Courtney Kirschbaum9/27/15UN, Peace & SecurityProfessor Shigehiro Suzuki Research Paper Outline

How the Ebola Virus Became a National Security Crisis: 3 Explanations

What factors contributed to the deadly Ebola Virus becoming a threat to national

peace and security? In the United Nation Security Council’s first public health emergency

meeting, the Ebola virus outbreak in West Africa was declared a national threat to peace and

security on September 18, 2014. During this time, the World Health Organization declared that

in their time of treating outbreaks they had never seen, “an emergency on this scale, with this

degree of suffering, and with this magnitude of cascading consequences.”1 At this time, reports

showed an estimate of those infected, stating that more than 5,500 people had been infected by

the virus, with over 2,500 of these cases resulting in death. The Ebola Crisis was becoming a

social crisis, an economic crisis, a humanitarian crisis in addition to a public health crisis.2 In

response to this, the United Nations launched an emergency health mission called United Nations

Mission for Ebola Emergency Response with five priorities of, “stopping the outbreak, treating

the infected, ensuring essential services, preserving stability, and preventing future outbreaks.”3

At this time, Ebola was no longer an infectious disease, but a national security crisis.

Existing literature attempts to answer this question with three explanations: a delayed

United Nations Response, lack of funding/heath care resources, and insufficient precautions in

place. These three possible causes are what scholars think can explain why Ebola was the first

ever disease epidemic to be declared a threat to national peace and security by the United

1 Chan, Margaret. "WHO Director-General Addresses UN Security Council on Ebola." WHO. 18 Sept. 2014. Web. 13 Sept. 2015. http://www.who.int/dg/speeches/2014/security-council-ebola/en/.2 Chan, Margaret, “WHO Director-General Addresses UN Security Council on Ebola”.3 Tsarkov, Andrey. "UN Announces Mission to Combat Ebola, Declares Outbreak 'threat to Peace and Security'" UN News Center. UN, 18 Sept. 2014. Web. 13 Sept. 2015. <http://www.un.org/apps/news/story.asp?NewsID=48746#.VfT2-BFViko>.

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Nations. The thesis this paper examines is as follows: The most significant factor that

contributed to the escalation of the Ebola outbreak to become a threat to national peace and

security was the delayed United Nations Response to the outbreak in West Africa, which led to

a lack in funding for health services and insufficient protocols put in place.

Existing Scholars Explanations and Analysis

Delayed United Nations Response

A common explanation among existing literature was that one of the major problems that

contributed to the escalation of the Ebola crisis was that the United Nation’s should have

responded to the crisis earlier. MSF’s International President Dr. Joanne Liu stated that, “It’s a

failure of political will that prevented the world form responding in the first six months, rather

than any problem with funding expertise or technology…West Africa is not a priority in terms of

trade or political leverage”.4 Scholar Carolyn Brown reflects on this and argues that wealthier

countries need to provide support and surveillance in less developed countries, and this needs to

be done on an international level, through bodies such as the United Nations. Scholar Sarathi

Kalra agreed with this point, stating, “Failure to act in a timely and coordinated fashion as a

global community has brought us to a position where we simply must act together or face the full

wrath of an out of control Ebola outbreak.”5 Sarathi Kalra says that one of the ways to prevent a

large scale security threat, in regards to health and disease, is the duty of global justice and

fairness to adhere to an ethical code of conduct and provide humanitarian assistance to those

affected. This large scale operation can only be carried out through early action by the United

Nations to target the underdeveloped nation BEFORE it starts to spread to the developed

4 Brown, Carolyn. "Ebola Lessons Guide International Health Regulations Review." Canadian Medical Association.Journal 187.10 (2015): E301-2. ProQuest. Web. 28 Oct. 2015.5 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat: From 'Lessons Learned' to Coordinated Multilateral Containment Efforts." Journal of Global Infectious Diseases 6.4 (2014): 164-77. ProQuest. Web. 28 Oct. 2015.

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nations.6 Scholar J. Feldman zones in on a specific case, the Ebola case in Texas, and recognizes

that, “A delay in diagnosis was sufficient enough to create a ‘near panic’ situation.”7

Scholar Butler Declan was relieved when the international community finally responded

to the Ebola Outbreak. Even so, Scholar Butler Declan states,” there are fears that quelling the

outbreak now will be more difficult that if it had been tackled earlier.”8 He explains that even

though the Ebola outbreak was first detected in March, only the humanitarian group Medecins

Sans Frontieres (MSF or Doctors without Borders) had implemented relief in the affected areas

of Liberia, Sierra Leone and Guinea. MSF repedeately demanded that the international

community needed to deploy a major effort to combat the outbreak.9

Resolution 2176 was adopted by the United Nations Security Council on September 15,

2014. Resolution 2176 expressed “grave concern about the extent of the outbreak of the Ebola

virus in West Africa, in particular in Liberia, Guinea and Sierra Leone…affirming the

Government of Liberia bears primary responsibility for ensuring peace, stability and the

protection of the civilian population.”10 This mandate did not make Ebola a global concern as it

should have, by stating that the responsibility lies within the West African Countries to fix the

problem. The United Nations failed to recognize that by making the outbreak a more pressing

issue up front, it would cost less lives, medical personnel and economic aid in the long run.

Although this placed primary responsibility for combatting the outbreak on the West African

governments, this resolution did urge the international community to assist governments in the

region to address the outbreak, such as responding quickly to the shortage of qualified medical

6 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat” 7 Feldman, J. Schools in Texas, Ohio close over Ebola panic. http://www.mediaite.com/online/schools-in%C2%A0texas-ohio-close-over-ebola-panic/. [Last accessed on 2014 Nov 9]. 8 Butler, Declan. "Global Ebola Response Kicks Into Gear at Last." Nature.com. Nature Publishing Group, 23 Sept. 2014. Web. 28 Oct. 2015. http://www.nature.com/news/global-ebola-response-kicks-into-gear-at-last-1.15985 9 Butler, Declan. "Global Ebola Response Kicks Into Gear at Last." 10 "Resolution 2176(2014)." United Nations Security Council, 15 Sept. 2014. Web. 28 Oct. 2015.

