(Updated Nov. 7, 2014)

The Centers for Disease Control and Prevention reported on Nov. 4 that the death toll from the Ebola outbreak in West Africa has risen to above 4,960 and that an estimated 8,168 people, mostly in Liberia, Sierra Leone and Guinea, have contracted the virus since March. It is the largest and most severe outbreak of the Ebola virus since it was first detected four decades ago. All but nine of the deaths were in those three countries; eight were in Nigeria and one patient died in the United States.

The CDC in October proclaimed that in the worst-case scenario, Sierra Leone and Liberia could have 1.4 million cases by Jan. 20, 2015, if the disease keeps spreading without immediate and immense intervention to contain the virus.

Two American aid workers infected with Ebola while working in West Africa were transported to a containment unit at Emory University in Atlanta for treatment, raising public fears about international spread of the highly virulent virus that has no known cure. The two were released from the hospital after being the first humans to receive an experimental Ebola drug called ZMapp. Another man who recently helped an Ebola victim in Liberia traveled to Texas and died in a Dallas hospital. Two of the nurses who treated him caught the virus as well, but have been released from the hospital. Some states have struggled with the moral 

We ask CISAC biosecurity experts David Relman and Megan Palmer to answer several questions about Ebola and the public health concerns and policy implications. Relman is the co-director of the Center for International Security and Cooperation who has served on several federal committees investigating biosecurity matters. He is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine and of Microbiology and Immunology at Stanford University School of Medicine, and Past-President of the Infectious Diseases Society of America.

Palmer is the William J. Perry Fellow in International Security at CISAC and a Researcher at the UC Berkeley Center for Quantitative Biosciences (QB3), and served as Deputy Director of Policy & Practices for the Multi-University NSF Synthetic Biology Engineering Research Center (SynBERC).

The two of them have answered the questions together.

What is Ebola and how dangerous is it compared to other diseases?

Ebola is an acute viral infectious disease, often associated with severe hemorrhagic fever. While initial symptoms are flu-like, they can rapidly progress, and include vomiting, reduced ability to regulate immune responses and other physiological processes, sometimes leading to internal and external bleeding. The disease has an incubation period that can last up to 21 days, but patients typically become ill four to nine days after infection, and die about seven to ten days later. Fatality rates for the current Ebola outbreak are nearing 60% (according to the CDC), while past outbreaks in the Republic of Congo have seen rates as high as 90%. This outbreak to date has resulted in nearly 1,000 deaths, more than any previous Ebola outbreak.

Ebola virus is believed to reside in animals such as fruit bats where it does not cause disease, but is then transmitted to and among humans and other primates, in whom disease typically does occur. The route by which the virus crosses between species remains largely unknown. People become infectious once they become symptomatic. Ebola is transmitted via blood or bodily fluid, but can persist outside the body for a couple days. Infection can occur through unprotected contact with the sick, but also when contaminated equipment such as needles cut through healthcare workers’ protective gear, and also through contact with infected individuals postmortem.

David Relman Photo Credit: Rod Searcey

Ebola’s horrific symptoms provoke public fear, and it becomes easy to lose perspective on the relative spread and toll of this outbreak. Ebola is relatively difficult to transmit. This means the latest Ebola outbreak is still small in comparison to the hundreds of thousands of people killed each year via more easily transmitted airborne influenza strains and other diseases such as malaria and tuberculosis. It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere.

Is there a vaccine or cure?

There is no vaccine for Ebola and no tried-and-true cure. Health workers can only give supportive care to patients and try to stop the spread to new victims.

Several experimental therapies for Ebola are under development. One receiving attention is ZMapp, a mix of antibodies produced by mice exposed to the virus that have been adapted to improve their human compatibility. Limited tests in primates show early promise, but the drug had not been tried on humans -- until now. Two Americans transported back to the U.S. from West Africa received the experimental therapy. While the two seem to be improving, it isn’t clear that ZMapp was responsible; another issue is that ZMapp and other potential therapies have not been cleared by the FDA for wider use in humans.

