As Stephen Gaojia, the coordinator for the Sierra Leone national Ebola response has said: ‘As long as Ebola remains in any country, I don’t think the world is safe. The longer it continues in this country, the worse it gets for the rest of the world.’
Almost three months ago, on August 8 the World Health Organization (WHO) declared the epidemic to be a ‘public health emergency of international concern.’ It has now become evident that this is an unprecedented outbreak of one of the deadliest and most terrifying diseases ever discovered, and that Guinea, Liberia and Sierra Leone need immediate and sustained international relief to control the spread of the epidemic.
Forecasts of future cases and fatalities vary widely but they all paint a bleak picture if the outbreak continues to grow. The estimated timeframe for the incidence to double is currently around 16 days for Guinea, 24 days for Liberia, and 30 days for Sierra Leone. Sadly, high incidence and fatality rates among healthcare staff were present at the beginning of the outbreak, and this resulted in a decreased capacity in the already insufficient health services available in Guinea, Liberia and Sierra Leone.
In a bit of good news, October 20 marked the date which Nigeria was formally regarded Ebola free by WHO. Over a two-month period, 20 cases had developed in Nigeria, of which 8 were fatal. As of October 20, no new cases of Ebola had been reported in 42 days, which is twice the 99th percentile of the estimated incubation period of the virus. The example of Nigeria shows that Ebola outbreaks can be contained if three key public health policies are quickly implemented:
- 1) Fast and thorough tracing of all potential contacts.
- 2) Ongoing monitoring of all of these contacts.
- 3) Rapid isolation of potentially infectious contacts.
Other urgent control measures include increased capacity for clinical management, safe burials, greater community engagement and support from international partners2. The 'virus can be treated successfully with general intensive care measure’3 even in patients who develop a severe case with serious complications. Full recovery has been achieved by patients given intensive medical care and routine treatment (i.e. without any Ebola-specific treatments.) The key factors to improve survival chances seem to be the early initiation of intravenous rehydration, and the improvement of clinical care and initial laboratory diagnostics.
We now know that: (a) Public health policies which can relatively quickly reduce the transmission rates of infection have been identified and tested. (b) There are well-defined, successful clinical treatments available, though they are currently very expensive. (c) The overstretched health care resources in Guinea, Liberia and Sierra Leone, where the epidemic is still growing exponentially, require urgent help from the international community.
Regarding the last point, several countries and international organizations have provided and/or promised funding to combat this outbreak. In this brief analysis we look at the generosity of donor countries measured by the amount of money pledged to humanitarian relief of the current Ebola epidemic. The funding we look at is compiled by the Financial Tracking Service of the United Nations’ Office for the Coordination of Humanitarian Affairs (OCHA). Though a great deal of money has already been committed, significant funding shortages exist especially with regard to the inter-agency plan for Guinea, Liberia, and Sierra Leone.
Funds promised and funds given to combat the spread of Ebola
The OCHA keeps track of funds actually committed and funds promised to fight the outbreak and has produced a comprehensive plan detailing the expected costs of immediate relief in West Africa. So far 49.8% of the plan has been covered, with an additional 28% made up of uncommitted pledges which are not yet ready to be spent until the corresponding funds are committed.
The 90-day comprehensive plan to control and reverse the spread of Ebola in West Africa has been in place for 30 days as of October 30, yet only 22% of the of the 4,707 planned Ebola Treatment Center beds and 4% of the 2,685 planned Community Care Centers beds are currently operational4. The WHO estimates that it still needs $260 million to meet its Ebola outbreak objectives.
As of October 28, the United States was by far the largest donor for combating this outbreak, providing 36.2% of total donations. In terms of total donations, the US is six times larger than the next most generous nation (Canada), with $312 million and $51 million pledged, respectively. Funds from the US alone represent a larger share than all of the intergovernmental organizations combined totaling $220 million, made up of to the World Bank ($105 million), the European Union ($55 million), the African Development Bank ($45 million) and the Central Emergency Response Fund ($15 million).
Other countries outside North America have contributed funds to fighting the epidemic. However, a fairer measurement of generosity should compare these countries’ donations to their total wealth as measured by daily Gross Domestic Output (dGDP = GDP/365).
The entire commitment of the US to fighting Ebola in West Africa represents 0.7% of their dGDP. In other words, the US could spend its whole budget allocated to fighting Ebola 142 times and only deplete the entire country’s total domestic production of a single day. Of course the US leads total donations by a considerable margin. Canada (the only country among the twenty largest economies that has contributed at least 1% of its dGDP) ranks second in terms of total contributions, followed by the UK, France, and Germany (see Table 1).
