In reference to: Stratton S. Ebola: who is responsible for the political failures? Prehosp Disaster Med. 2014;29(6):553–554.

Florence Nightingale in the Crimea: “get the horses out of the drinking water,” she told the British brass.Reference Amaratunga ¹ Anne Catherine Bajard in Liberia: “when we are not living fear, we are living sadness.”Reference Bajard ²

Rational response strategies to deal with societal threats are the responsibility of national governments and the international community. Strategies of disaster preparedness, response, recovery, and rehabilitation have interrelated parts. Their elaboration and deployment are complex processes, both politically and technically. Ebola in West Africa has underscored needs for more effective approaches to disaster management, improved intercommunications, and more appropriate funding. Dealing with disaster by governments and by the international community has a long list of failures, including: in the Balkans (1990-2000) and with recent flooding; in Syria with an ongoing polio epidemic amidst civil war;Reference Sparrow ^{3 ,} Reference Levett ⁴ in Palestine, in continuum; and in GreeceReference Papanikolaou, Leon, Kyriopoulos, Levett and Pallis ⁵ with forest fires, flooding, and an ongoing creeping disaster ⁶ generated by austerity.Reference Levett ⁷ Some countries have greater vulnerability, weaker governance, and fewer competences in their health systems, which makes disaster mitigation more difficult. When disaster erupts, vulnerability rises, more so in the presence of poverty.

Ebola, with more than 20,000 cases and 8,000 dead, is yet another example of the uneasy dynamics between developed and developing countries and the inability of poorer countries to contain such outbreaks. This is why humanitarian aid is mandatory more than ever and health diplomacy increasingly becomes necessary.

According to the World Health Organization (Geneva, Switzerland), the Ebola virus has precipitated a most serious epidemic whose course and final outcome are unpredictable, even though confidence for containment grows. One official statement by the UN Security Council is that “Ebola is a public health emergency of international concern.” ⁸ One claim by Martin-Moreno, et al is that the response of the international community was slow as a result of inaction and neglect and suggests that it may precipitate a geopolitical crisis.Reference Martin-Moreno, Ricciardi, Bjegovic-Mikanovic, Maguire and McKee ⁹ Another says “we must admire the stunning courage and commitment of local health-care workers in Africa.”Reference Amaratunga ¹ The writer, Amaratunga, when a student at the time of the Apollo moon landing (1969) and working in Liberia, asked herself, “how is it possible to spend millions for man to step onto the moon, while in the villages of Africa, people are sick, destitute, and hungry?”Reference Amaratunga ¹ In Canada, it was “old fashioned public health and public education” that made the difference for the containment of severe acute respiratory syndrome (SARS).Reference Levett ¹⁰ Amaratunga adds that SARS is not a helpful model for Ebola.Reference Amaratunga ¹

In an insightful EditorialReference Stratton ¹¹ on the deadly but controllable Ebola virus (a potential bioterrorism agent), Samuel J. Stratton argues that the United States should have been well prepared to respond. To the contrary, he says, it failed to prepare emergency and health care providers adequately, that “the political leaders dependent on health experts and health science have been betrayed,” and that the emergent distrust influenced American Congressional elections. Although these inferences are drawn from a single case of Ebola in Texas (USA), which penetrated the sanitary shield of the United States (there were more), he infers that what went wrong “awoke the world to the risk of the virus.” His words ring true; examples include: failure to contain Ebola in West Africa; lack of expert enabling power to persuade health policy makers and political leaders of Ebola’s dangers; confusion relating to the use of appropriate guidelines; erroneous actions; emerging instant expertise; academics rushing to publish rather than to inform; media shock tactics; and questionable political and scientific leadership.

Ebola’s death toll in West Africa is incredible, the integrity of the USA has been damaged, and civil liberties have been affected. He uses five reasonable arguments, or propositions, to summarize failure and concludes that it is the health community that has failed politics and people. This seems at least asymmetrical in both space and in time.

I would argue that the most significant driving forces damaging to population health and of import to Ebola are: (1) the enormous levels of inequality throughout the world;Reference Piketty ¹² (2) reluctant political recognition for public health; (3) few incentives for politicians to act in support of applied prevention or to embrace public health as a strategy for development; (4) budgetary imbalances and diminishing fiscal support for the health sector; and (5) a current deficit in the science of disaster and health disaster management.

Skyrocketing inequality defeats social progress and puts a brake on development; no-profit-incentive public health is ignored by both politicians and markets while its available infrastructure is maintained poorly; and politicians accept the deliberate downplay of risk and pay little more than lip service to health and economic equality. In addition, the worldwide environmental crisis, and the inability of governments to tackle climate change, nudges society towards instability. In Greece, for example, environmental issues are bypassed. Public health is allocated less than two percent of the shrinking health budget, with the largest share going to therapy with curative services dominated by a concern for pharmaceuticals and biomedical technologies; the public sector, with its diminished resources, is now in greater demand, a result of austerity.Reference Levett ^{13 ,} Reference Levett ¹⁴

Stratton’s Editorial on Ebola draws attention to weaknesses and faulty preparedness of the health sector, the poorly developed response capacity of society for disastrous events, and the limitations on available competences (human resources). His important message is that it is time to tease out the political determinants of population health and better contain population vulnerability.Reference Piketty ¹² Politicians and the public alike should keep in mind that to predict the what, where, and when of the next disastrous event is almost impossible, and the lesson of experience shows that once any crisis is over, good intentions and promises made are usually set aside. I would add that the World Association for Disaster and Emergency Medicine (WADEM) can help stimulate a well-coordinated combination of the attributes of public health and disaster management. The goals of these two domains, or societal functions, are confluent. At a time of growing inequality and with new and emerging threats to population health, a neglect of public health with its proven track record can only lead to further disaster.

It is encouraging that the President of the United States argues the science of quarantine. History tells us that when charismatic leaders enter the health arena, positive things can happen, provided that a competent human resource exists, good policy is enacted, and cutting-edge science and best evidence are applied; examples include: Roosevelt (The New Deal; 1933; USA), Eleftherios Venizelos (a revolution in public health; 1929; Greece), Clement Atlee (The British National Health Service; 1948; United Kingdom) and Lyndon Johnson (War on Poverty; 1964; USA). However, restrictions on civil liberties through quarantine (Ebola), isolation (suspected carrier or dangerous patient), and incarceration (dangerous criminal) should be used sparingly, most ethically, and within a framework of justice and human rights.

In recovery and rehabilitation phases of the Ebola crisis in West Africa, the public health infrastructure should undergo reinforcement and adequate humanitarian support should be attracted. A significant improvement of societal equality can only be achieved by the global penetration of values implicit in public health and by the strengthening and renewal of the World Health Organization and the agencies of the United Nations.Reference Donev, Laaser and Levett ¹⁵