(Updated Nov. 7, 2014)

The Centers for Disease Control and Prevention reported on Nov. 4 that the death toll from the Ebola outbreak in West Africa has risen to above 4,960 and that an estimated 8,168 people, mostly in Liberia, Sierra Leone and Guinea, have contracted the virus since March. It is the largest and most severe outbreak of the Ebola virus since it was first detected four decades ago. All but nine of the deaths were in those three countries; eight were in Nigeria and one patient died in the United States.

The CDC in October proclaimed that in the worst-case scenario, Sierra Leone and Liberia could have 1.4 million cases by Jan. 20, 2015, if the disease keeps spreading without immediate and immense intervention to contain the virus.

Two American aid workers infected with Ebola while working in West Africa were transported to a containment unit at Emory University in Atlanta for treatment, raising public fears about international spread of the highly virulent virus that has no known cure. The two were released from the hospital after being the first humans to receive an experimental Ebola drug called ZMapp. Another man who recently helped an Ebola victim in Liberia traveled to Texas and died in a Dallas hospital. Two of the nurses who treated him caught the virus as well, but have been released from the hospital. Some states have struggled with the moral 

We ask CISAC biosecurity experts David Relman and Megan Palmer to answer several questions about Ebola and the public health concerns and policy implications. Relman is the co-director of the Center for International Security and Cooperation who has served on several federal committees investigating biosecurity matters. He is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine and of Microbiology and Immunology at Stanford University School of Medicine, and Past-President of the Infectious Diseases Society of America.

Palmer is the William J. Perry Fellow in International Security at CISAC and a Researcher at the UC Berkeley Center for Quantitative Biosciences (QB3), and served as Deputy Director of Policy & Practices for the Multi-University NSF Synthetic Biology Engineering Research Center (SynBERC).

The two of them have answered the questions together.

What is Ebola and how dangerous is it compared to other diseases?

Ebola is an acute viral infectious disease, often associated with severe hemorrhagic fever. While initial symptoms are flu-like, they can rapidly progress, and include vomiting, reduced ability to regulate immune responses and other physiological processes, sometimes leading to internal and external bleeding. The disease has an incubation period that can last up to 21 days, but patients typically become ill four to nine days after infection, and die about seven to ten days later. Fatality rates for the current Ebola outbreak are nearing 60% (according to the CDC), while past outbreaks in the Republic of Congo have seen rates as high as 90%. This outbreak to date has resulted in nearly 1,000 deaths, more than any previous Ebola outbreak.

Ebola virus is believed to reside in animals such as fruit bats where it does not cause disease, but is then transmitted to and among humans and other primates, in whom disease typically does occur. The route by which the virus crosses between species remains largely unknown. People become infectious once they become symptomatic. Ebola is transmitted via blood or bodily fluid, but can persist outside the body for a couple days. Infection can occur through unprotected contact with the sick, but also when contaminated equipment such as needles cut through healthcare workers’ protective gear, and also through contact with infected individuals postmortem.

David Relman Photo Credit: Rod Searcey

Ebola’s horrific symptoms provoke public fear, and it becomes easy to lose perspective on the relative spread and toll of this outbreak. Ebola is relatively difficult to transmit. This means the latest Ebola outbreak is still small in comparison to the hundreds of thousands of people killed each year via more easily transmitted airborne influenza strains and other diseases such as malaria and tuberculosis. It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere.

Is there a vaccine or cure?

There is no vaccine for Ebola and no tried-and-true cure. Health workers can only give supportive care to patients and try to stop the spread to new victims.

Several experimental therapies for Ebola are under development. One receiving attention is ZMapp, a mix of antibodies produced by mice exposed to the virus that have been adapted to improve their human compatibility. Limited tests in primates show early promise, but the drug had not been tried on humans -- until now. Two Americans transported back to the U.S. from West Africa received the experimental therapy. While the two seem to be improving, it isn’t clear that ZMapp was responsible; another issue is that ZMapp and other potential therapies have not been cleared by the FDA for wider use in humans.

The process for approval, and who gets priority access to such drugs, are complex policy issues. The WHO will be convening leaders and medical ethicists next week to discuss how to develop and distribute experimental therapies. This is not a simple task; many factors need to be taken into consideration and balanced with limited information to guide decisions.