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professionals, appropriate equipment, and preventative measures necessary.”11 That resolution

did not heighten fear globally, and did not declare the outbreak as a threat to peace or security.

Finally, the Security Council passed the third resolution on a health crisis and the first

recognition by the Council of the threat posed by an epidemic to international peace and security

in September 2014. Resolutions 2177 ensured the United Nations sections accelerated their

response to the outbreak, encouraged the World Health Organization to enhance its operational

efforts and partner with the government, lifted border restrictions that led to isolation of the

affected countries, encouraged governments of affected West Africa to speed up national

mechanisms for rapid diagnosis, quarantine and public education, and coordinate international

assistance through health works and relief supplies.12 UN secretary-general Ban Ki-moon

launched the United Nations Mission for Ebola Emergency Response to “deploy resources from

UN agencies in coordination with efforts from member nations and donors.” 13 The mission

included: stopping the outbreak, treating the infected, ensuring crucial services, and preventing

further outbreaks. Ban estimated that current efforts needed to be scaled to 20 times the amount

in order to be successful.14

The core arguments drawn from this school of thought are very strong. They address that

scholars, international health organizations and important personnel urged for global intervention

from the United Nations and how action should have been taken sooner. This delay in concrete

global action that was not taken until the UN adopted Resolution 2177 caused the situation’s

threat to society to tremendously increase. However, a weakness to this school of thought is that

11 Resolution 2176(2014)." United Nations Security Council.12 "With Spread of Ebola Outpacing Response, Security Council Adopts Resolution 2177 (2014) Urging Immediate Action, End to Isolation of Affected States | Meetings Coverage and Press Releases." UN News Center. UN, 18 Sept. 2014. Web. 28 Oct. 2015. 13 Butler, Declan. "Global Ebola Response Kicks Into Gear at Last." 14Butler, Declan. "Global Ebola Response Kicks Into Gear at Last."

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it fails to include or consider the thoughts of the governments and people of the West African

Countries and whether they thought they needed earlier assistance.

Lack of Funding/ Healthcare Resources

A second existing explanation for the escalation of Ebola is that the affected countries of

West Africa lacked the appropriate funding and medical resources to effectively treat, prevent

and combat the disease. Scholar Sarathi Kalra stated that, “some government officials of Liberia

were openly concerned about lack of resources to effectively deal with Ebola” 15 In addition, the

director of operations for MSF in Geneva, Switzerland explained that the treatment centers in the

three countries most affected were overwhelmed, contributing to the spread of the disease

because health centers were forced to send away infected people who would then contaminate

other people.16 For example, in Kenema Hospital in Liberia, WHO sent some staff and supplies

in June of 2014, but it was not enough. The head doctor Khan was “often the only doctor in

charge of treating 80 people…supplies were dwindling…he often felt alone and afraid for his

life.”17 Khan died shortly after due to this issue, and with no one to treat the Ebola patients, the

disease spread even more rapidly. The lack of resources caused WHO officials to almost close

down the center, but having no center at all would spread the disease even more.

Mr. Niamah from a treatment center in Monrovia, Liberia, petitioned for help regarding

the deaths of the healthcare workers, “Right now, as I speak, people are sitting at the gates of our

centers, begging for their lives…we are trying to treat as many people as we can but there are not

enough treatment centers and patient beds.18” Many speakers urged for the addressing of the

15 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat”.16 Butler, Declan. "Global Ebola Response Kicks Into Gear at Last." 17 Hayden, Erika. "Infectious Disease:Ebola's Lost Ward." Nature. Nature News Feature, 24 Sept. 2014. Web.

18 "With Spread of Ebola Outpacing Response,” UN News Center.

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situation buy the United Nations system, and stressed the vulnerability of these affected countries

that lacked viable health services.19

Scholar Robert Fowler emphasizes that intensive care units in Guinea have no

mechanical ventilators, no piped oxygen, and unstable supply of running water aids the spread of

communicable diseases such as Ebola. “The constellation of limited public health infrastructure,

low levels of health literacy, few acute care and infection control resources, densely populated

areas, a mobile population and a highly transmissible and lethal viral infection have created a

perfect storm underlying this outbreak”20 This long list represents the complexity of the situation,

how Ebola can escalate so quickly through so many different outlets, with the easiest platform

for rapid spread of disease being an underdeveloped country.

Scholars conclude that Ebola may never have spread outside of African borders if the

countries of Liberia, Sierra Leone, and Guinea had sufficient resources and a stable economy.

Scholar Sarathi Kalra explains that more than 20% of the population of these countries lives in

poverty and the medical personnel are incredibly understaffed. “With a forecast of 550,000-

1,400,000 cases predicted by early next year, the outbreak may reach a global cost of $32 billion

over the next two years…in contrast to the estimated $1 billion needed to currently contain the

outbreak of Ebola.”21 This exemplifies that the earlier on the funding and medical supplies are

received, the lower the cost, but financially and in a humanitarian aspect.

The validity of this school of thought is crucial to understanding why the physical disease

of Ebola spread so rapidly until it was declared a national threat to peace and security. Existing

explanations highlight that the underdeveloped affected areas did not have the necessary funding,

knowledge or facilities to diagnose, treat, or contain the virus and as a direct result the outbreak 19 "With Spread of Ebola Outpacing Response,”UN News Center. 20 Fowler, Robert A., et al. "Caring for Critically Ill Patients with Ebola Virus Disease: Perspectives from West Africa." American Journal of Respiratory and Critical Care Medicine 190.7 (2014): 733-7. ProQuest. Web. 28 Oct. 2015.21 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat”

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got out of hand. Scholars also conclude that the necessary means to halt the rapid outbreak would

be the infusion of proper education, experienced health personnel, and funding from wealthier

countries, such as the United States. A weakness of this school of thought is that it fails to

consider perspectives of those African’s that believe in “self/spiritual healers” who stay away

from modern medicine and contributed greatly to the spread of the disease.

Insufficient Precautions

A final existing explanation for the cause of Ebola’s emergence as a national peace and

security threat is the lack of proper precautions for containing the spread of the disease. In order

to do this, adequate screening protocols to ensure “front-line’ personnel are appropriately

educated on procedures is necessary. It is vital to have effective screening and isolation policies

in place, as well as potential contaminated contact tracking to those affiliated with an affected

person or area.

