat our paths crossed. During the Ebola response, we uncovered a toxic ethos that enabled the pathogen to spread and cause destruction. Such a culture, we learned, was the underbelly of large-scale infectious disease outbreaks of differing pathogens. We called it outbreak culture.

Outbreak culture is the collective mindset that emerges in the early stages of a disease outbreak among those who are involved in the response. It forms in the crucible of a chaotic, unpredictable, and potentially fatal environment, when initial reactions may be based on fear, or the instinct to protect ones self or others, or a desire for exploitation and personal gain. Outbreak culture dictates how we will respond to news of the spread of a deadly or highly contagious pathogen. It often inhibits efficient action and, at its worst, can even perpetuate the epidemic. We compared Ebola to prior large-scale infectious disease outbreaks and found, regardless of the name of the pathogen, that similar patterns emerged. The pathogen is in many ways secondary to the culture that dictates the local response. Outbreak culture is something we need to contend with and shape if we want to succeed in the fight against infectious agents.

When this book was first published, we knew the world was in a race against time before it would find itself facing down another lethal and contagious virus that could be much more widespread. Anyone reporting and tracking infectious disease outbreaks knew a pandemic lay ahead and could deduce possible pathogens. It was only a matter of what and when. In December 2019, a year after our book was published, a novel coronavirus was detected in Wuhan, China, that within weeks had launched a global pandemic.

Although COVID-19the disease caused by the novel coronavirusvaries greatly from Ebola, both outbreaks shared striking similarities in the toxic environment created across health systems, and we watched with dismay as we saw the reemergence of a culture that seemed to propagate the viruss devastating effects. For example, global agencies and leaders misled the public by downplaying the severity of the outbreak. Terms like China Virus were used to place blame on others, which led to counterproductive displays of hostility and xenophobia. Supplies, including personal protective equipment, were swiftly depleted in even the most developed countries that once touted national stockpiles expected to withstand such health emergencies. In the United States, severe shortages led to bidding wars among states for medical equipment at the expense of health care workers lives.

While we hoped some of the lessons learned from Ebola would be applied to a subsequent epidemic, the core culture of outbreak response remains unchanged. Before COVID-19, many who read this book and were not involved in outbreak response may have regarded our account from a healthy distance. Some readers may have even felt removed from such a culture. Following the coronavirus pandemic, every single one of us has experienced outbreak culture in some form and has become a part of the narrative you are about to read.

The purpose of this book is to unpack the culture of outbreak response. We chose to do this through the lens of the Ebola outbreak, but the premise of this book applies to all epidemics, including COVID-19. Our narrative is rooted in a painful event that became a metaphor for many of the problems of outbreak culture: the death of Dr. Sheik Humarr Khan, the head of Kenema Government Hospital in Sierra Leone. Khan was a renowned physician with unparalleled expertise in tropical diseases, and Kenema Hospital was one of only two centers in West Africa with the capacity to detect and treat viral hemorrhagic fevers such as Ebola. Pardis Sabeti was working with Dr. Khan in 2014 as he and the hospital found themselves at the epicenter of the outbreak in Sierra Leone. Khan should have been able to focus on building Kenemas capacity to handle the surge of Ebola patients. Instead, he faced pressure by individuals who appeared to be seeking to undermine his efforts. He was treating more than eighty Ebola patients in a center designed to handle only a dozen, and his repeated calls for help were not heeded. What is devastating is not only that he ultimately died from Ebola, but that he died feeling a lack of support, a victim of the destructive culture of outbreak response.

We are not the first to tell Khans story. He was the subject of a number of profiles during his life and after his death. In addition to relying on these and our own personal interactions, we contacted several of his family members, including one of his brothers, his sisters, and his father, Ibrahim Seray Khan, who gave us permission to share their stories. While it was not our intention to write Khans biography, we wanted to provide a comprehensive account of his life and work in the context of the Ebola outbreak. In an effort to place Khans story in a broader context, we surveyed over 200 individuals who could offer their experiences of and perspectives on the Ebola outbreak and the culture surrounding it.