Many of the top twenty largest donors also are represented in the world’s twenty largest economies. The US, the UK, France and Germany lead while seven of the twenty wealthiest countries (Brazil, Russia, Mexico, South Korea, Indonesia, Turkey and Saudi Arabia) have not yet provided any funds.
Table 2 shows the twenty most generous countries in terms of funds provided relative to their daily GDP. The generosity of the US in absolute terms is still notable – it is the fifth most generous nation and the second among the top twenty wealthiest nations. It is noteworthy that three of the top four most generous countries on this list do not appear on the list of the twenty wealthiest countries, with Canada being an exception.
| Table 2: Top twenty countries in terms of funding to fight Ebola relative to daily GDP (dGDP). | |||||
| GDP Rank | Country | GDP Trillion USD (2012) | Funding Million USD (2014) | % Daily GDP | |
| 1 | 21 | Sweden | 0.52 | 27.63 | 1.93 |
| 2 | 34 | Denmark | 0.31 | 11.48 | 1.33 |
| 3 | 11 | Canada | 1.82 | 51.20 | 1.03 |
| 4 | 52 | Kuwait | 0.18 | 5.00 | 1.00 |
| 5 | 1 | USA | 16.24 | 312.66 | 0.70 |
| 6 | 6 | UK | 2.47 | 44.41 | 0.66 |
| 7 | 24 | Norway | 0.50 | 8.42 | 0.62 |
| 8 | 75 | Luxembourg | 0.06 | 0.88 | 0.58 |
| 9 | 20 | Switzerland | 0.63 | 8.48 | 0.49 |
| 10 | 32 | Venezuela | 0.38 | 5.00 | 0.48 |
| 11 | 5 | France | 2.61 | 25.38 | 0.36 |
| 12 | 54 | New Zealand | 0.17 | 1.59 | 0.34 |
| 13 | 155 | Liechtenstein | 0.01 | 0.05 | 0.33 |
| 14 | 12 | Australia | 1.56 | 13.89 | 0.32 |
| 15 | 4 | Germany | 3.43 | 22.65 | 0.24 |
| 16 | 26 | Belgium | 0.48 | 3.18 | 0.24 |
| 17 | 169 | Andorra | 0.00 | 0.02 | 0.23 |
| 18 | 46 | Ireland | 0.21 | 1.25 | 0.22 |
| 19 | 107 | Estonia | 0.02 | 0.12 | 0.20 |
| 20 | 42 | Finland | 0.25 | 1.04 | 0.15 |
The most generous country by a wide margin is Sweden, with a ratio of 1.93 funds to dGDP. After Sweden, Denmark is quite generous with a ratio of 1.33 followed by Canada (1.03), and Kuwait (1.00). All four of these countries have contributed to emergency funding with at least 1% of their dGDP. The US, UK and Norway are also on this list as the fifth, sixth and seventh most generous nations after spending around 0.66% of their dGDP’s.
These tables do not present the entire story though. A great deal of potential funding has been mentioned by the OCHA even though no formal agreement has been initiated to mandate that these funds be made available. Such pledged yet undelivered funds are called ‘unconfirmed’ by the OCHA but we will denote them as ‘promised’, as much of them may never materialize without being included into formal government budgets.
Table 3 shows the top twenty countries in terms of their confirmed and promised funding as percentage of their dGDP. It is clear that some nations seem to be promising much more than they are currently providing. Surprisingly, Timor-Leste, a country with a total GDP rank of 159 in the world, has promised $2 million in combatting Ebola, over 13% of its dGDP.
Such a figure places this south-eastern Asian country at the top of the generosity league table for promised plus delivered funding for Ebola aid (the last column in the table). Other countries with relatively small economies, for example Namibia, Côte d'Ivoire and Bolivia, have also promised funds over 1% of their dGDP.