Although there were many instances within Sierra Leone, Guinea and Liberia of health

workers becoming contaminated with the disease, the biggest shock came when the protocols of

modern advanced hospitals were insufficient. The first case of Ebola outside of West Africa was

in Madrid, discovered on October 6, 2014. The victim was a 44 year old hospital worker who

volunteered to care for two Spanish missionaries that were flown from Africa contaminated with

the disease.22 The Economist argues that it was well known that health workers in Africa often

would become contaminated with the disease, but “in the developed world hospitals have

elaborate protocols to cope with the danger of contagion…Ms. Romero should have worn the

right protective clothing, known the safety protocols and been quickly spotted as a danger to

public health once ill.”23 This brings up the excellent point that protection from the disease does

22 "Europe's First Ebola Victim." The Economist (Online) Oct 08 2014ProQuest. Web. 27 Oct. 2015 .23 "Europe's First Ebola Victim." The Economist (Online) 

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not only include physical protection within a hospital, but protection of the public from

contamination of someone that is ill. Instead of immediately being put in isolation with her first

symptoms, Ms Romero caught the virus, spent 10 days vacationing in center city Madrid, and

took a public exam.24 She was taken to a local hospital because she did not have a high enough

fever, and placed isolation many hours later.

Scholar Sarathi Kalra argues that there was too much ambiguity on what was the best

personal protective equipment when treating patients with the Ebola infection. In addition, the

picture is not complete as to the virus’ ability to survive under varying physical conditions.25

Sarathi states that “appropriate use of standard and contact precautions along with personal

protective equipment, including gloves, a disposable impermeable gown and apron, and facial

protection with a face shield or googles and a mask are needed.”26 Although this is a basic

guideline, it is also important to base the protective gear on the situation at hand. Having the

knowledge to choose the right type of protection is also key. One must determine the necessary

personal protective equipment based around the known mechanisms of transmission.

Another aspect of protection that must be considered is that conventional public health

measures were not applicable for a disease to this extent. There must be a shift to more creative

out of the box approaches, such as the recent idea for a “robot” care taker, “ that could help assist

in the care of Ebola patients by delivering supplies, disinfecting, and transporting hazardous

specimens,” so human lives would not be at risk.27

This school of thought provides a direct explanation as to how those that are not

protected, for example, front line health care workers, directly contract the disease. The existing

24 "Europe's First Ebola Victim." The Economist (Online25 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat” 26 Fowler, Robert A,"Caring for Critically Ill Patients with Ebola Virus Disease”27 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat”

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explications accurately portray that if these gaps in protection did not occur, the contagion would

have never contaminated the person that caught the disease, which would have contained the

spread of the disease. However, I think a weakness of this school of thought is that it cannot

stand alone. Although it accurately explains the physical transmission and cause for the rapid

spread of Ebola leading to its threat to security, lack of protective measures is not the root cause.

I think that the lack of protective measures stems from a bigger problem of lack of appropriate

healthcare.

How to Examine the Causes of Ebola becoming a National Security Threat

Case Selection Logic

The cases being studied in this analysis are the causes of the escalation of the Ebola

outbreak that led it to become a threat to national peace and security in both Liberia, West

Africa, and Madrid, Spain from 2012- Present. There is both geographical and temporal variation

present in this case study. The geographical variation refers to the different countries, as well as

the different level of development of the countries. There is temporal variation because Ebola is

being analyzed over time, a period of 3 years; however the main focus is on the 2014 crisis. I

chose that time period to highlight the most recent crisis. I chose these countries because Africa

is underdeveloped and where the disease originated, and Spain is developed and was the first

location to have someone contract the disease outside of West Africa. The question at hand

requires determining which factors were the most responsible for escalating the severity of the

outbreak, and it is very important to consider whether the geographical and developmental

differences between countries play a role in the outbreak.

Key ConceptsThe variables being studied in this case represent the main concepts that can explain and

effectively answer the question about the escalation of Ebola. The dependent variable in this

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study is the spread of the Ebola disease. The independent variables in this case are how long it

took for effective action to take place, the funding and health services that were provided, and

the quality of protection in place. The first key concept, the length of time it took for action to

take place, was measured through response timelines of the United Nations to Ebola requests and

interactions in West Africa. The second key concept, the funding and health services provided

was measured with financial data regarding funding of health care institutions (in both locations)

found on government and health organization data bases and compared to national statistics. The

third key concept, the quality of protection in place, was measured through qualitative

explanations of protocols used in both cases and statistics on the respective mortality rates.

Data and Methods

Sources utilized for research conducted were verified to be credible high quality sources.

The sources analyzed comprise of both secondary and primary sources. The secondary sources

analyzed are mainly accredited journal articles such as ProQuest, and the primary sources

analyzed are government websites and research institutions analysis. Data was collected from the

Center of Disease Control, the World Health Organization, the United Nations Charters, and the

Congressional Research Database.

The paper utilizes a combination of both qualitative and quantitative analysis. The

qualitative measurements found in the analysis are derived from time lines of outbreak

responses, in addition to scholarly qualitative findings and analysis. Quantitative data is derived

from numbers and statistics shown in data tables and graphs in order to illustrate different trends

being analyzed. There is wide representativeness in the sources utilized: information is included

from one of the least developed countries to one of the most with the number seven health care

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system in the world. Each source contains information that aids in the discussion of the

explanations of the escalation of the Ebola epidemic as a threat to national peace and security.

It is necessary to acknowledge limitations within this paper’s analysis. In the respect that the

Ebola outbreak is a relatively new topic, accumulating statistics and studies understanding exact

causes and perfect protocols pertaining to the cases are not known, as the world is

still learning.

