Ebola: Failures of Imagination

by Jody Lanard and Peter M. Sandman

The alleged U.S. over-reaction to the first three domestic Ebola cases in the United States – what Maryn McKenna calls Ebolanoia – is matched only by the world’s true under-reaction to the risks posed by Ebola in Liberia, Sierra Leone, and Guinea. We are not referring to the current humanitarian catastrophe there, although the world has long been under-reacting to that.
We will speculate about reasons for this under-reaction in a minute. At first we thought it was mostly a risk communication problem we call “fear of fear,” but now we think it is much more complicated.
Some of the world’s top Ebola experts say they are worrying night and day about the possibility of endemic Ebola, a situation in which Ebola will continue to spread, and then presumably wax and wane repeatedly, in West Africa.
They – and we – find it difficult to understand why Ebola has not yet extended into Cote d’Ivoire, Mali, and Guinea-Bissau. (After we drafted this on October 23, a case was confirmed in Mali.)
Fewer experts refer publicly to what we think must frighten them even more (and certainly frightens us even more): the prospect of Ebola sparks landing and catching unnoticed in slums like Dharavi in Mumbai or Orangi Town in Karachi – or perhaps Makoko in Lagos. (Imagine how different recent history might have been if the late Ebola-infected Minnesota resident Patrick Sawyer had started vomiting in Makoko instead of at Lagos International Airport on July 20.)

The Pandemic Scenario

The possibility of an Ebola pandemic throughout the developing world is the scenario that keeps us up nights. We think it must keep many infectious disease experts up as well. But few are sounding the alarm.
The two of us are far less worried about sparks landing in Chicago or London than in Mumbai or Karachi. We wish Dallas had served as a teachable moment for what may be looming elsewhere in the world, instead of inspiring knee-jerk over-reassurance theater about our domestic ability to extinguish whatever Ebola sparks come our way. We are glad that Dallas at least led to improvements in CDC guidelines for personal protective equipment and contact tracing, and belatedly jump-started front-line medical and community planning and training. But it doesn’t seem to have sparked the broader concern that is so vitally needed.
Americans are having a failure of imagination – failing to imagine that the most serious Ebola threat to our country is not in Dallas, not in our country, not even on our borders. It is on the borders of other countries that lack our ability to extinguish sparks.
But we are also having our own failure of imagination. In fact, we are having two.
First, we cannot make our imaginations take seriously any of the optimistic scenarios that would prevent the current situation in West Africa from ending very, very badly for the world:

• The people of West Africa and the governments of West Africa rise to the occasion, radically altering deeply embedded cultural practices, from political corruption to the way they bury their dead.
• The epidemic stops spreading exponentially, so the gap between needs and resources stops getting wider every day than the day before.
• The world’s nations actually fill that gap, providing enough money, supplies, and people to outrace the epidemic.
• Treatment, isolation, contact tracing, and contact monitoring reach the percentage of cases needed to “break the epidemic curve.”
• Meanwhile the epidemic doesn’t cross into too many more countries. And all the sparks that land in other countries are extinguished with minimal collateral damage, as has been the case so far in Nigeria, Senegal, Spain, and the United States. (As of the evening of October 23, the U.S. now has a second index case to cope with.)
• Fears that sparks will travel more widely and launch new epidemics in Asia, Latin America, and elsewhere prove unfounded.
• Or, alternatively, a spectacularly successful vaccine is quickly discovered, tested, mass-produced, and mass-distributed.

There may be people in high places – politicians, public health officials, and even technical experts – whose imaginations can embrace the hopeful scenarios above. That might account for their failure to warn the public about the alternative: a massively disruptive global catastrophe, far beyond the current humanitarian disaster.
But there are other reasons besides optimism why the risk of an Ebola pandemic in the developing world rarely gets publicly discussed.
It could be pessimism. Maybe they think there is nothing to be done anyhow, so they might as well fiddle, in office instead of out of office, while Rome or Mumbai or Karachi begins to burn.
Or it could be the reason we mentioned at the start of this essay: fear of fear and its close cousin “panic panic.” Maybe they think the American people can’t take it: They’re in panic about panicking the public. (Even if they’re not worried about panicking the public, they could be worried about getting accused of trying to panic the public.)
A fourth possibility: Maybe they are having trouble keeping the picture of a developing-world Ebola pandemic in focus. It is so close to unimaginable, so almost unimaginably horrible.
Those are the four reasons we have thought of that could explain the lack of headlines about this calamitous prospect. The people out there talking about Ebola:

• don’t think it’s likely enough to be worth talking about;
• don’t think there’s anything to be done about it anyway;
• don’t think the public can take it; or
• can’t bear to keep the horrific prospect in focus.

We have some sympathy for the fourth possible explanation. In fact, that’s our second failure of imagination: We too are having a hard time focusing our minds on the pandemic scenario.

Failure to Imagine, Failure to Warn

Even though we correspond with more than ten friends and colleagues working there, we find it hard enough to picture – really picture – what’s already happening in West Africa. Our minds shy away even more from what might happen in the months to come. It’s just too awful. So we end up parsing Dallas risk communication errors and the CDC’s failure to apologize instead.
Despite our intellectual sense that the developing-world pandemic scenario is credible, despite our visceral sense that the world may already have shifted on its axis, it is very hard for us to imagine concretely what that dire scenario might be like. We are just two risk communication experts. No one is fleshing this out for us.
We barely try to imagine what a developing-world pandemic would be like for people who live there. We try and fail to imagine what it would be like for us and our loved ones.
What would it be like:

• if there are dozens of sparks landing in the U.S. and other developed countries, not just from West Africa but from all over the world?
• if healthcare workers won’t come to work?
• if cancer patients and HIV-infected persons and children with asthma can’t get their medicines because 40 percent of generic drugs in the U.S. come from India, where production and shipping have halted?
• if refugees, under pressure from civil unrest, insurrection, famine, and economic collapse, are pouring across every border – some sick, some healthy, some incubating?
• if Ebola in the developing world launches the next Global Financial Crisis?
• if the Holy Grail, the deus-ex-machina – a successful Ebola vaccine – cannot be developed, produced, and distributed before all this happens?

We have been here before.
When it looked to many experts (and to us) like H5N1 avian influenza was about to go pandemic, we both had a similar sense of dread.
This time feels different to Jody, like it is already inexorably happening. To Peter, it’s a scenario likely enough to worry about, to lose sleep over, and to take drastic action to prevent or mitigate – but it doesn’t feel necessarily inevitable … not yet, anyway.
SARS, climate change, and the possibility of nuclear disaster have similarly occupied us.
It hasn’t escaped our notice that neither H5N1 nor SARS has gone pandemic yet; we haven’t had a nuclear holocaust yet; the effects of climate change continue to be debated (even their debatability is debated – like the issue of “airborne Ebola”). So there is precedent for hoping we could be wrong about Ebola.
A leitmotif of our writing about these other threats has been the failure of officials and experts to sound the alarm with sufficient determination, courage, candor, or skill to arouse what we considered a suitable level of public apprehension.
But the failure to sound the alarm about pandemic Ebola has achieved a previously unheard-of level of silence. In the mainstream media – in all media except for fringe blogs – this possibility is virtually underground, manifestly off-limits for discussion, and possibly off-limits to the imagination.
But not quite. Recently we have seen an increasing number of Ebola articles and op-eds that briefly mention “India,” or “global spread,” or even “pandemic.” These references are almost always brief and buried way down in the story … almost throwaway lines. The risk of an Ebola pandemic in the developing world is a sidelight, not the main point.
Even in articles about how many Ebola-infected travelers can be expected to get to this or that country per month or per year, the risk of an Ebola pandemic in the developing world is not the main point.
And even in stories that talk (briefly) about the risk of an Ebola pandemic in the developing world, the likely effects of such a pandemic – and especially its likely effects here at home – rarely rate as much as a single sentence.
The writers get close to it, and then they veer away.
When it looked like an H5N1 pandemic might be imminent, a woman who went by the nom-de-flu “Canada Sue” wrote a wonderful extended fictional diary of the pandemic, which helped the prepper community picture what we were prepping for. Now we desperately need an Ebola Canada Sue to help us imagine what life might be like with the developing world in flames.