| Table 3: Top twenty countries in terms of funding plus promises relative to dGDP. | ||||||
| GDP Rank | Country | GDP Trillion USD (2012) | Funding Million USD (2014) | Promised Million USD (2014) | Funding + Promised % Daily GDP (2014) | |
| 1 | 159 | Timor-Leste | 0.006 | 0.00 | 2.00 | 13.55 |
| 2 | 6 | UK | 2.472 | 44.41 | 295.22 | 5.02 |
| 3 | 21 | Sweden | 0.524 | 27.63 | 38.83 | 4.63 |
| 4 | 127 | Namibia | 0.013 | 0.00 | 1.00 | 2.85 |
| 5 | 34 | Denmark | 0.315 | 11.48 | 3.50 | 1.74 |
| 6 | 42 | Finland | 0.247 | 1.04 | 9.44 | 1.55 |
| 7 | 102 | Côte d'Ivoire | 0.024 | 0.00 | 1.00 | 1.50 |
| 8 | 4 | Germany | 3.426 | 22.65 | 109.31 | 1.41 |
| 9 | 99 | Bolivia | 0.027 | 0.00 | 1.00 | 1.35 |
| 10 | 11 | Canada | 1.821 | 51.20 | 6.13 | 1.15 |
| 11 | 52 | Kuwait | 0.183 | 5.00 | 0.00 | 1.00 |
| 12 | 18 | Netherlands | 0.771 | 1.22 | 19.43 | 0.98 |
| 13 | 24 | Norway | 0.500 | 8.42 | 3.41 | 0.86 |
| 14 | 1 | USA | 16.245 | 312.66 | 46.51 | 0.81 |
| 15 | 74 | Kenya | 0.055 | 0.00 | 1.00 | 0.66 |
| 16 | 75 | Luxembourg | 0.055 | 0.88 | 0.00 | 0.58 |
| 17 | 20 | Switzerland | 0.631 | 8.48 | 0.00 | 0.49 |
| 18 | 32 | Venezuela | 0.382 | 5.00 | 0.00 | 0.48 |
| 19 | 5 | France | 2.611 | 25.38 | 0.00 | 0.35 |
| 20 | 54 | New Zealand | 0.171 | 1.59 | 0.00 | 0.34 |
An important announcement was made recently by the government of the UK introducing a non-binding agreement to supply nearly $300 million to combating Ebola, although only $44 million have been registered so far. This makes the UK seem much more generous than it actually has been.
If the promised funds materialize, it would be the equivalent of around 5% of the UK’s dGDP, just above Sweden’s relative contribution of 4.6% dGDP, where it is placed above. The US ranks number 14 in this table with a respectable 0.8% dGDP, though it has already provided 87% of the funding plus promised resources, whilst this figure is 13% and 42% for the UK and Sweden5.
The need for urgency
The current Ebola outbreak is still out of control in Guinea, Liberia and Sierra Leone. Without external resources, it will continue its destructive and exponential trajectory. There have been some encouraging signs recently, as international help is reaching West Africa and more countries have declared their intention to supply clinical and public health assistance.
It is difficult to evaluate at this time the efficiency of the administration and use of these resources, and how decisive its impact on the epidemic will be in the short and long term. Of immediate concern is the promotion of early diagnosis, isolation and treatment where the disease has spread, research into improving clinical management and public health policies and the crucial need for vaccine research and development.
The striking virulence of Ebola in humans and its consequences manifested in the outbreak of 2014 demand immediate, innovative and imaginative measures from the international community. We urge fellow statisticians to lobby their governments and international organizations to commit further funding to combat Ebola. As the age-old poem by John Donne exhorts, ‘No man is an island, entire of itself… any man's death diminishes me, because I am involved in mankind – and therefore never send to know for whom the bell tolls – it tolls for thee.’
Footnotes
- 1. The London School of Hygiene and Tropical Medicine and the WHO maintain up-to-date summaries of the epidemic.
- 2. 95% confidence interval, 69% to 73%. See WHO Ebola Response Team (2014) Ebola Virus Disease in West Africa – The First 9 Months of the Epidemic and Forward Projections, N Engl J Med, 371, 1481-1495.
- 3. The clinical management of a patient who acquired the infection in Sierra Leone and was treated in an isolation facility in Hamburg after being airlifted to Germany is described in detail by Kreuls B et al (2014) A Case of Severe Ebola Virus Infection Complicated by Gram-Negative Septicemia, N Engl J Med.
- 4. October 29 Ebola Response Roadmap Situation Report.
- 5. Another important Swedish contribution is Professor Hans Rosling, who travelled to Liberia on the 20 October, 2014 'on request from the UN'.
- 6. Please note that the ranking by funding provided includes organisations such as World Bank (ranked 2), Private donations (3), European Union (4), African Development Bank (6), Central Emergency Response Fund (11), and the United Nations (12)