Ebola as a Threat to National Peace and Security: Causes and Explanations

In March 2014, the Ebola virus was reported in Guinea, West Africa, with an

unprecedented amount of deaths in growing numbers. However, although organizations such as

the MSF or Doctors without Borders urged for immediate international response, the United

Nations saw that Ebola was contained within West African borders and put the responsibility on

those national governments to contain and cure the disease.28 However, as a result of lack of

funding/healthcare resources and sufficient protocols in these countries, the outbreak escalated to

a level where it was declared as a National threat to peace and security by the United Nations on

September 18, 2014. 29 Shortly after, the first case ever contracted outside of West Africa

occurred in Madrid, Spain October 6, 2014, and later the United States was also affected while

providing care for Ebola patients. The differentiating factors that make the Ebola outbreak

unique are its introduction into West Africa, simultaneous multi country outbreaks, urban area

disease transmission, and a rapid and unpredictable pace of transmission. In an August 2014

report, WHO estimated that it would cost roughly $500 million to contain the outbreak by

January.30

28 Chan, Margaret. "WHO Director-General Addresses UN Security Council on Ebola." WHO. 18 Sept. 2014. Web. 13 Sept. 2015. http://www.who.int/dg/speeches/2014/security-council-ebola/en/. 29 Chan, Margaret. "WHO Director-General Addresses UN Security Council on Ebola." 30 Chan, Margaret. "WHO Director-General Addresses UN Security Council on Ebola."

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In order to try to contain the outbreak, it is important to understand the factors that

contributed to its escalation in detail: the delayed international response of the United Nations,

the lack of funding/healthcare resources, and insufficient treatment protocols. Although Guinea,

West Africa and Madrid, Spain dramatically vary in development levels, each Ebola affected

country experienced its own respective deficiencies in these categories.

Delayed United Nations Response to the Ebola Outbreak

Ebola Timeline

The United Nations has been heavily criticized by the media, the general public, and

private health organizations for failing to adequately respond to the Ebola outbreak, thus

escalating the crisis to a level where it became a threat to national peace and security. According

to MSF representative Marie Christine Ferir, "there was a clear lack of leadership from the

WHO: decisions on setting priorities, attributing roles and responsibilities, ensuring

accountability for the quality of activities, and mobilizing the resources necessary were not taken

on the necessary scale.”31 Medicins Sans Frontieres/Doctors Without Borders (MSF) was warned

of the rapidly growing Ebola disaster in March of 2014, and for months after that MSF,

volunteers from private organizations, and ill-equipped national health authorities were the only

ones providing significant aid and relief in the epidemic. The MSF kept begging the international

community for help, and warning the world that the Ebola outbreak was out of control. The

WHO called the 221 cases and 146 deaths in Guinea “relatively small still”. The United Nations

not only did the world a disservice by not springing to action, but the UN accused MSF for

causing “unnecessary panic”. Even when awareness of Ebola started to increase, the WHO did

not provide the necessary information sharing to the disease stricken countries that would have

31 Russell, George. "Front-line Doctors Blame UN for Delayed Ebola Response ." Fox News. FOX News Network, 23 Mar. 2015. Web. 03 Dec. 2015. http://www.foxnews.com/health/2015/03/23/front-line-doctors-blame-un-for-delaying-ebola-response.html

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educated them and enabled solutions to be effective more quickly.32 These actions illustrate that

the United Nations did not want to take drastic action and cause a widespread panic, especially

when the virus was detached from the world outside of West Africa at the time.

To put the action and inaction of the UN in perspective, it is important to analyze the

timeline of key events in relation to the Ebola outbreak. In December of 2013, a two year old boy

of Guinea was playing in a tree when he contracted the virus, died, and spread it to his mother

and sister who also died and quickly spread it around their village of Meliandu. It was not until

March 21st 2014 that the disease was identified as the Ebola virus, a hemorrhagic virus that

spreads through bodily fluids and direct contact. No methods had been taken to prevent its spread

the past three months, so it was already loose in the Guinean and neighboring community.33

Figure A34

32 Russell, George. "Front-line Doctors Blame UN for Delayed Ebola Response ." 33 "How We Lost Control of the Ebola Virus in 2014." BBC, 9 May 2015. Web. 3 Dec. 2015.http://www.bbc.co.uk/timelines/z9gkj6f34 "Number of New Ebola Cases Rises for First Time in 2015: WHO." Digital Journal, 04 Feb. 2015. Web. 07 Dec. 2015. http://www.digitaljournal.com/news/world/number-of-new-ebola-cases-rises-for-first-time-in-2015-who/article/425225

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In Figure A above, Ebola’s most significant events are notated from the initial disease

contraction to the beginning of the epidemics decline, along with the United Nations responses

along the way. Figure A illustrates that July 30th, with a death count of 887, the MSF declared

Ebola “out of control”. However, it was not until five months after the disease was confirmed, on

August 8th, that the United Nations expressed a view on the situation. The United Nations did not

affirm MSF’s statements about the outbreak being out of control, but rather declared a “public

health emergency of international concern.”35 What sparked this concern was the alarming nature

that a more developed country (Nigeria) had confirmed Ebola cases, thus making the situation

more “real”. By the time the United Nations adopted its first Resolution 2176 regarding the

Ebola outbreak, the death toll had increased to around thirty five (35x) times the death toll of

March six months earlier. These six months were crucial, and the delay in diagnosis of the

severity of the situation was sufficient on its own in creating a near panic situation.36

Even though minimal action was taken place by the UN and the international community

to combat the outbreak, just the awareness alone, created by the WHO’s previous statement

about a public health emergency, enhanced the requested support to the international community

to aid in the situation. Figure B below, is a graphical representation in the EVD International

Funding Requests from March when the disease was first confirmed, to September. The months

where there is the largest increase in requested funding are between August and September,

doubling the previous request of $490.0 million. This is a result of the statements put out by the

MSF and WHO at this time.

35 "Number of New Ebola Cases Rises for First Time in 2015: WHO36 Feldman, J. Schools in Texas, Ohio close over Ebola panic.

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Figure B37

As a result of a

lack of response by the UN and international community to combat the Ebola Outbreak, food,

aid and supplies to help contain and treat the emergency were not deployed as early as they

should have been. Figure C below illustrates the total supplies, aid, and food sent out by the

World Food Program and Humanitarian Exchange in comparison to the number of affected

people reached. What is most important to note in this graph is that supplies were not even sent

out till late September, six months after the virus was declared. In addition, the first affected

recipients did not get the aid until mid-October, and at this point the virus had escalated

astronomically, including into developed nations such as Madrid, Spain in early October.

