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
