Lessons Lost: How 'Outbreak Culture' Is Shaping the COVID Response

Keren Landman, MD


August 04, 2020

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In their 2018 book Outbreak Culture: The Ebola Crisis and the Next Epidemic, journalist Lara Salahi and evolutionary geneticist Pardis Sabeti, MD, from the Harvard School of Public Health, examined a broken outbreak response system through the lens of the largest and most lethal Ebola outbreak to date — and proposed a better way. They had no idea their work would become so relevant so soon.

Medscape spoke with Salahi about the book's lessons for COVID-19 and whatever may come next.

What do you mean by "outbreak culture?"

Lara Salahi (Photo courtesy of Kristen Walsh)

In examining the Ebola outbreak and other major outbreaks around the world — SARS, MERS, AIDS, but also smaller ones — we found a pattern in outbreak response. Regardless of the pathogen, early in the outbreak, the response is driven by overriding fear or politics rather than science or public health. That pattern is what we call "outbreak culture."

In outbreak culture, the pathogen becomes the backdrop to advancing agendas amid competing interests and misaligned incentives, which can lead to inconsistencies in response efforts. Sometimes, outbreak culture helps propagate the epidemic rather than mitigate it.

An outbreak is a crucible—a melding of forces in this intense, high-stakes, pressure-filled environment. There are so many unknowns. The environment is volatile. The situation is rapidly evolving. After the outbreak, we'll have clarity on a lot of what went wrong and what we can do better. But we have to acknowledge that during the outbreak [itself], there is going to be fear and we'll be making decisions based on things we don't know.

What manifestations of outbreak culture have you seen play out during the COVID-19 pandemic to date?

Much as in the Ebola epidemic, the seriousness of this pandemic was initially downplayed, which resulted in certain public health measures being overlooked.

Another parallel we saw is the lack of preparedness — shortages and inadequate levels of equipment needed for frontline healthcare workers to do their job.

If we continue to see outbreaks as a political issue rather than a humanitarian one, we're going to keep responding to them that way. Outbreak culture won't change without shifting to a culture of preparedness.

It sounds like we keep making the same mistakes on a global scale. Who's responsible for changing the way the world responds to outbreaks?

There are bad actors in any outbreak scenario because there's a lot at stake. People can use fear to interpret data and dictate policy. But I think it's indulging outbreak culture to place blame on one group or another; the U.S. withdrawal from the World Health Organization (WHO) plays into outbreak culture, for example.

What's needed is a level of strong leadership — a global governance system that as of right now does not exist. Pathogens know no boundaries, so there needs to be global consistency and cooperation. This is not going to be the last pandemic.

This leadership is something that has to be developed during the quiet period between epidemics. This was recommended after the Ebola outbreak but wasn't followed through. I hope COVID-19 has driven home this lesson: There should be follow-through.

A lot of people might think of the WHO as a global governance system. What additional capacity would that organization need to be what you're envisioning?

We envision enhanced accountability and transparency of all actors involved in outbreak response. Under the current structure of the WHO, there's not enough in terms of oversight and the security of financial resources to prepare and respond to a global crisis. And the WHO doesn't have governance over any other entity's ability to act or not act in an outbreak scenario.

Are there changes the global community can make even now, in the middle of the COVID-19 pandemic, to improve the success of its response?

We need collaboration at a global level — an outbreak in one part of the country or one part of the world, as we're learning, is essentially a threat globally. So we must talk about creating a system that's going to work for all parties involved in an outbreak response.

During both the Ebola and the COVID-19 outbreaks, we've seen extraordinary loss of life among healthcare workers. A lot of it was because they didn't have the proper equipment. They worked overtime and didn't receive the pay. They were stigmatized in their communities.

We've got to protect our protectors; we've got to ensure that outbreak responders have what they need to safely do their jobs. We also need to empower communities to act. Communities have to feel invested in breaking the transmission chain, even if that means changing their way of life, which can be incredibly uncomfortable.

What scares you about this outbreak?

Pathogens expose every vulnerability of health systems. During Ebola, those of us outside of the hardest-hit countries criticized them for rejecting health messages, like the messaging about folks not attending funerals, social distancing, the family unit isolation. Yet some of these same rejections took hold with COVID-19, and not just in low- and middle-income countries.

Those who lived through Ebola witnessed the societal breakdown and trauma that accompanies an outbreak over a prolonged period of time. The result was a big upsurge in the incidence of mental health disorders, including depression, anxiety, posttraumatic stress, and substance abuse. We are already beginning to see major psychosocial consequences as a result of this pandemic.

What has surprised you about this pandemic?

I find it interesting how quickly outbreak fatigue has set in in this particular outbreak. There's a rush to get back to a particular way of life without a system in place. Here in Massachusetts, for example, a makeshift intensive care unit at the convention center was closed because there wasn't a need for it — but did we have a test-trace-isolate system in place at the time? No. So it will be interesting to see how public health measures respond to our sense of outbreak fatigue.

We've seen many people reject public health messaging during COVID-19. Do you have any advice on how to make it less likely this messaging will be rejected?

We should be hearing more publicly from the Centers for Disease Control and Prevention. People receive messaging very differently when a public health expert is speaking about the measures that should be in place and when a politician speaks about it.

That said, there's a heavy resistance to top-down messaging in outbreak settings. During Ebola, a lot of what helped was community members being the leaders in the messaging. It wasn't an outsider coming in and telling a community what to do; it was religious leaders or elders in a community who drove the message that people should trust the system.

What gives you hope about the response to COVID-19?

One of the central figures we interviewed for our book, Nahid Bhadelia, MD, said it best: "We forget the lessons we learn from outbreaks, so we make the same mistakes."

What we're seeing now is sort of a testament to that. But this is really a teaching moment. Once we get over this, more than any other time, it will be a time to act.

Keren Landman is a journalist, physician, and epidemiologist based in Atlanta, Georgia. Find her on Twitter: @landmanspeaking

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