Successful or not, and despite any approval, it’s still uncertain whether enough of such drugs could even be produced quickly enough to respond to this particular outbreak, and if not - whether they’d be effective in a future outbreak.

You can listen to Relman in this KQED Public Radio talk show.

Relman joins other experts in a Stanford panel on Ebola

Why has this Ebola outbreak involved so many more people, and spread to a wider geographic area,  than previous outbreaks?

This is an evolving investigation and many potential contributing factors are being examined by scientists racing to collect information that can help them get ahead of the outbreak.

One factor is population density. This latest outbreak spread early into denser population areas within Liberia and Sierra Leone, rather than remain confined to isolated villages, as in earlier outbreaks in Central Africa. With a greater number of people being exposed within a smaller geographic area, the likelihood of transmission increases. Of particular concern is the prospect that the virus might take hold in Lagos, Nigeria, where a handful of cases have been recently identified. If this were to spread in Lagos, Africa’s most populous city, the death toll would likely increase dramatically.   

Another factor is the ability of affected regions to mount an effective public health response. This outbreak is occurring in three of the poorest African countries: Sierra Leone, Liberia, and Guinea. Civil wars have likely contributed to degradation of an already relatively poor public health infrastructure. This is also the first Ebola outbreak in the region, and the inexperience of local authorities can delay responses and fuel fearful community responses, undermining the ability to deal with the outbreak early when it’s more easily contained.

Cultural practices around the care of the sick and the dead can also fuel progression of an outbreak. In some parts of Western Africa, washing deceased relatives is commonplace. Customs like these increase the likelihood of the infection spreading through proximity between infected individuals and their family members

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What can be done to curtail the outbreak?

Isolation and quarantine are key to fighting the spread of Ebola. Isolation involves removing infected individuals from the general population to prevent the spread of disease. Quarantine, however, involves removing uninfected or potentially infected individuals from the general population to limit the spread of disease.

Thus far, the strategy to fight Ebola is dependent on isolating infected patients. Unsurprisingly, isolation efforts have proven hard to enforce. Some families, faced with the prospect of being confined to their homes, have denied the existence of Ebola in their localities, or refuted doctors who claim that one of their family members is sick. This is not unique to Africa; Americans had violent reactions to quarantine during the spread of smallpox. Some regions are now taking more extreme measures: Sierra Leone has deployed its army to enforce isolation at clinics and infected families’ homes, but this also risks civil unrest.

These tensions underscore the necessity of improved education and enforcement mechanisms within public health strategies. Response measures involve fundamental tradeoffs between liberty and safety. Because negotiations occur through complex local, national and international processes, one of the biggest risks is that decisions don’t keep pace with disease spread.

It’s important that we not lose sight of more chronic, but less headline-grabbing diseases that will be pervasive, insidious long-standing challenges for Africa and elsewhere."

How likely is it that the disease will spread into and within the United States?

Currently, airports in Liberia, Sierra Leone, and Guinea are screening all outbound passengers for Ebola symptoms such as fever. This includes asking passengers to complete healthcare questionnaires. However, it is difficult to reliably know who has been infected until they are symptomatic. Individuals could theoretically board a plane before they show symptoms, but develop them upon landing in the United States or elsewhere. This makes containing Ebola difficult, but not impossible.

If the virus were to enter the United States, it would be easier to contain and harder to spread. This virus does not transmit that easily to other humans, especially in settings with good infection control and isolation.

As viruses spread, the chances of genetic variation increase. Yet despite all the concerns from the current outbreak, Ebola is relatively bad at spreading in comparison to respiratory viral diseases such as influenza or measles. The likelihood of a pandemic Ebola virus in the near future seems slim as long as it cannot be transmitted via air.  While it’s possible that the Ebola virus could evolve, there is little evidence to suggest major genetic adaptations at this time.

What are some broader lessons about the dynamics and ecology of emerging infectious diseases that can help prevent or respond to outbreaks now and in the future?

These latest outbreaks remind us that potential pathogens are circulating, replicating and evolving in the environment all the time, and human action can have an immense impact on the emergence and spread of infectious disease.

We are starting to see common factors that may be contributing to the frequency and severity of outbreaks. Increasing human intrusion into zoonotic disease reservoir habitats and natural ecosystems, increasing imbalance and instability at the human-animal-vector interface, and more human population displacement all are likely to increase the chance of outbreaks like Ebola.