The process for approval, and who gets priority access to such drugs, are complex policy issues. The WHO will be convening leaders and medical ethicists next week to discuss how to develop and distribute experimental therapies. This is not a simple task; many factors need to be taken into consideration and balanced with limited information to guide decisions.

Successful or not, and despite any approval, it’s still uncertain whether enough of such drugs could even be produced quickly enough to respond to this particular outbreak, and if not - whether they’d be effective in a future outbreak.

You can listen to Relman in this KQED Public Radio talk show.

Relman joins other experts in a Stanford panel on Ebola

Why has this Ebola outbreak involved so many more people, and spread to a wider geographic area,  than previous outbreaks?

This is an evolving investigation and many potential contributing factors are being examined by scientists racing to collect information that can help them get ahead of the outbreak.

One factor is population density. This latest outbreak spread early into denser population areas within Liberia and Sierra Leone, rather than remain confined to isolated villages, as in earlier outbreaks in Central Africa. With a greater number of people being exposed within a smaller geographic area, the likelihood of transmission increases. Of particular concern is the prospect that the virus might take hold in Lagos, Nigeria, where a handful of cases have been recently identified. If this were to spread in Lagos, Africa’s most populous city, the death toll would likely increase dramatically.   

Another factor is the ability of affected regions to mount an effective public health response. This outbreak is occurring in three of the poorest African countries: Sierra Leone, Liberia, and Guinea. Civil wars have likely contributed to degradation of an already relatively poor public health infrastructure. This is also the first Ebola outbreak in the region, and the inexperience of local authorities can delay responses and fuel fearful community responses, undermining the ability to deal with the outbreak early when it’s more easily contained.

Cultural practices around the care of the sick and the dead can also fuel progression of an outbreak. In some parts of Western Africa, washing deceased relatives is commonplace. Customs like these increase the likelihood of the infection spreading through proximity between infected individuals and their family members

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What can be done to curtail the outbreak?

Isolation and quarantine are key to fighting the spread of Ebola. Isolation involves removing infected individuals from the general population to prevent the spread of disease. Quarantine, however, involves removing uninfected or potentially infected individuals from the general population to limit the spread of disease.

Thus far, the strategy to fight Ebola is dependent on isolating infected patients. Unsurprisingly, isolation efforts have proven hard to enforce. Some families, faced with the prospect of being confined to their homes, have denied the existence of Ebola in their localities, or refuted doctors who claim that one of their family members is sick. This is not unique to Africa; Americans had violent reactions to quarantine during the spread of smallpox. Some regions are now taking more extreme measures: Sierra Leone has deployed its army to enforce isolation at clinics and infected families’ homes, but this also risks civil unrest.

These tensions underscore the necessity of improved education and enforcement mechanisms within public health strategies. Response measures involve fundamental tradeoffs between liberty and safety. Because negotiations occur through complex local, national and international processes, one of the biggest risks is that decisions don’t keep pace with disease spread.

It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere."

How likely is it that the disease will spread into and within the United States?

Currently, airports in Liberia, Sierra Leone, and Guinea are screening all outbound passengers for Ebola symptoms such as fever. This includes asking passengers to complete healthcare questionnaires. However, it is difficult to reliably know who has been infected until they are symptomatic. Individuals could theoretically board a plane before they show symptoms, but develop them upon landing in the United States or elsewhere. This makes containing Ebola difficult, but not impossible.

If the virus were to enter the United States, it would be easier to contain and harder to spread. This virus does not transmit that easily to other humans, especially in settings with good infection control and isolation.

As viruses spread, the chances of genetic variation increase. Yet despite all the concerns from the current outbreak, Ebola is relatively bad at spreading in comparison to respiratory viral diseases such as influenza or measles. The likelihood of a pandemic Ebola virus in the near future seems slim as long as it cannot be transmitted via air.  While it’s possible that the Ebola virus could evolve, there is little evidence to suggest major genetic adaptations at this time.

What are some broader lessons about the dynamics and ecology of emerging infectious diseases that can help prevent or respond to outbreaks now and in the future?

