埃博拉疫情早有預警

The conventional wisdom among public health authorities is that the Ebola virus, which killed at least 10,000 people in Liberia, Sierra Leone and Guinea, was a new phenomenon, not seen in West Africa before 2013. (The one exception was an anomalous case in Ivory Coast in 1994, when a Swiss primatologist was infected after performing an autopsy on a chimpanzee.)

在利比里亞、塞拉利昂和幾內亞肆虐的埃博拉疫情已經造成至少1萬人死亡。公共衛生機構的慣常思維是，埃博拉病毒的流行是一種新現象，在2013年前沒有在非洲西部出現過。（有一個例外，1994年在科特迪瓦出現過一例反常病例，當時一名瑞士的靈長類動物學家在對黑猩猩的屍體進行解剖後感染了病毒。）

The conventional wisdom is wrong. We were stunned recently when we stumbled across an article by European researchers in Annals of Virology: “The results seem to indicate that Liberia has to be included in the Ebola virus endemic zone.” In the future, the authors asserted, “medical personnel in Liberian health centers should be aware of the possibility that they may come across active cases and thus be prepared to avoid nosocomial epidemics,” referring to hospital-acquired infection.

這種慣常思維是錯誤的。我們最近偶然發現了《病毒學年鑑》(Annals of Virology)上的一篇文章，令我們頗爲驚訝：“研究結果似乎說明，需要將利比里亞納入埃博拉病毒流行區。”文章作者強調，將來，“利比里亞衛生機構的醫務人員應該意識到，他們可能會遇到活躍病例，因此應該做好準備，避免疾病在院內傳播。”

What triggered our dismay was not the words, but when they were written: The paper was published in 1982.

讓我們感到不安的並非文字本身，而是寫下這些文字的時間：這篇論文發表於1982年。

As members of a team drafting Liberia’s Ebola recovery plan last month, we systematically reviewed the literature on Ebola surveillance since the virus’s discovery in central Africa in 1976. We learned that the virologists who wrote that report, who were from Germany, had analyzed frozen blood samples taken in 1978 and 1979 from 433 Liberian citizens. They found that 26 (or 6 percent) had antibodies to the Ebola virus.

作爲上個月擬定利比里亞後埃博拉時期恢復計劃的團隊成員，我們系統地查閱了自1976年首次在非洲中部發現這種病毒以來的有關埃博拉疫情監控的文獻。我們得知，撰寫上述報告的德國病毒學家分析了一些凍存血樣——於1978年到1979年間取自433名利比里亞人。他們發現，其中26人（即6%）體內攜帶埃博拉病毒抗體。

Three other studies published in 1986 documented Ebola antibody prevalence rates of 10.6, 13.4 and 14 percent, respectively, in northwestern Liberia, not far from its borders with Sierra Leone and Guinea. These articles, along with other forgotten reports from the 1980s on antibody prevalence in neighboring Sierra Leone and Guinea, suggest the possibility of what some call “sanctuary sites,” or persistent, if latent, Ebola infection in humans.

另有三篇發表於1986年的論文顯示，在利比里亞西北部，距離該國與塞拉利昂及幾內亞邊境不遠的地方，埃博拉抗體的攜帶率分別爲10.6%、13.4%和14%。上述文章，以及那些發表於20世紀80年代的被遺忘的有關鄰國塞拉利昂和幾內亞的埃博拉抗體攜帶率的報告都說明，可能存在一些人所說的“避難所”，也就是持續攜帶潛藏的埃博拉病毒的人體。

There is an adage in public health: “The road to inaction is paved with research papers.” In a twist of fate, the same laboratory that confirmed the first positive Ebola test results in Guinea last year, the Pasteur Institute, was the publisher of Annals of Virology. Yet the institute’s April 2014 report said, “This subregion was not considered to be an area in which EBOV was endemic” (using the medical term for the Ebola virus).

公共衛生領域有一條格言：“通往無所作爲的道路上鋪滿了研究報告。”命運弄人的是，去年確認幾內亞第一例檢測結果爲陽性的埃博拉病例的實驗室——巴斯德研究所(Pasteur Institute)——正是《病毒學年鑑》的出版方。然而，這家研究所在2014年4月發表的報告稱，“該分區並未被認爲是埃博拉病毒的流行區。”

Part of the problem is that none of these articles were co-written by a Liberian scientist. The investigators collected their samples, returned home and published the startling results in European medical journals. Few Liberians were then trained in laboratory or epidemiological methods. Even today, downloading one of the papers would cost a physician here $45, about half a week’s salary.

造成這一問題的部分原因在於，這些論文都不是由利比里亞科學家合寫的。研究人員採集樣本，帶回去，然後在歐洲的醫學期刊上公佈驚人的研究結果。那時候，幾乎沒有利比亞里人受到實驗室或流行病學研究方法的培訓。就算到了今天，利比里亞的醫生下載一篇論文可能要花費45美元（約合280元人民幣），幾乎相當於半周的薪水。

The story is not an unusual one. As it happened, the subjects in the 1986 antibody studies worked on the world’s largest rubber plantation (which then supplied 40 percent of the latex used in the United States). During the current outbreak of Ebola, we saw rubber trees stretch as far as the eye could see from clinics in rural Margibi County — clinics shuttered after nurses died after supplies of latex gloves and other protective gear ran out. The way this part of Liberia was trawled for vital medical knowledge thus mirrored the way the West extracted the rubber it needed.

