# Update on the Ebola outbreak

Over the past couple of months, we’ve put some time into trying to understand the Ebola containment effort and whether it represents a strong giving opportunity. Our process has included conversations and correspondence with about 15 people including major private donors to the containment effort and representatives of the UN, CDC, WHO, and Doctors without Borders. We have also kept informed on the outbreak by reading updates from the UN, CDC, WHO, and University of Pittsburgh Medical Center. (More on our process)

Yesterday, we published a writeup summarizing the status of the outbreak and control effort, the picture of funding provided and needed, and our view on the cost-effectiveness of donations.

The key points, in our view, are:

• It has been very difficult – we think unnecessarily so – to get a picture of the funding needs and the likely impact of additional donations. It’s inevitable that a situation like this one will be difficult to understand and follow as it’s unfolding, but we’ve struggled to find even fairly basic information. We haven’t been able to find any consolidated estimate of how much total funding is needed for core activities and how much of that funding has come in so far. The closest we’ve found has been an appeal specific to UN partner agencies and major NGOs; this appeal doesn’t appear to account for the (significant) activities undertaken and funds provided directly by donor governments. (Note that Center for Global Development scholars have expressed similar sentiments about the lack of reliable information on donor contributions, in a post titled How Much Is Actually Being Spent on Ebola?) Furthermore, the description of planned activities for the UN partner agencies and major NGOs is very broad and high-level. We’ve found very little information on how additional funds would be spent. More
• Substantial funding has come forward, particularly from governments. As of November 28, over $2 billion in funding for immediate relief efforts had been tracked, and more recently the US Congress approved over$5 billion in funding “to contain and end the Ebola outbreak at its source in Africa, enhance domestic preparedness, speed the procurement and testing of vaccines and therapeutics, and accelerate global capability to prevent the spread of future infectious diseases.” (It appears that about half of this will be spent domestically.) We believe that this outbreak may have been less compelling for individual donors than disasters such as the 2010 Haiti earthquake and 2011 Japan earthquake/tsunami; on the other hand, it has attracted significant funding from governments, perhaps in part because of fears that the outbreak might spread beyond Africa. More
• There has been significant progress toward stopping the outbreak, though there are still areas with intense transmission. It’s hard to have high confidence in data about the containment effort, but broadly speaking, it looks as though the effort has ramped up significantly; that it has largely (though not completely) met its goals regarding safe burials and case isolation; and that the overall number of cases in Liberia (where the outbreak has affected the most people) has declined substantially and come in very far below projections made at the beginning of the outbreak. The situation appears to be worst in Sierra Leone, where there are still major Ebola “hotspots,” and it remains possible that the course of the outbreak could change rapidly. More
• On the margin, we don’t expect additional donations from our audience to be critical to stopping the outbreak. We see the current funding gap as hindering how far into the future the Ebola response team can plan (e.g. contracts for some employees lasting 2 months instead of 6) or leading to the use of lower-quality equipment (e.g. ambulances with a dial-up modem instead of a VSat) rather than as, for example, preventing work in some areas altogether. More funding may be needed in the future, but we are optimistic that government donors will come forward with the bulk of such funding. More
• We aren’t recommending additional donations to the containment effort in place of donations to our top charities, but we do feel the containment effort has been an outstanding use of funding. We estimate that the several billion dollar effort, taken as a whole, could easily have saved lives as cost-effectively as our top charities – something that we don’t believe is usually the case in a disaster. We doubt that additional donations from our audience – beyond what has already been committed and will likely be committed in the future from others – would have comparable cost-effectiveness. We see the commitments governments have provided as outstanding uses of funds and hope they deliver on their commitments and close any remaining funding gap. More
• We remain interested in opportunities to strengthen disease surveillance over a longer time frame, to prevent the spread of this outbreak and help contain future outbreaks at earlier stages. We previously argued: “The best opportunities to prevent or contain the epidemic were probably before it was widely recognized as a crisis (and perhaps before Ebola had broken out at all – more funding for preventive surveillance could have made a big difference).” In our conversations around this outbreak, we have heard that there may be opportunities to rebuild health systems with stronger general surveillance capacity, and we are interested in this as part of our work on biosecurity (a likely priority of our Open Philanthropy Project work on global catastrophic risks).

As is usually the case in a vivid and widely publicized disaster, a large amount of funding has come forward, and it’s been hard to understand the developing situation and the role of additional donations – two factors that generally make us unlikely to recommend giving. In this case, the size of the threat and the potential difference to be made by a containment effort were unusually large, and we believe that the funding that went to this effort has generally been money unusually well spent.