These latest outbreaks remind us that potential pathogens are circulating, replicating and evolving in the environment all the time, and human action can have an immense impact on the emergence and spread of infectious disease.

We are starting to see common factors that may be contributing to the frequency and severity of outbreaks. Increasing human intrusion into zoonotic disease reservoir habitats and natural ecosystems, increasing imbalance and instability at the human-animal-vector interface, and more human population displacement all are likely to increase the chance of outbreaks like Ebola.

Megan Palmer Photo Credit: Rod Searcey

The epicenter of this latest outbreak was Guéckédou, a village near the Guinean Forest Region. The forest there has been routinely exploited, logged, and neglected over the years, leading to an abysmal ecological status quo. This, in combination with the influx of refugees from conflicts in Guinea, Liberia, Sierra Leone, and Cote d’Ivoire, has compounded the ecological issues in the area, potentially facilitating the spread of Ebola. There seems to be a strong relationship between ecological health and the spread of disease, and this latest outbreak is no exception.

While forensic analyses are ongoing, unregulated food and animal trade in general is also a key factor in the spread of infectious diseases across large geographic regions. Some studies suggest that trade of primates, including great apes, and other animals such as bats, may be responsible for transit of this Ebola strain from Central to Western Africa.

What are some of the other political and security implications of the outbreak and response?

Disease outbreaks can catalyze longer-term political and security issues in addition to more acute tensions.

There are complex international politics involved in emergency response and preparedness. Disease outbreaks often occur in poor regions, and demand help from more wealthy regions. The nature of the response reflects many factors - technical, social, political, legal and economic. Leaders often lack the expertise to take all these factors into account. It is an ongoing challenge to adapt our governance processes to be more reliable and move from damage control to planning. Organizations like the World Health Organization can provide guidance, but more resources and expertise are needed to get ahead of future disasters.

When help is provided, there is often mistrust of non-local workers, who can even be seen as sources of the disease. At a political level, distrust has been fueled by disguising political missions as health interventions, as was the case with the effort that led to the locating of Osama Bin Laden.

There are other security implications of this latest epidemic. This outbreak has led to a dramatic increase in the availability of Ebola virus in unsecured locations across West Africa, as well as to a growing number of labs across the world studying the disease. The immediate need to study the disease and develop beneficial interventions needs to be coupled to considerations of safety and security. From a safety standpoint, a rise in the handling of Ebola samples risks accidental transmission. From a security standpoint, those who wish to cause harm with this virus could acquire it from bodies, graves and other natural sources in the affected region. Both of these risks demand attention and efforts at mitigation.

On June 30, CDDRL Director Larry Diamond delivered a lecture in Lagos, Nigeria on poverty, terrorism and democracy. Presented as part of the Freedom House Lecture Series, Diamond emphasized that the country’s core problem is not terrorism or poverty but bad governance and suggested six reforms to address the country’s democratic landscape.

Asked to summarize his biography and career, Donald K. Emmerson notes the legacy of an itinerant childhood: his curiosity about the world and his relish of difference, variety and surprise. A well-respected Southeast Asia scholar at Stanford since 1999, he admits to a contrarian streak and corresponding regard for Socratic discourse. His publications in 2014 include essays on epistemology, one forthcoming in Pacific Affairs, the other in Producing Indonesia: The State of the Field of Indonesian Studies.

Emmerson is a senior fellow emeritus at the Freeman Spogli Institute for International Studies (FSI), an affiliated faculty member of the Center on Democracy, Development and the Rule of Law, an affiliated scholar in the Abbasi Program in Islamic Studies, and director of the Southeast Asia Program at the Shorenstein Asia-Pacific Research Center. Recently he spoke with Shorenstein APARC about his life and career within and beyond academe.

Your father was a U.S. Foreign Service Officer. Did that background affect your professional life?