Figure C38

Resolution 2176

37 Salaam-Blyther, Tiaji. "Timeline of International EVD Funding Requests.” World Health Organization. N.p., 29 Oct. 2014. Web. 03 Dec. 2015. http://www.who.int/topics/ health_systems38 "Food Aid and Dispatched Supplies During Ebola Emergency." Tableau Public. World Food Program, 16 Apr. 2015. Web. 03 Dec. 2015. data.hdx.rwlabs.org

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The United Nations Security Council took action when adopting Resolution 2176 on

September 15, 2014, however it was not enough. At this time, there had not been any spread of

the virus to a developed country outside of Africa, and therefore the resolution limited its

involvement by stating, “expressed grave concern for the extent of the Ebola virus in West

Africa….urging the international community to respond swiftly to the shortage of qualified

medical professionals and appropriate measures to address the Ebola outbreak in West Africa.”39

These words do not ignite a call to action, or demand an international response to combat the

disease, but to merely “address it”. In addition, Resolution 2176 places the primary responsibility

of the governments of West Africa to ensure for peace stability and the protection of the civilian

population.40

Resolution 2176 did not make the disease a global responsibility whatsoever, and

confirmed West African beliefs to keep to themselves, only worsening the situation. When

Guinea was called an unprecedented epidemic by the MSF, they responded by “only to count

laboratory-confirmed cases of Ebola when, in reality, many people were dying before they could

be tested”, afraid that the panic would cause foreign companies to pull out of the country.41 The

United Nations did the international community a disservice by adopting this resolution, not

understanding that by making the issue transparent it would cost less money, aid , and lives.

Resolution 2177

On September 18th, 2014, the United Nations took their first definitive action and

declared the Ebola Outbreak a threat to national peace and security, urging immediate action, and

an end to isolation of the affected states. The United Nations Mission for Ebola Emergency

Response was deployed to, “stop the outbreak, treat the infected, ensure crucial services, and

39 Feldman, J. Schools in Texas, Ohio close over Ebola panic.40 Feldman, J. Schools in Texas, Ohio close over Ebola panic.41 "How We Lost Control of the Ebola Virus in 2014." BBC.

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prevent future outbreaks, increasing efforts at least 20 times the current amount to be

successful.”42 This was the first concrete response of the United Nations, encouraging the WHO

to enhance its operational initiatives and work with governments directly. If these efforts were

implemented prior to the escalation of the outbreak, the United Nations could have prevented the

outbreaks severity to a level where it never had to become a threat to national peace and security.

UN Reflections

As a result of the harsh criticism the United Nations is receiving, the WHO published

brief escalations as to why the response took so long, which are important factors to consider

when evaluating the argument. The first justification was that it took “three months for health

officials and their international partners to identify the Ebola virus as the causative agent and by

that time the virus was already primed to explode.”43 In addition, West Africa was not equipped

to diagnose or treat the disease, stemming from the inability to orchestrate an appropriate

response. According the WHO, this enabled, “An old disease in a new context that favored rapid

and initially invisible spread.”44 WHO argued that the combination of those two factors with the

fragile state of healthcare in West Africa and the easy spread via air travel is what pushed Ebola

over the edge. However, many of the factors WHO described could have been improved on, such

as lack of funding, if the United Nations was proactive in combatting the situation.

Insufficient Funding/Healthcare Resources

Overall

A significant factor that explains the escalation of Ebola to become a national threat to

peace and security is the lack of financial and medical resources necessary to effectively treat

and contain the disease. Although the severity of the situation was immensely higher in West 42 Butler, Declan. "Global Ebola Response Kicks Into Gear at Last."43 "Factors That Contributed to Undetected Spread of the Ebola Virus and Impeded Rapid Containment." World Health Organization. N.p., Jan. 2015. Web. 03 Dec. 2015. http://www.who.int/csr/disease/ebola/one-year-report/factors/en/44 "Factors That Contributed to Undetected Spread of the Ebola Virus and Impeded Rapid Containment." 

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Africa, Guinea and Madrid both had deficiencies in funding and healthcare resources that

impacted the Ebola epidemic. Although many UN speakers stressed the vulnerability of the

affected countries that lacked viable health services, unfortunately the action to deploy this aid

was very delayed. In Figure D below, the WHO classifies Ebola’s Outbreak Containment with

the deficiencies of the six components of a health system: Governance, Financing, Human

Resources, Commodities, Service Delivery and Information.

Figure D45

In respect to a lack of funding healthcare resources, focus on the Financing, Commodities

and Information sections of Figure D, however, every component has an effect on each other.

For example, the insufficient financial resources funding local responses and personnel not only

foster the spread of the disease but also contribute to human resource shortages.  Hospital staff

strikes occurred often in West Africa, “after staff were not paid for weeks or months, did not

receive promised hazard pay, or were asked to work under unsafe conditions associated with the

deaths of many colleagues.”46 The combination of the strikes and the statistics that more than

45 Salaam-Blyther, Tiaji. "Impact of Health System Deficiencies on Ebola Outbreak Containment." World Health Organization. N.p., 29 Oct. 2014. Web. 03 Dec. 2015. http://www.who.int/topics/ health_systems46 Salaam-Blyther, Tiaji. "Selected Health System Financing Statistics." World Health Organization. N.p., 29 Oct. 2014. Web. 03 Dec. 2015. http://www.who.int/topics/ health_systems

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half of the workers in West Africa were dying, led to abandonment of the sick and a more rapid

spread of disease. This domino effect only adds to the severity of the disease and heightens the

threat to national peace and security.

Guinea, West Africa

It has been noted that Ebola may never have spread outside the West African borders if

those countries were more developed with stable economies, as around a quarter of the

population of these countries lives in poverty. According to The World Bank, Guinea is a low

income level, with a GDP of $6.624 billion and population of 12.28 million with a poverty head

count of 55.2% and a health expenditure of 4.7% of total GDP. For example, to translate these

numbers into concepts, “intensive care units in Guinea have no mechanical ventilators, no piped

oxygen, and an unstable supply of running water, which aids the spread of communicable

diseases.”47 The possibility of catching a disease common and treatable in a developed country in

Guinea can have drastic effects, and when you put a deadly disease with no cure into the mix it is

a recipe for disaster.