Why Warn the Public?

Why should experts and officials talk to the public about the prospect of pandemic Ebola?
First, it would help Americans put the few domestic Ebola cases into context. We don’t share the widespread judgment that people are panicking over Ebola. Nearly all measurable data suggest that most people are going about their business, riveted and even anxious but not panicked. Whatever over-reaction is taking place is in our judgment a normal and sometimes even useful “adjustment reaction,” exacerbated by people’s justified sense that officials’ handling of the first three cases had real deficiencies in competence, candor, and caution. Not to mention that being ridiculed for “panicking” has never yet calmed anybody down.
Still, one tried-and-true way to help people put a fearful risk into context is to teach them about a more fearful risk. Not obesity, auto accidents, and flu. People are already as worried as they choose to be about those. This is their month to decide how worried to be about Ebola. And not the “humanitarian crisis” in West Africa, either; our worry budget and our sympathy budget are in separate psychological boxes. But a different, bigger, more serious, global Ebola worry stands a real chance of partially replacing people’s excessive domestic Ebola worry.
Second, and much more important, talking to the public about the risk of an Ebola pandemic might help build a bigger head of steam for action to avert that risk.
We’re not knowledgeable enough to say what that action agenda should be. Surely the quest for an Ebola vaccine is one action item. That quest is obviously moving a lot faster than it was a few months ago. But to us it still seems anemic, half-hearted, not nearly as desperate as it ought to be.
Another action item – if it’s actionable – is the effort to buy time for vaccine development by reducing the number of sparks emanating from West Africa to other developing countries, and by helping those countries better prepare to extinguish the sparks that reach their shores. There seems to be a consensus that Nigeria is key; it is at risk from its West African neighbors and it’s a likely source of risk to more distant countries, especially India. What is the comparative value of sending CDC experts to Nigeria to strengthen its ability to fend off sparks, compared to sending them to Liberia, Sierra Leone, or Guinea … or New York? We don’t know, but a public discussion of pandemic Ebola in the developing world would serve up the question.
Finally, teaching Americans how an Ebola pandemic in the developing world could affect their lives would give them – give us all – a chance to start getting through our adjustment reaction about that:

• First apathy and ignorance (where most people are now);
• Then denial (a longing to stay apathetic and ignorant just a little while longer);
• Then over-reaction, taking precautions that may be unwise, ineffective, or premature (you can’t skip that part);
• Then new learning, new wisdom, and new determination to take effective action.

If there are tough times ahead, as there may be, we will face them better as a country if they don’t take us quite so much by surprise.
Of course warning about an Ebola pandemic that never materializes has costs. Some people’s excessive worry could damage their health; many people’s appropriate worry could damage the stock market; everybody’s irritation if the worry turns out unnecessary could damage officials’ reputations.
But not warning about an Ebola pandemic that catches us by surprise has much higher costs. It’s not damned if you do and damned if you don’t. It’s darned if you do (warn) and damned if you don’t.
And if our leaders don’t sound the alarm, somebody else will. People will start to find out or figure out that they have bigger Ebola problems than they faced in Dallas (and now face in New York). If our leaders aren’t the ones who tell them, they will not trust our leaders to guide them through it.
Our friend Michael Osterholm has a favorite quote about the uncertainties of emerging infectious diseases. Scrooge, in A Christmas Carol, asks the Ghost of Christmas Yet to Come:

Are these the shadows of the things that Will be, or are they shadows of things that May be, only?

We can’t prove that the difference lies in our leaders’ willingness to share terrifying possibilities now – to imagine those possibilities, then to help us imagine them, and then to ask our help in figuring out how best to address them. But we can imagine that it might.
Disclosure: We have no financial conflicts of interest with regard to a potential Ebola vaccine. Since early May 2014, we have done a lot of Ebola risk communication work – most of it unsuccessful, none of it paid. http://www.psandman.com/col/Ebola-3.htm