Indeed it did. Thanks to my dad’s career, I grew up all over the world. We changed countries every two years. I was born in Japan, spent most of my childhood in Peru, the USSR, Pakistan, India and Lebanon, lived for various lengths of time in France, Nigeria, Southern Rhodesia (now Zimbabwe) and the Netherlands, and traveled extensively in other countries. Constantly changing places fostered an appetite for novelty and surprise. Rotating through different cultures, languages, and schools bred empathy and curiosity. The vulnerability and ignorance of a newly arrived stranger gave rise to the pleasure of asking questions and, later, questioning the answers. Now I encourage my students to enjoy and learn from their own encounters with what is unfamiliar, in homework and fieldwork alike. 

Were you always focused on Southeast Asia? 

No. I had visited Southeast Asia earlier, but a fortuitous failure in grad school play a key role in my decision to concentrate on Southeast Asia. At Yale I planned a dissertation on African nationalism. I applied for fieldwork support to every funding source I could think of, but all of the envelopes I received in reply were thin. Fortunately, I had already developed an interest in Indonesia, and was offered last-minute funding from Yale to begin learning Indonesian. Two years of fieldwork in Jakarta yielded a dissertation that became my first book, Indonesia’s Elite: Political Culture and Cultural Politics. I sometimes think I should reimburse the African Studies Council for covering my tuition at Yale – doubtless among the worst investments they ever made. 

Indonesia stimulated my curiosity in several directions. Living in an archipelago led me to maritime studies and to writing on the rivalries in the South China Sea. Fieldwork among Madurese fishermen inspired Rethinking Artisanal Fisheries Development: Western Concepts, Asian Experiences. Experiences with Islam in Indonesia and Malaysia channeled my earlier impressions of Muslim societies into scholarship and motivated a debate with an anthropologist in the book Islamism: Contested Perspectives on Political Islam. 

What led you to Stanford?

In the early 1980s, I took two years of leave from the University of Wisconsin-Madison to become a visiting scholar at Stanford, and later I returned to The Farm for shorter periods. At Stanford I enjoyed gaining fresh perspectives from colleagues in the wider contexts of East Asia and the Asia-Pacific region. In 1999, I accepted an appointment as a senior fellow in FSI to start and run a program on Southeast Asia at Stanford with initial support from the Luce Foundation.

As a fellow, most of your time is focused on research, but you also proctor a fellowship program and have led student trips overseas. How have you found the experience advising younger scholars?

In 2006, I took a talented and motivated group of Stanford undergrads to Singapore for a Bing Overseas Seminar. I turned them loose to conduct original field research in the city-state, including focusing on sensitive topics such as Singapore’s use of laws and courts to punish political opposition. Despite the critical nature of some of their findings, a selection was published in a student journal at the National University of Singapore (NUS). NUS then sent a contingent of its own students to Stanford for a research seminar that I was pleased to host. I encouraged the NUS students to break out of the Stanford “bubble” and include in their projects not only the accomplishments of Silicon Valley but its problems as well, including those evident in East Palo Alto.

That exchange also helped lay the groundwork for an endowment whereby NUS and Stanford annually and jointly select a deserving applicant to receive the Lee Kong China NUS-Stanford Distinguished Fellowship on Contemporary Southeast Asia. The 2014 recipient is Lee Jones, a scholar from the University of London who will write on regional efforts to combat non-traditional security threats such as air pollution, money laundering and pandemic disease.

Where does the American “pivot to Asia” now stand, and how does it inform your work? 

Events in Iran, Iraq, Afghanistan, Syria and now in Crimea as well, have pulled American attention away from Southeast Asia. Yet the reasons for priority interest in the region have not gone away. East Asia remains the planet’s most consequential zone of economic growth. No other region is more directly exposed to the potentially clashing interests and actions of the world’s major states – China, Japan, India and the United States. The eleven countries of Southeast Asia – 630 million people – could become a concourse for peaceful trans-Pacific cooperation, or the locus of a new Sino-American cold war. It is in that hopeful yet risky context that I am presently researching China’s relations with Southeast Asia, especially regarding the South China Sea, and taking part in exchanges between Stanford scholars and our counterparts in Southeast Asia and China. 