Figure E48

47 Fowler, Robert A., et al. "Caring for Critically Ill Patients with Ebola Virus Disease: Perspectives from West Africa." American Journal of Respiratory and Critical Care Medicine 190.7 (2014): 733-7. ProQuest. Web. 28 Oct. 2015.48 Salaam-Blyther, Tiaji. "Selected Health System Financing Statistics." 

19

Figure E above illustrates Guinea’s heath system financing in comparison with other

West African countries and the rest of the world. Guinea has 43.3% of the population living on

less than $1, which is double the amount of the average for the rest of the world. The government

health budget of total government spending is less than half of the world, and most West African

countries. In addition, the per capita government healthcare spending is 0.0242 of that of the

world. This data suggests that Guinea is an extremely poor nation, with little importance placed

on healthcare. Dr. Fowler summarizes this idea by saying, “the potential effect of supportive care

is great for a condition with high baseline mortality and one usually occurring in resource-

constrained settings…With more personnel, basic monitoring, and supportive treatment, many of

the sickest patients with Ebola virus disease do not need to die.” As a result of this financial and

resource shortage, Guinea an excellent place for the disease to thrive and spread in

overwhelming numbers.

As a result of the lack in previous financing, healthcare resources and structures are

extremely ill-equipped in Guinea to diagnose, treat, and cure an infectious disease like Ebola.

WHO director of strategy describes his personal account of working with insufficient resources,

“In the last week of September 2014, more than 900 Ebola cases were reported from West

Africa. There were probably more. There weren’t enough hospital beds, and two thirds of

patients were dying.”49 Figure F below illustrates one example of a common insufficient

resource: sanitary hospital beds.

Figure F50

49 Dye, Chris. "Ebola: Then and Now by Chris Dye." World Health Organization. N.p., 2015. Web. 03 Dec. 2015. http://who.int/features/2015/ebola-then-now-dyec/en/

20

As displayed by Figure F, Guinea has the smallest discrepancy out of the

three West African countries, yet only around 62% of the sick patients

receive beds, leaving almost 40% of the infected to seek other methods

of care, such as homecare, which wiped out entire families and soon

towns were left deserted. Having proper beds to contain patients is

integral to treating and preventing further outbreak, but there are

“multiple health services needed to control the outbreak including rural

areas quick access to healthcare, Ebola treatment centers, contact tracing

and safe burial practices.”51

There is a proven correlation between funding for healthcare services and the health of

citizens, further illustrating that the lack of financial support and healthcare resources did play a

large influential role in the escalation of the epidemic. For example, according to the Word

Health Organization, the life expectancy of a resident in Guinea is 52 years, as they spend only

$7.00 a person compared to Norway, in which they spend $7,160.00 a person which increases

the average life expectancy to 81 years. The substantial increase in life expectancy exemplifies

how integral proper funding is in providing proper healthcare. In order to improve these services

in Guinea, it is estimated that between now and 2017, Guinea has budgeted $1.176 billion and

still needs to raise an estimated amount of $386.5 million.52

Madrid, Spain

Although Spain is a developed country and the circumstances regarding funding and

healthcare resources are very different, Spain still did not have the proper funding allocated for

resources to run a successful infectious disease unit. According to the World Bank Data, Spain’s

GDP is $1.404 trillion with a population of 46.40 million. Spain allocates 8.9% of its GDP for

healthcare spending, which double the amount is allocated in Guinea. Spain has the seventh best

healthcare system in the world, and it was because of their excellent reputation, especially with

50 Salaam-Blyther, Tiaji. "Bed Capacity in Ebola Treatment Units by Country." World Health Organization. N.p., 29 Oct. 2014. Web. 03 Dec. 2015. http://www.who.int/topics/ health_systems51 Salaam-Blyther, Tiaji. "Bed Capacity in Ebola Treatment Units by Country." 52 "Ebola Recovery Is Impossible Unless Resilient Health Systems Are Rebuilt in Guinea, Liberia, and Sierra Leone." WHO. World Health Organization, 5 July 2015. Web. 03 Dec. 2015. http://www.afro.who.int/en/media-centre/pressreleases/item/7828-ebola-recovery-is-impossible-unless-resilient-health-systems-are-rebuilt-in-guinea-liberia-and-sierra-leone.html

21

As displayed by Figure F, Guinea has the smallest discrepancy out of the

three West African countries, yet only around 62% of the sick patients

receive beds, leaving almost 40% of the infected to seek other methods

of care, such as homecare, which wiped out entire families and soon

towns were left deserted. Having proper beds to contain patients is

integral to treating and preventing further outbreak, but there are

“multiple health services needed to control the outbreak including rural

areas quick access to healthcare, Ebola treatment centers, contact tracing

infectious diseases, that the two Spanish missionaries working in Sierra Leone upon contraction

of the disease were evacuated to Carlos III Hospital. Spain’s health minister was, “confident that

the hospitals strict protocols would prevent transmission of the virus to health workers and other

patients.”53 However, it was not, and the Spanish nurse Teresa Romero became the first person to

contract the disease outside of Africa after caring for one of the missionaries, Manuel García

Viejo that died September 25th, 2014.54

Figure G55

Figure G above illustrates the quality of healthcare human capital resources, with Spain ranking

highest over the West African countries and the developed nation of the United States. These

figures exemplify Spain with a Doctor per 100,000 population that is almost quadruple that ratio

of Guinea. This data combined with the confidence of the health minster fooled Spain into

thinking that transmission of the virus would be prevented, but behind closed doors there was a

an insufficiency present in the system: financial backing.

This internationally shocking occurrence can partly be attributed to a lack of funding for

Spain’s pre-eminent center for highly infectious diseases, “which had been taken apart in recent

months after budget cuts, then hastily reassembled.”56 Before Ebola even reached Spain, 100 53 Abend, Lisa. "Spain's Ebola Case Exposes Gap in Disease Defenses." Time. Time, 7 Oct. 2014. Web. 07 Dec. 2015. http://time.com/3478888/spain-ebola-nurse/54 Abend, Lisa. "Spain's Ebola Case Exposes Gap in Disease Defenses." 55 "Number of New Ebola Cases Rises for First Time in 2015: WHO." Digital Journal56 Abend, Lisa. "Spain's Ebola Case Exposes Gap in Disease Defenses." 

