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It is now just more than a year since the official confirmation of an outbreak of Ebola haemorrhagic fever in west Africa. With new cases occurring at their lowest rate for 2015, and the end of the outbreak in sight for all three countries predominantly affected, now is the time to consider strategies to prevent future outbreaks of this, and other, zoonotic pathogens. The Ebola outbreak, like many other emerging diseases, illustrates the crucial role of the ecological, social, political, and economic context within which diseases emerge. Increasing anthropogenic environmental changes, coupled with a globalised network of travel and trade, allow zoonotic pathogens to spill over into human beings with increasing frequency, and leave us supremely vulnerable to their international spread. Pandemics are no longer simply the domain of public health and clinical medicine, but are a social issue, a development issue, and a global security issue. The cost of management of infectious disease outbreaks is almost always greater than the cost of avoiding them. For severe acute respiratory syndrome (SARS), the global cost of a single outbreak was estimated to be between US$13 billion and US$50 billion at the currency values of the 2003 outbreak. For Ebola, the cost might be higher—both in the direct, short-term cost of control, patient care, and hospital admission, and in the indirect, longer-term dislocation of the regional economies in west Africa. The economic costs of disease emergence are projected to continue to rise in line with increasing frequency of outbreaks driven by expanding socioeconomic and environmental changes that cause diseases to emerge. Mitigation of future pandemic threats such as Ebola is therefore more cost-effective than the current approach of responding to outbreaks after they have begun to spread rapidly in the human population. What would mitigation strategies to deal with future pandemic risks of zoonotic disease look like? Analyses of emerging disease trends during the past six decades have shown that Ebola fits the AMI5 inhibitor pattern. This pattern involves zoonotic spillover from wildlife or livestock driven by changes in land use, crop choices, migration patterns, animal husbandry, trade, transport, and travel. The west African Ebola outbreak, similar to previous outbreaks of Ebola, HIV, SARS, influenza, and most other emerging diseases, probably began with a zoonotic spillover from a wildlife reservoir, in this case thought to be bats. Targeted programmes for behaviour change, focusing on incentives for bushmeat hunting, should be part of the mitigation strategy. This approach was trialled in central Africa, with education programmes designed to reduce the consumption of primates found dead in forests, and has been shown to offer a cost-effective way to mitigate the risk of an Ebola outbreak. Additionally, projects aimed to reduce dependency on bushmeat need to be supported, either through creative approaches to farming of some wildlife species, or by expansion of livestock production, with appropriate biosecurity and surveillance to prevent emergence of other zoonoses.
Access to health-care information for citizens is a key determinant to reach both the Millennium Development Goals (MDGs) and the emerging post-2015 Sustainable Development Goals, but this challenge has repeatedly been relegated to the sidelines. What might kickstart progress? An obvious candidate is the mobile phone, which is becoming ubiquitous in low-income and middle-income countries. It is vital that citizens in these countries have access to actionable health-care information, largely because they typically have no access to trained health workers. People who need medical attention in such contexts are especially vulnerable to ineffective or even harmful treatment from parents, lay carers, or traditional healers; in these settings, mistreatment and delays in obtaining effective treatment can contribute to increased morbidity and mortality. For example, findings from a study in India showed that four in ten children with acute diarrhoea were incorrectly given less to drink than normal, potentially increasing their risk of death from dehydration. We recently commissioned a survey of 1700 projects of mobile technology for health (known as mHealth). Our findings showed that none of these services provided essential, actionable, offline guidance for direct use by citizens addressing the range of acute health-care situations commonly encountered in low-resource settings, and very few provided any such content at all (an example is HealthPhone, see below).
What few people thought possible little more than a decade ago is now reality: scientific and operational advances are greatly reducing the number of deaths from HIV. The number of infant infections has decreased by 58% between 2001 and 2013 and mother-to-child transmission (MTCT) of HIV might well be eliminated in the next few years. By contrast, the prevention and management of hepatitis B virus (HBV) infection lags well behind, at least in sub-Saharan Africa.