Tell us something we don’t know about you.

Okay. Here are three instructive failures I experienced in 1999, the year I joined the Stanford faculty. I was evacuated from East Timor, along with other international observers, to escape massive violence by pro-Indonesian vigilantes bent on punishing the population for voting for independence. The press pass around my neck failed to protect me from the tear gas used to disperse demonstrators at that year’s meeting of the World Trade Organization – the “Battle of Seattle.” And in North Carolina in semifinal competition at the 1999 National Poetry Slam, performing as Mel Koronelos, I went down to well-deserved defeat at the hands of a terrific black rapper named DC Renegade, whose skit included the imaginary machine-gunning of Mel himself, who enjoyed toppling backward to complete the scene. 

The Faculty Spotlight Q&A series highlights a different faculty member at Shorenstein APARC each month giving a personal look at his or her teaching approaches and outlook on related topics and upcoming activities.

Andres Moreno is not just unearthing the genetic backgrounds of many Latin Americans and Caribbeans. He’s also making sense of the history of this region, and piecing together a clearer genetic medical history of understudied populations. By looking at the genetic history of Mexicans, Cubans, Puerto Ricans, Dominicans, Hondurans and Colombians, Moreno’s research unearths these populations’ ties to Europe, native tribes and Africans, and serves as a way to understand the waves of migration in these populations.

And he’s able to do much of this work because of the Dr. George Rozenkranz Prize for Health Care Research in Developing Countries, given out by the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR) to a promising young researcher.

“The Rosenkranz Prize is such a unique opportunity to promote the work of some of Stanford’s most promising young investigators,” CHP/PCOR Director Douglas K. Owens, also a senior fellow at the Freeman Spogli Institute for International Studies and a professor of medicine, said. “We’ve had researchers from within our centers, and with Andres we have a Rosenkranz recipient who’s thinking about international health from a completely new angle for CHP/PCOR.”

The $100,000 prize is given to young Stanford researchers focusing on how to improve health care access in developing countries. The award’s namesake, George Rozankranz, first synthesized cortisone in 1951, and later progestin (the active ingredient in oral birth control pills). He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.

“The Rosenkranz Prize has allowed me to build research independence upon original ideas and collaborative efforts initiated in different regions throughout Latin America and the Pacific,” Moreno said. “These efforts are paving the way to conduct population and medical genomics research in populations from developing regions traditionally underrepresented in large-scale genetic projects.”

Moreno continued: “This is only the beginning though. There is much to do to bridge the gap between developed and developing countries in terms of biomedical research, so funding opportunities like the Rosenkranz Award are essential to tackle this problem.”

As part of this work, Moreno published article in PLOS Genetics in November 2013, with two more anticipated in 2014.

“In this publication we especially wanted to focus on people in the Caribbean,” Moreno said. “We felt that this region has been understudied in terms of genetic complexity, and wanted to know which part of Africa, Europe and a Native American tribal genes existed. And its implications for medicine.”

In understanding a person’s genetic history, a doctor can determine whether a patient has gene variants that correlate with a disease. For example, because Ashkenazi Jewish women have an increased likelihood of having breast and ovarian cancer, their health providers are more likely to monitor for these cancers. 

Moreno’s advisor and co-author on the PLOS papers, Stanford Genetics Professor Carlos Bustamente, described Moreno’s work on this project: “Andres was extraordinary in putting the data all together, developing algorithms and doing simulation work,” he said. Moreno would seek to understand the implications of their findings, think through how this would affect their design of the next round of experiments and  “translate it into future genetic studies and interpretation of genomes that come into the clinic.”

The findings also tell a historical story of the region. In the Caribbean, Moreno and his co-authors were able to pinpoint where in Africa particular segments of the population had come from and when they contributed to the genetic pool. The first wave of Africans came from the western tip of Africa (present day Senegal and Gambia), a region that was an original contributor for all African slaves. But another strand of African heritage also emerged in their studies—from Africa’s gold coast (Nigeria and the Gulf of Guinea). Moreno explained, “We can now genetically pinpoint when and where ancestry came from in Africa.”