22

Spanish nurses asked the court in July to examine the country’s defenses as they predicted the

infected would arrive, and they did not think Spain’s medical system was prepared. Yet, that is

the opposite of what took place. According to Doctor Marciano Sanchez, president of the

Federation of Associations for the Defense of Public said, "The fundamental reason was the

spending cuts…with Carlos III cutting its medical staff by 12% in 2013.”57 These cuts began the

process of dismantling the sixth floor infectious disease unit, only to be re assembled last minute

a few days before the priests came. As a result of the reduction in financial support for healthcare

resources, the chance of contamination was greatly increased and it ultimately led to the first

Ebola case outside of Africa. The contamination of a health care person in a developed nation

heightened international fear about the outbreak.

Insufficient Protocols

Overall

Aside from a faster United Nations response and increased funding for greater healthcare

resources, ensuring the proper protocols and precautionary methods are in place when coming

into contact with an Ebola patient is essential. If they are not in place, it significantly increases

the risk of contamination and the spread of the outbreak. These general protocols include

employing adequate screening, ensuring that the 'front-line' personnel are familiar with pertinent

policies, ensuring that the medical staff in the Emergency Departments is prepared, that

appropriate screening and isolation policies are in place, and that “vigilance and clinical

suspicion are sufficient enough to readily identify individuals who have recently traveled to

EBOV-affected areas…keeping in mind the pertinent incubation periods and other key

information about the characteristics of the virus.”58 A large contribution to the problem is that

57 Parry, Roland, and Elodie Cuzin. "Spanish Medics Blame Budget Cuts for Ebola Infection." Spanish Medics Blame Budget Cuts for Ebola Infection. N.p., 10 Oct. 2015. Web. 03 Dec. 2015. http://medicalxpress.com/news/2014-10-spanish-medics-blame-ebola-infection.html58 Fowler, Robert A.. "Caring for Critically Ill Patients with Ebola Virus Disease: Perspectives from West Africa." 

23

because it is a new epidemic it is not known what the most optimal decontamination procedure

is, and are in disagreement over what the best personal protective equipment is. In addition, “we

do not have a complete picture of the virus' ability to survive extracorporeally under a variety of

physical conditions.”59 Figure H below illustrates a poster created by the Center for Disease

Control for guides to correctly put on your personal protective equipment.

Figure H60

administered and tests given to ensure that each health care worker can successfully put on the

equipment, and then this poster can serve as a helpful reminder.

Guinea, West Africa

Poor precautionary measures in combination with previously inadequate facilities created

a disaster for Guinea. A study by the CDC in July of 2013 in West Africa found, “multiple

opportunities for transmission of Ebola virus to HCWs, including exposure to patients with

59 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat: From 'Lessons Learned' to Coordinated Multilateral Containment Efforts." 60 CDC Data

24

The sequence for putting on the

equipment closely aligns with a sign

commonly seen at restaurants regarding

steps to assist someone that is choking.

Although the simplicity in the design

and diagrams could be beneficial for

most to easily understand, it does not

cover steps in detail enough to ensure

equipment is being put on correctly.

Extensive training sessions should be

undetected Ebola in the hospital, inadequate use of personal protective equipment during

cleaning and disinfection of environmental surfaces in the hospital, and potential transmission

from an ill HCW to another HCW.”61 Those findings exemplify the transmission of the disease

from patient to health care worker alone should have invoked international concern. Figure I

below illustrates the number of cases of the Ebola virus in Guinea, compared to the deaths that

resulted from the disease.

Figure I 62

Although some patients were cured, it is interesting to note that the gap widened significantly

after the outbreak was declared an international threat to peace and security, and foreign aid had

begun to be administered. If the aid had come sooner, one can accurately predict that the gap

would have followed the trend faster as well, minimizing the severity of the outbreak.

Madrid, Spain

61 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat: From 'Lessons Learned' to Coordinated Multilateral Containment Efforts." 62 "2014 Ebola Outbreak in West Africa - Reported Cases Graphs." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 02 Dec. 2015

25

Although Spain has significantly better resources and protocols dealing with infectious

diseases, they did not appropriately deploy the proper protocol necessary to prevent the

transmission of the virus. Similar to the lack of response by the United Nations to take caution

and control on an international scale, Spain failed to examine Teresa Romero’s symptoms with

the caution that they should have, “She started to feel unwell on September 30th, but the fever

was ignored, and she was admitted to Alcorcón hospital in the southwest of Madrid, near her

home, rather than going to the larger hospital where she worked, only transferred to the

quarantine unit at Carlos III on October 6th when the virus was identified. “63All of this time, she

was not properly isolated, and posed an immense risk to all of the workers that treated her.

Figure J below illustrates the timeline in which action in Spain took place.

Figure J64

Figure J illustrates how long proper contact monitoring took, almost two full months after

initial diagnosis. This was a direct result from the lack of sufficient protocols that were in place

when she came down with the virus, leaving so many people exposed as potential contaminants 63 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat: From 'Lessons Learned' to Coordinated Multilateral Containment Efforts." 64 Lópaz, Jenaro. "Eurosurveillance - First Secondary Case of Ebola outside Africa: Epidemiological Characteristics and Contact Monitoring, Spain, September to November 2014." Eurosurveillance - First Secondary Case of Ebola outside Africa: Epidemiological Characteristics and Contact Monitoring, Spain, September to November 2014. Eurosurviellance, 30 Nov. 2014. Web. 03 Dec. 2015. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21003

26

of the disease. For example, “In the 24 hours before the nurse was officially diagnosed and in the

five days that she felt unwell with fever, she had used public transportation, frequented bars,

restaurants and supermarkets, and spent time with friends.  Many of the people she came in

contact with while she was feverish and potentially contagious are virtually impossible to

identify.” 65The idea that disease could be present in the busy capital unknowingly infecting

many was very alarming to the international community. The nursing council’s president

claimed that the staff was not receiving any kind of in depth training that they should have, and

those that cared for the missionaries were not isolated.66 In addition, Romero admitted to

potentially touching her face with her glove as a potential cause of her contamination, an

accident that could have turned fatal.

