The Current Ebola Outbreak
Implications for Asia and Global Health Innovation
First reported in March 2014, the Ebola outbreak in West Africa has become the deadliest occurrence of the disease since its discovery in 1976, having now killed more than all other known outbreaks combined. As of early December, more than 5,600 deaths from Ebola have been reported in six countries as a result of this outbreak: Guinea, Liberia, Nigeria, Mali, Sierra Leone, and the United States. NBR spoke with BT Slingsby, CEO and Executive Director of the Global Health Innovative Technology Fund, about what makes the 2014 outbreak so different, why no approved tools yet exist to prevent and control the disease, and what the implications of the outbreak are for the United States, Asia, and global health R&D.
The 2014 Ebola outbreak in West Africa is significantly different from past outbreaks of the disease. Why has this outbreak occurred, and why do no effective, affordable, and approved tools to prevent and treat the disease exist yet?
The simplest explanation for why this outbreak is significantly different correlates to three factors: (1) dysfunctional health systems, (2) a tardy response by local and international authorities, and (3) human mobility. Until recently, Ebola outbreaks have been primarily limited to isolated rural areas in Africa, where the disease can effectively be controlled via containment. However, this becomes more difficult in an urban environment and with air travel.
Once Ebola enters into an urban environment, its ability to infect individuals increases significantly. The virus has anywhere from a two to three week latency period, and because of that, can spread without anyone knowing. This happened with the Ebola case in Dallas, Texas, where a man traveling from Liberia showed no symptoms when he arrived in the United States. We clearly need a diagnostic that can detect the virus when it is not presenting symptoms, but that is extremely difficult to create.
Potential solutions to Ebola have been underway for several years, primarily supported by U.S. government partnerships with biotech companies. Unfortunately, these partnerships have not produced solutions in time to prevent—or stop—the current epidemic in West Africa. And because of a lack of funding, many products showing promise in early testing were abandoned.
The lack of innovation is due to the reality that Ebola products lack a market (i.e., the number of people at risk is very small). Up until this recent outbreak, the multiple outbreaks over the past 38 years (since the official discovery of the disease) have been properly contained with fewer than 1,500 deaths total.  This historically small number of deaths (less than 2,000 cases over four decades), while incredibly tragic, is just not enough to persuade most pharmaceutical companies to dedicate the hundreds of millions of dollars and decades of time required to bring an Ebola solution to market. This is very different from a “market failure,” where the number of people infected (and at risk of becoming infected) is very high—as in the case of tuberculosis, malaria, or dengue fever—with the majority of those individuals also typically being unable to pay for treatment.
What does this Ebola outbreak in West Africa mean for Asia? What lessons should Asia be learning about potential outbreaks of other infectious diseases?
To date, there are no reported cases of Ebola in Asia. However, when discussing how Asia should think about Ebola, it is important to start by assessing the potential health risk. When not diagnosed or attended to with an early clinical response, Ebola has a high mortality rate. It spreads through human-to-human transmission via direct contact with bodily fluids of infected people and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids. It is important to note here that mere casual contact is not a route of transmission. Still, today neither proven treatments nor licensed vaccines are yet available, though a range of potential treatments are currently being evaluated and two potential vaccines are undergoing safety testing.
In terms of implications for countries in Asia, I need to re-emphasize the role and importance of human mobility. Travel to and from countries in Asia is increasing significantly, and the number of flight routes, particularly between China and many countries in Africa, has increased more than anywhere else globally in the past decade. This will likely be the case over the next decade, as Asia continues its global economic rise and human mobility only increases. With the amount of global travel, infectious disease could potentially spread to the world’s most populous metropolitan cities, many of which are in Asia.
The most crucial determinant of proper containment of Ebola is a robust health system. Recent Ebola outbreaks have been successfully contained in Nigeria, Congo, Spain, and New York City because their health systems were ready for the disease. Conversely, the three most affected countries in West Africa, and to a certain extent the hospital system in Dallas, were ill-prepared. Should an infectious disease with a relatively long latency period—like Ebola—infiltrate one of Asia’s major cities, it would prove a significant public health risk. It is likely that Ebola would be controlled and contained in cities with strong health systems, such as Tokyo, Singapore, or Hong Kong. However, if Ebola emerges in densely populated Asian cities with more varied and underfunded health systems, such as Bangalore or Shanghai, the disease will be much more difficult to control.
In addition to the public health impact, an Ebola outbreak in a major city in Asia could also have serious ramifications for the region’s economy, global stock markets, and bilateral and multilateral relationships.
There is certainly much we still need to learn about Ebola. This is just one of many areas that need more funding, and there is much room for collaboration, including between U.S. and Asian partners. SARS and avian flu raised some of the same issues for countries in Asia. These crises have certainly tested relationships between and among Asian countries. However, they have probably strengthened the region in many ways, too, including in terms of information sharing and global health collaboration efforts.
What implications does the Ebola outbreak in Africa have for U.S.-Asia relations?