這個故事並不罕見。事實上，1986年開展的抗體研究的受試對象是世界上最大的橡膠園的工作人員（當時美國使用的40%的乳膠產自該橡膠園）。在最近這輪埃博拉疫情爆發期間，從馬及比縣的那些診所——橡膠手套及其他防護裝備的缺乏導致護士死亡後，診所被關閉——看去，橡膠樹不斷延伸，一望無際。我們在利比里亞的這個地區獲取重要醫療信息的方式，與西方國家獲取他們所需的橡膠的方式別無二致。

Sierra Leone’s and Liberia’s recent histories of civil conflict made it difficult to confirm an outbreak of the disease. Public health laboratories were not functioning in either country; it was months before Ebola was identified as the culprit pathogen. That made it impossible for the region’s few doctors and nurses to deliver effective care.

塞拉利昂和利比里亞近期進行的內戰使得醫護人員難以確認疫情的爆發。這兩個國家的公共衛生實驗室均未良好運轉；拖了好幾個月的時間埃博拉病毒才被確定爲罪魁禍首。因此，該地區本已稀缺的醫生和護士無法進行有效的醫療服務。

In all recognized Ebola epidemics to date, the disease has been transmitted primarily in the course of caring for the sick or burying the dead — hence the 1982 warning about transmission within hospitals and clinics. It was just as the German scientists had predicted: Liberia’s under-resourced health facilities became the fault lines along which Ebola erupted across the country and the wider region.

在迄今爲止所有被確認的埃博拉疫情中，這種疾病都主要是在護理患者或掩埋屍體的過程中傳播的。所以，1982年的論文提醒人們注意醫院和診所內部的感染。情況正如德國科學家所預測的那樣：利比里亞捉襟見肘的衛生設施成爲了軟肋。埃博拉沿着它們向全國乃至更廣闊的地區擴散。

To our knowledge, no senior official now serving in Liberia’s Ministry of Health had ever heard of the antibody studies’ findings. Nor had top officials in the international organizations so valiantly supporting the Ebola response in Liberia, including United Nations agencies and foreign medical teams.

據我們所知，利比里亞衛生部在職的高級官員中，沒人聽說過前述抗體研究的發現。在利比里亞勇敢地支持抗擊埃博拉活動的國際組織，包括聯合國機構和外國醫療團隊，它們的高層官員也沒聽說過。

When the history of this epidemic is written, it will chronicle the myriad ways that — from Guéckédou and Monrovia, to Geneva and Dallas — we were not prepared. But none of us can in good conscience say there was no warning.

如果有人撰寫這種傳染病的歷史，我們缺乏準備的無數個地方都會被計入其中，從蓋凱杜和蒙羅維亞，到日內瓦和達拉斯。但我們誰都不能憑良心說沒有過警告。

Ebola was here already. Understaffed and underequipped hospitals and clinics were sure to intensify, rather than stop, a major outbreak. And among its primary victims would be health care professionals. Had the virologists’ findings been linked to long-term efforts to train Liberians to conduct research, to identify and stop epidemics, and to deliver quality medical care, the outcome might have been different.

埃博拉病毒早就來到了這裏。人手不足、設備匱乏的醫院和診所肯定會加劇，而非阻止一場大規模的疫情爆發。主要受害者將包括醫護專業人士。如果那些病毒學家的發現，能和訓練利比里亞人開展研究、辨認並阻止疫情、提供優質醫療護理的長期行動結合在一起，結果或許會有所不同。

We all had friends and co-workers fall ill during this epidemic. But the fates of the afflicted reflect grotesque disparities. Of the 10 Americans infected with Ebola, all were airlifted to specialist hospitals with excellent clinical care in the United States. Nine have recovered, and the 10th is, we pray, well on his way to a full recovery. At the start of the last major chain of transmission recorded in urban Liberia, last month, 11 of 11 people in one cluster perished.

我們都有朋友或同事在這場疫情中病倒。但被傳染者的命運卻反映出了奇特的懸殊差異。10名感染了埃博拉的美國人，全都被用飛機送到了美國的專科醫院，那裏有極好的臨牀護理。其中九人已康復，我們祈禱剩下那名患者也能儘快地完全康復。而上月，利比里亞城市地區有記載的最後一次大規模連鎖傳染剛剛開始，其中一個集體病例中的11人就全部死亡。

A lasting legacy of this terrifying health crisis must be a new architecture for global health delivery, with a strong focus on building local capacity to respond effectively to such crises. Equity must be an indispensable goal in protecting from threats like Ebola, and in the quality of care delivered when prevention fails. Only then can we leave behind the rubber plantation model of international health and draw on the science that must inform these endeavors.

這場駭人的衛生危機的持久影響之一，是必須爲全球衛生救護建立新的架構，着重建設當地有效應對這類危機的能力。在預防埃博拉等威脅，以及預防失敗後提供的醫護服務的質量方面，公平必須成爲一個不可或缺的目標。只有這樣，我們才能丟棄國際衛生的橡膠種植園模式，利用必須與這些努力聯繫在一起的相關科學研究。