Figure K67

Figure K above illustrates the contact monitoring that was done as a result of Teresa Romero’s

contagion. The epidemiological investigation began at the time of diagnosis, where information

on the patient’s possible exposure was requested and contact identification, risk classification

and monitoring began from a variety of sources. Because of the faulty protocol that got Spain 65 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat”66 Kalra, Sarathi, et al. "The Emergence of Ebola as a Global Health Security Threat”67 Lópaz, Jenaro. "Eurosurveillance - First Secondary Case of Ebola outside Africa: Epidemiological Characteristics and Contact Monitoring, Spain, September to November 2014." Eurosurveillance - First Secondary Case of Ebola outside Africa: Epidemiological Characteristics and Contact Monitoring, Spain, September to November 2014. Eurosurviellance, 30 Nov. 2014. Web. 03 Dec. 2015.

27

into this situation prior, it was essential that the contact monitoring be as complete and accurate

as possible. Although this contact tracing is an element of correct protocol, there would have

been smaller numbers of potential contacts if effective precautions were taken right away.

A Final Analysis of Ebola as a Security Threat

The escalation of the Ebola Virus becoming a threat to national peace and security was a

result of three factors: the delay in the United Nations response to the outbreak in West Africa,

the lack of funding and healthcare resources, and the insufficient protocols to handle Ebola that

were in place. Qualitative data regarding the timeline of United Nations actions and responses,

the financial requests for aid and relief, as well as the failure of Resolution 2176 to adequately

take international action to combat the disease all illustrated the severe damage of the United

Nations delayed response For example, by the time the United Nations declared Ebola a national

threat to peace and security, the death toll had already rung in at over 3,000.68 Quantitative

statistics about the healthcare funding, percentage of GDP spent on healthcare, the deficiencies

of appropriate medical supplies and treatment professionals in both Guinea and Spain

exemplified that this lack of funding and resources also contributed to the escalation of the Ebola

epidemic. For example, in Guniea, only around 62% of the sick patients receive beds, leaving

almost 40% of the infected to seek other methods of care. 69Similarly, both qualitative and

quantitative data, such as CDC PPE instruction posters, graphics showing the gap between Ebola

cases and deaths increase as protocols were enhanced, and the lack of appropriate response to

Teresa Romero’s symptoms exemplified that deficient protocols were in place. For example,

Teresa Romero was showing symptoms 6 full days before she was isolated, fostering rapid and

extensive potential contaminations as a result of the insufficient precautionary measures.

68 "Number of New Ebola Cases Rises for First Time in 2015: WHO." Digital Journal, 04 Feb. 2015. Web. 07 Dec. 2015. http://www.digitaljournal.com/news/world/number-of-new-ebola-cases-rises-for-first-time-in-2015-who/article/42522569 Salaam-Blyther, Tiaji. "Bed Capacity in Ebola Treatment Units by Country." 

28

The process used in analyzing the major contributions to the escalations of the outbreaks

in both Guinea and Madrid was not one of direct comparison, but rather side by side analysis.

With Guinea’s GDP at $6.624 billion with 4.7% of it spent on health care and Spain’s GDP is

$1.404 trillion with 8.9% of it spent on healthcare, the developmental gap is very significant

between the two.70 However, each Country exhibited deficiencies in certain areas that aided in

the spread of the Ebola epidemic and heightened international concern. Figure L below

summarizes the differences in the proportion of cured cases in both highly developed countries,

and less developed countries, illustrating a much higher mortality rate in less developed

countries.

Figure L.71

This data includes Guinea in the less developed section, and includes Madrid in the

highly developed section. For the cases in Guinea, the biggest issue was the insufficient funding

which led to lack of proper resources and protocol to be able to be implemented. For the case in

Madrid, Spain the bigger influencer to the problem was the insufficient protocols in place, which

in turn would have enabled Spain to improve upon the health assistance structure as personnel

deemed fit. Regardless of the country, the biggest explanation that can be attributed to why

70 Fowler, Robert A., et al. "Caring for Critically Ill Patients with Ebola Virus Disease: Perspectives from West Africa." American Journal of Respiratory and Critical Care Medicine 190.7 (2014): 733-7. ProQuest. Web. 28 Oct. 2015.71 "Number of Ebola Cases and Deaths in Affected Countries." Humanitarian Data Exchange. WHO Ebola Response Roadmap, 15 Nov. 2015. Web. 03 Dec. 2015. https://data.hdx.rwlabs.org/dataset/ebola-cases-2014

29

Ebola became a threat to national peace and security is the lack of United Nations Response. If

the response had been deployed earlier, it would have improved upon the financing, healthcare

resources and protocols in Guinea and the rest of the West African region.

According to the World Health Organization, as a result of the United Nations actions from 2014

as part of an international response initiative we have gone from few diagnostic services, no

vaccine, few medical teams and trained responders to having four rapid diagnostic tools, 24

testing laboratories, a vaccine, a global network of medical professionals, and nearly 7000

experts trained in clinical management. Having the international community come together to

create and solidify the resources and plan of action is what is necessary to contain and prevent

any future outbreak.72 “When people think global health security they think disease

surveillance…in this interconnected world …no one is immune from disease outbreaks. This is

the lesson the West African Ebola outbreak has taught us.  We need to ensure health systems

everywhere can detect and treat emerging diseases and still keep their routine healthcare services

up and running.”73

If the United Nations stepped in earlier to combat the Ebola outbreak in West Africa, the

epidemic would not have escalated to become a threat to national peace and security. The lack of

action on the United Nations behalf to provide international assistance and funding to West

Africa prohibited the affected areas from having the necessary medical facilities, education and

protective procedures to contain and combat the outbreak. If this global effort was taken sooner,

the disease may not have spread to developed nations as it did.

72 "Ebola Response in Action." Ebola Response in Action. World Heath Organization, 2015. Web. 06 Dec. 2015. <http://apps.who.int/ebola/our-work/achievements>.73 Ebola Response in Action." Ebola Response in Action. World Heath Organization, 2015. Web. 06 Dec. 2015. <http://apps.who.int/ebola/our-work/achievements>.

30

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