• Ian Turner on December 24, 2014 at 2:37 pm said:

Really interesting, thanks for sharing.

• Daniella Maciel de Souza on December 26, 2014 at 9:24 am said:

My 8 year-old daughter is interested in donating to help the Ebola efforts, but I’ll read her this article to see if she still wants to do that. If so, what is a top charity you would recommend? Thanks in advance.

• A friend of mine who works on the Ebola response remarked that people power is the biggest area of need. Do you have a sense of whether the human resources needs of the Ebola response are being met? What’s the case for building a corps of “medical reservists” to avoid such gaps in the future?

• Jake Marcus on January 23, 2015 at 4:57 pm said:

Daniella – Sorry for the late reply. Great to hear your daughter using GiveWell! We haven’t looked closely at the best place to donate to in order to support the response efforts, but Dr. Nordström (http://files.givewell.org/files/conversations/Anders%20Nordstrom%2012-9-14%20(public).pdf) told us that donations to the UN’s Ebola Response Multi-Partner Trust Fund (http://mptf.undp.org/factsheet/fund/EBO00) would provide flexible funding to the response efforts, which could be used for improving management practices, building epidemiological capacity and coordinating work across organizations and governments. Your daughter might consider donating there.

Mike – Thanks for the question. I don’t have a good sense of how well the human resources needs are being met for the Ebola response. Those needs are rapidly changing as the outbreak evolves. The UN recently released an update on human resources requirements, for example, which calls for smaller, more active and localized public health teams. Our investigation of giving opportunities in biosecurity (https://www.givewell.org/labs/causes/biosecurity), which could include investments in building up a corps of medical reservists, is ongoing.

• Rhinoplasty NYC on February 19, 2015 at 6:17 am said:

Thanks for sharing this.

• Aram on March 5, 2015 at 5:39 pm said:

In the section titled “The giving opportunity” of your full report (https://www.givewell.org/ebola-outbreak-december-2014 ), there is an estimate that the cost per life saved of the response to date was \$7000. This is based on an assumption that without intervention we would have seen the CDC estimate of 1.4 million, or something in that ballpark.

In fact, Liberian cases had peaked in the thousands sometime around September *before* the international intervention had reached the majority of patients. This strongly suggests that behavior change was responsible and that in the absence of intervention the total number of cases would have been in the tens, not hundreds, of thousands.

It is importnat to realize that the CDC estimate was an extrapolation of exponential growth for several months based on data that at the time was very noisy, and also that it (necessarily) assumed that behavior wouldn’t change. So it is not an appropriate counterfactual for “no intervention”

• Aram – Thanks for the comment. I should have included more discussion of the limitations of the CDC’s projections. That being said, I think there still could have been hundreds of thousands of cases in the absence of an intervention, because: (1) Ebola could have spread to other countries. (2) Ebola could have become endemic. (3) At least for some period of time, Sierra Leone looked worse than the CDC’s projections. It is not clear that Liberia’s experience would have applied to other countries.

• Mitul Sarkar on March 27, 2015 at 8:16 pm said:

Paramedic capacity building (maybe online seminars, video-training sessions, basic “certification” etc) and mobile phone-based surveillance and geomapping is worth an investment. Because the virus is still very much there, and will get more chances to bounce back in the future.

• Jak,e I still disagree. I think “could have been hundreds of thousands” is unevidenced speculation. Maybe it would have been true if there was zero response, but what you care about is at the margins, and if the response were 50% smaller it’s hard to see that. Here is an article that explains how irrelevant the US government response was in Liberia:

http://www.nytimes.com/2015/04/12/world/africa/idle-ebola-clinics-in-liberia-are-seen-as-misstep-in-us-relief-effort.html

I agree with Mitul’s points. More generally to stop future emerging diseases we need for the sort of horizontal programs with harder-to-quantify benefits that do not fit the givewell model.

• Aram – In the “The giving opportunity” section, I was trying to get a rough picture of the average cost-effectiveness of the global response, but I think the question you raise about the cost-effectiveness of the response at different levels of funding is an interesting one. It doesn’t seem implausible that a large proportion of contributions to the response did little to change the trajectory of the outbreak.

Re: “More generally to stop future emerging diseases we need for the sort of horizontal programs with harder-to-quantify benefits that do not fit the givewell model.” I agree that there may be opportunities in this area outside of the GiveWell model. We’re interested in this as part of our work on biosecurity (a likely priority of our Open Philanthropy Project work on global catastrophic risks). See our latest update on that work here.