Moreno said in looking at the populations, a major difference was between the genetic heritage of the island and mainland populations. In the case of the four islands, there were very consistent results of roughly the same date of European genes—about 500 years ago, which, Moreno pointed out, is exactly when colonization happened.

But in the mainland areas, Moreno and colleagues didn’t find European lines until two generations later, meaning Europeans first settled in the islands and then moved to the mainland.

Similarly, the Native American strands are distinct. Moreno and his co-authors believe that the Native American genes among the Caribbean populations are from inland Amazon tribes—a completely different Native American background than what’s typically found among Native American descendants in the United States.

Bustamente said Moreno has great breadth, commanding the whole operation—sampling in the field, collecting the data in the lab, doing the data scrubbing and analysis. Each of these tasks is typically undertaken by a different person. “He does all of this—and it gives him a real edge,” Bustamente said. “He thinks in a very integrated fashion. Plus he’s an MD!”

Kathryn McDonald, executive director for CHP/PCOR, said Moreno’s work represents the essence of the Rosenkranz Prize. “We really wanted this award to reach all angles of the Stanford health policy research community, and Andres embodies this. He’s expanding our understanding of health care and predisposition for diseases in a host of developing countries. It’s exciting—and such important—work.”

Teal Pennebaker is a freelance writer.

Stanford's Center on Democracy, Development, and the Rule of Law (CDDRL) is pleased to announce that undergraduate senior honors student, Anna Barrett Schickele, received the Firestone Medal for Excellence in Undergraduate Research. This university award is given to the top ten percent of honors theses in social science, science, and engineering.

Schickele's thesis entitled, "One Drop At A Time," examines the factors that inform farmers' decisions to use modern irrigation systems in the Lurín Valley of Peru, where she spent several months conducting fieldwork with a Lima-based NGO. Schickele — a public policy major —was able to collect primary data through interviews with farmers and fieldworkers to inform her research study that includes policy recommendations to the NGO community and government officials.

Anna Schickele (center) with Francis Fukuyama (left) and Larry Diamond (right).

Martin Carnoy, the Vida Jacks Professor of Education at the Stanford Graduate School of Education, served as Schickele's thesis advisor together with Rosamond L. Naylor, the director of the Center on Food Security and the Environment at FSI.

"Ana's thesis is an important contribution to our understanding of the barriers and openings for stimulating agricultural development among subsistence farmers," said Carnoy. "Her original insights make the thesis particularly valuable for those addressing development issues in the world’s poorest regions."

In August, Schickele will begin a research position at the Abdul Latif Jameel Poverty Action Lab at the Massachusetts Institute of Technology.

CDDRL's best thesis award was given to Kabir Sawhney, a management science and engineering major, who wrote his thesis on the effect of regime type and the propensity to default on sovereign debt. Advised by Professor of Political Science Gary Cox, Swahney cited the cases of Romania in the 1980s and more recently of Greece to conclude that the quality of government — rather than regime type alone — determines whether a country chooses to default. 

After graduation. Sawhney will join the consulting firm Accenture as an analyst in their San Francisco office.  

Three honors students' received fellowships from Stanford's Haas Center of Public Service to pursue public service-related work after graduation. Keith Calix and Imani Franklin both received the Tom Ford Fellowship in Philanthropy and will be working in New York for grant-making foundations, and Lina Hidalgo received the Omidyar Network Postgraduate Fellowship to work with an international organization.     

The CDDRL Undergraduate Senior Honors Program is an interdisciplinary honors program led by Francis Fukuyama, the Olivier Nomellini Senior Fellow at FSI. The program recruits a diverse group of talented students interested in writing original theses on topics impacting the field of democracy, development, and the rule of law. During the year-long program, students write their thesis in consultation with a CDDRL faculty member, participate in research workshops, and travel to Washington, D.C. for "honors college."

The nine members of the graduating class of 2013 CDDRL undergraduate honors students include: