Ebola's Greatest Threat: A Third-World Pandemic

Underestimating the Ebola epidemic is a sure way to make it worse.
An ambulance carrying Texas Health Presbyterian Hospital nurse Nina Pham arrives at Love Field airport.

Yesterday, I accidentally took a double dose of my blood pressure medication. This had several exciting side effects, but the two most relevant to this story were dizziness and nausea every time I had to stand up. The reason that these were notable is what I had to do next: get on an airplane.

I staggered through the airport. I stumbled through the boarding line. I hurled my bag into the first open overhead space I could find, and collapsed into my seat with my head between my knees. Eventually, I looked up to find that I had the avid attention of every passenger in the area.

"I took too much blood pressure medicine," I said. "I don't have Ebola." They laughed. But it seemed to me they also relaxed.

How much should we be worried about Ebola, here in the U.S.? By the numbers, "not very." As things stand right now, unless you are an emergency room worker or an infectious disease specialist at a handful of hospitals, you should spend much more time worrying about wet floors and people who text and drive. Because your risk of those things hurting you is, statistically, much higher.

That's not to say it's not worrisome. Liberals and conservatives have split on this, in a way that Scott Alexander explored at length in an interesting post. Just as some of the worrying is overwrought, so some of the pooh-poohing seems to misunderstand what's scary about the disease. I saw this NPR graph circulating a lot on social media, for instance:


This correctly illustrates that the risk of Ebola infection is relatively low. On the other hand, I saw people incorrectly say that Ebola is harder to get than HIV. Ebola is easier to get than HIV if you are exposed to someone who is contagious; the reason that the average infected person doesn't infect that many other people is that by the time you are infected, you are too sick to move much, and very likely to die. HIV takes longer to make you sick, so you have more time to infect someone. The common cold infects a lot of people because most of its victims are healthy enough to move around; I'm not sure I'd therefore say that a reasonable person should be more scared of a cold than of Ebola.

To complicate things further, most of our experience with Ebola is in poor countries that lack the infrastructure to do intensive interventions. Infectious disease expert Paul Farmer says that in a Western hospital setting, with lots of supportive treatment and rapid diagnosis, the fatality rate for Ebola should be more like 10 percent, which is a lot less scary. But those interventions make health-care workers more vulnerable, because they involve putting things into peoples' veins, exposing the workers who perform the procedures to virus-laden blood. Following strict safety procedures can mitigate those risks; as we've seen in Dallas, however, those procedures sometimes fail.

Most previous epidemics in Africa were also confined to rural areas where they burned out pretty quickly. Most Americans don't live in rural areas; we live in cities or suburbs where we spend a lot of time interacting with strangers. A loose case of Ebola could travel a lot farther and faster here than it can in a poor country. Just imagine an Ebola patient using a public restroom in an airport or a mall, and failing to properly wash their hands. Better yet, don't, unless you've laid in a good supply of Ambien.

Now before you start shopping for seed banks and disaster prep kits, I'm not suggesting we're at risk of an Ebola pandemic. We've had some spectacular early failures, but I'm pretty confident that the U.S. health-care system will be able to contain any outbreak quickly. I'm confident about this precisely because Ebola is very, very scary indeed: moderately contagious, with a very high mortality rate. We're a rich country with a good health-care system and huge resources, and we will mobilize whatever is needed to stop Ebola in its tracks.

The nightmare scenario is not Ebola getting here; even if it does, it is hard to imagine it competing with, say, NSAIDs as a cause of U.S. mortality. No, Yuval Levin outlines the actual nightmare:

The very nature of the debate we are now having, including the debate over the travel ban, is evidence of the fact that we probably have not yet learned not to underestimate this outbreak. We are still thinking about it in terms of a crisis in Guinea, Liberia, and Sierra Leone that could reach our shores by the various means that connect us to them. But the real danger, to us and to others, is probably far greater than that. Our greatest worry should not be that the disease could get to the United States from those West African nations but that it will get to Nigeria's larger population centers or to, say, India or other places with massive population density and weak public-health systems, and from there will become an epidemic throughout the third world. The scale that this outbreak is now likely to reach in West Africa will make it rather difficult to prevent that, raising the risk of a far more colossal human catastrophe than the nightmare we are already witnessing and of a greater threat to the U.S. population.

The good news is that Nigeria successfully contained and ended an outbreak of Ebola that occurred in Lagos early in the epidemic. That doesn't mean that travel bans going up in various developing countries will necessarily hold new infected arrivals to zero. Ebola may yet leap out of its reservoir in rural Africa, and attack denser, more popular areas that are still too poor to mount an effective response in the face of an epidemic that is most likely to kill caregivers. That is, as Levin says, the greatest threat to billions of people in the developing world, and also to us. If the world stops this from happening, it will probably be because we got really scared of Ebola, and took the steps we needed to make sure it didn't spread.

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