The United States and countries in Asia have a tremendous opportunity to make an impact in the fight against Ebola—and neglected diseases more broadly—through an alignment of their global health funding policies and collaborations. The United States is considered a global leader in its policies toward public health risks. U.S. policies cover a plethora of “bio-threats,” such as Ebola, SARS, avian flu, and anthrax, as well as such persisting high-burden diseases as malaria, tuberculosis, and neglected tropical diseases.
Over the last several decades, the U.S. government has invested hundreds of millions of dollars in R&D around these issues—representing an investment to combat health risks to the country and its interests, as well as risks that transcend national boundaries. The call for this investment comes from a myriad of U.S. government agencies, such as the Biomedical Advanced Research and Development Authority under the Department of Health and Human Services, which has a mandate to protect U.S. citizens; the Defense Advanced Research Agency under the Department of Defense, which protects U.S. soldiers; and the National Institute of Health, which leads the charge for both domestic and global health innovation science.
The Ebola crisis will hopefully serve as a reminder to the international community that infectious diseases are a public health risk to global society. The United States should not be the only country leading in terms of policy and significant investments; countries in Asia must also become involved. One example of Asia stepping up is Japan’s establishment of the Global Health Innovative Technology (GHIT) Fund in 2013. By creating this fund, Japan made a concerted effort not only to increase government funding for global health R&D but also to bring the country’s domestic pharmaceutical sector along through a unique public-private partnership. Japan’s top pharmaceutical companies have put real money into the fund, as well as their technology and R&D capacity.
The United States should look to its partners in Asia to align their activities toward Ebola and other high-risk diseases that lack a commercial market—not just at the level of government policy but also more broadly to include the private and civil sectors. For example, as the United States is home to numerous world-leading pharmaceutical and biotech companies, there may be opportunities through a GHIT-type model to partner and leverage these companies’ technology and innovation.
No specific drug or vaccine has been approved to control and prevent Ebola, but there is clearly a strong need for such innovation. Whose responsibility is it to create these tools?
I would argue that no one country or sector is responsible. Instead, it is the responsibility of society in general to create the right kind of environment to encourage and advance innovation that lacks a market (as I described earlier). This could include financial incentives that enable the innovation of new health technologies and tools to fight against Ebola and other neglected diseases.
With regard to fostering innovation in the field of global health technology, history has shown us that if given the right environment and with incentives in place, real advances might be possible to develop new tools for addressing diseases that lack a market through cross-sector and cross-border R&D partnerships.
For example, eighteen countries in sub-Saharan Africa suffered frequent outbreaks of meningitis, with enormous human and economic consequences. A partnership between the World Health Organization, the U.S. Food and Drug Administration, a European nonprofit organization, the Bill & Melinda Gates Foundation, and an Indian vaccine company recently yielded a new vaccine for meningitis A. The vaccine has been distributed throughout the “meningitis belt” and over the first few years has already helped break the cycle of epidemics in the region. This collaboration represents a paradigm shift from the idea that such research might be the “responsibility” of a single country or company.
The United States has invested more money into controlling diseases that do not just pose domestic risks than any other country. As a result, the world relies largely on U.S.-funded innovation, which has certainly accelerated. However, as we’ve seen with the Ebola outbreak, our global society is at risk if we need to depend on the United States to drive forward public health innovation. More diversification in sources, as well as new innovation, is needed.
Countries in Asia have a deep history of combatting and defeating infectious diseases, as well as a great wealth of global health technology innovation. Today, for example, Japan’s government and industry play a large role in finding solutions through the GHIT Fund. In addition, India is a world leader in generic pharmaceuticals, and the sophistication of Singapore’s and China’s life sciences R&D sectors is growing.
A key part of maintaining this momentum is continuing to create incentives for innovation and environments where it can take place. The United States has historically provided one of the best environments for innovation, but governments around the world are examining how to create more such environments that enable game-changing innovation
How is the current Ebola outbreak influencing global health R&D priorities, funding, and collaboration?
There needs to be a transcendental shift in how to approach the development of anti-infectives, as well as a shift in how the global policymaking and scientific communities approach multilateral, multi-sectorial responses to infectious diseases. A global call to action is needed to reassess how to approach infectious diseases in a way that is pre-competitive, meaning that it fosters R&D collaboration among multiple partners but does so in an environment that avoids direct competition.
Right now, several pre-competitive incentives to develop anti-infectives do exist, and they should be expanded. However, I fear that change may only happen after a potentially catastrophic incident. For example, if there were an outbreak of an infectious disease like drug-resistant tuberculosis in New York or another major metropolitan city, particularly one in North America or Europe, there would be an immediate transcendental shift in how to approach those diseases. However, at that time it would be too late, because creating a drug or a vaccine is not possible overnight—not even within a year, two years, or even three years. So then where are we? For any response to be truly transformative, there needs to be a call to action at the G-20 or G-7 level. This call should recognize the problem and commit to creating an environment within and between countries that can foster innovation. Collaboration is absolutely necessary moving forward, whether it aims to prevent the further spread of Ebola or another similarly dangerous infectious disease.
 Centers for Disease Control and Prevention, “Outbreaks Chronology: Ebola Virus Disease,” http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html.
This interview was conducted by Claire Topal, Senior Advisor for International Health at NBR. She provides strategic guidance to NBR’s Executive leadership on the development of NBR’s international health programming.