Megan Palmer Photo Credit: Rod Searcey

The epicenter of this latest outbreak was Guéckédou, a village near the Guinean Forest Region. The forest there has been routinely exploited, logged, and neglected over the years, leading to an abysmal ecological status quo. This, in combination with the influx of refugees from conflicts in Guinea, Liberia, Sierra Leone, and Cote d’Ivoire, has compounded the ecological issues in the area, potentially facilitating the spread of Ebola. There seems to be a strong relationship between ecological health and the spread of disease, and this latest outbreak is no exception.

While forensic analyses are ongoing, unregulated food and animal trade in general is also a key factor in the spread of infectious diseases across large geographic regions. Some studies suggest that trade of primates, including great apes, and other animals such as bats, may be responsible for transit of this Ebola strain from Central to Western Africa.

What are some of the other political and security implications of the outbreak and response?

Disease outbreaks can catalyze longer-term political and security issues in addition to more acute tensions.

There are complex international politics involved in emergency response and preparedness. Disease outbreaks often occur in poor regions, and demand help from more wealthy regions. The nature of the response reflects many factors - technical, social, political, legal and economic. Leaders often lack the expertise to take all these factors into account. It is an ongoing challenge to adapt our governance processes to be more reliable and move from damage control to planning. Organizations like the World Health Organization can provide guidance, but more resources and expertise are needed to get ahead of future disasters.

When help is provided, there is often mistrust of non-local workers, who can even be seen as sources of the disease. At a political level, distrust has been fueled by disguising political missions as health interventions, as was the case with the effort that led to the locating of Osama Bin Laden.

There are other security implications of this latest epidemic. This outbreak has led to a dramatic increase in the availability of Ebola virus in unsecured locations across West Africa, as well as to a growing number of labs across the world studying the disease. The immediate need to study the disease and develop beneficial interventions needs to be coupled to considerations of safety and security. From a safety standpoint, a rise in the handling of Ebola samples risks accidental transmission. From a security standpoint, those who wish to cause harm with this virus could acquire it from bodies, graves and other natural sources in the affected region. Both of these risks demand attention and efforts at mitigation.

The first Tonkin Gulf incident occurred exactly 50 years ago this week, giving the United States government the legal basis for the Vietnam War. But as CISAC Affiliated Faculty Member $people1% notes in this Huffington Post commentary, there has been little coverage of the anniversary in the media.

"Given that the war cost 58,000 American lives and somewhere between 1,000,000 and 3,000,000 Vietnamese, and each of its major rationales was later shown to be false, the nation's lack of memory is stunning, and dangerous," Hellman writes.

Karl Eikenberry, a William J. Perry Fellow in International Security at CISAC and Shorenstein APARC Distinguished Fellow in the Freeman Spogli Institute, says we mustn’t assume that tensions between China, a rising power, and the United States, a status quo power, will lead to conflict, in American Review.

He says the Thucydides Trap, a term derived from the Athens-Sparta dynamic which eventually lead to conflict more than 2,400 years ago, would be largely misapplied if used to describe the current context of U.S.-China relations.

“While it is generally true that struggles between rising and status quo powers historically have led to war, the various cases of the past – and Athens-Sparta in particular – are quite different from each other and certainly from today’s rivalry between the United States and China,” Eikenberry writes.

While the future of U.S.-China relations is uncertain, and if mismanaged, could lead to conflict, analysts in both countries would be unwise to assume a re-enactment of the Peloponnesian War.

His essay can be found on American Review online. A Stanford Report news release on 20 August covered his essay.

Jonathan Hunt, a postdoctoral MacArthur Nuclear Security Fellow at CISAC, writes in this commentary in The National Interest that the secret history of Cold War détente offers a case study in how back-channel discussions at multilateral talks might help the United States and Iran resolve their differences.

U.S. Secretary of State John Kerry and foreign ministers from the six-nation group negotiating a nuclear agreement with Iran will resume talks in Vienna this weekend. The foreign ministers are trying to forge a a comprehensive nuclear deal by a July 20 deadline.

“The annals of nuclear diplomacy between the United States and the Soviet Union might afford a useful case study from which American and Iranian leaders could learn,” writes Hunt, who has a Ph.D. in History and wrote his dissertation on nuclear internationalism during the Cold War.

“In contrast to the conventional wisdom that Nixon and Kissinger masterminded Soviet-American détente, those who brokered the Nuclear Nonproliferation Treaty (NPT) during the presidency of Lyndon Baines Johnson in fact laid the groundwork for superpower cooperation,” he writes. 

Martha Crenshaw, a senior fellow at CISAC and FSI and one of Stanford's leading experts on terrorism, says the terrorist group known as ISIS poses a danger to the United States if it grows more powerful. But that organization, she adds, may be overreaching in its ruthlessness and religious zealotry. Crenshaw answers questions in this Stanford Report interview with the Stanford News Service.

Meanwhile, the U.S. government has not found a way to deal with the larger Iraq conflict that now involves ISIS, says Crenshaw, who founded and runs the Mapping Militant Organizations project. 

CISAC Co-Director Amy Zegart writes in The American Interest that a strong and rising China, as well as a weak an unstable one, should concern the United States. But perhaps most troubling is the uncertainty about which scenario will eventually play out, and Washington’s strategic orientation toward Europe and the Middle East.

CISAC Co-Director Amy Zegart writes in The American Interest that the United States should be concerned about both a strong and rising China, as well as a weak and unstable one. But perhaps most troubling of all, she writes, is the uncertainty about which scenario will eventually play out – and Washington’s strategic orientation toward Europe and the Middle East.

“Today opinions range between nervous hope that everything will turn out all right to outright fear that things will be worse than we can possibly imagine,” she says. “Part of the fear stems from the fact that that the U.S. and China are both literally and figuratively worlds apart, with vastly different political and cultural histories.”

Regardless of these vast differences and uncertainties in China, Zegart argues, Asia will be the most important strategic region for American national security in the 21^st century.

The United States and Russia should keep working together to stop the spread of nuclear weapons even while disagreeing on issues like Ukraine, Stanford scholars say.

In a recent article in the Bulletin of the Atomic Scientists, Professor Siegfried Hecker and researcher Peter Davis advocate continued U.S.-Russia collaboration on nuclear weapon safety and security.

"The Ukraine crisis has exacerbated what had already become a strained nuclear relationship," Hecker said in an interview. "As one of our Russian colleagues told us, nuclear issues are global and accidents or mishaps in one region can affect the entire world."

Hecker is a professor in the Department of Management Science and Engineering and a senior fellow at CISAC and the Freeman Spogli Institute for International Studies. Over the past 20-plus years, he has worked with Russian scientists to help stop nuclear proliferation. He and Davis returned from a trip this spring to Russia, where they met with nuclear scientists.

"We agreed that we have made a lot of progress working together over the past 20-plus years, but that we are not done," they wrote in the journal essay.

Hecker and Davis described Moscow as a reluctant partner in talks on nuclear proliferation. As for the United States, it actually backed away from cooperation first. A House of Representatives committee recently approved legislation that would put nuclear security cooperation with Russia on hold. And though the White House has opposed this, the Energy Department has issued its own restrictions on scientific interchanges as part of the U.S. sanctions regime against Russia.

But, Hecker said, "Cooperation is needed to deal with some of the lingering nuclear safety and security issues in Russia and the rest of the world, with the threats of nuclear smuggling and nuclear terrorism, and to limit the spread of nuclear weapons."

Washington does not have to choose between the two. It still can pressure Moscow on Ukraine while cooperating on nuclear issues, Hecker and Davis wrote.

They called for further nuclear arms reductions between the two countries, rather than a resumption of the nuclear arms race that took place in the mid-20th century.

Changing relationship

Hecker and Davis acknowledged that the U.S.-Russian relationship overall is changing.

"We realize … that the nature of nuclear cooperation must change to reflect Russia's economic recovery and its political evolution over the past two decades," they wrote.

For example, due to the strained relationship, nuclear proliferation programs must change from U.S.-directed activities to more jointly sponsored collaborations that serve both countries' interests.

As they noted, one huge problem is that Russia still has no inventory or record of all the nuclear materials the Soviet Union produced – or where those materials might be today.

"Moreover, it has shown no interest in trying to discover just how much material is unaccounted for. Our Russian colleagues voice concern that progress on nuclear security in their country will not be sustained once American cooperation is terminated," Hecker and Davis said.

Iran is a flashpoint

America needs Russia to help in its effort to stop Iran from building a nuclear weapon, Hecker and Davis wrote. Russia is a close ally of Iran: "Much progress has been made toward a negotiated settlement of Iran's nuclear program since President Hassan Rouhani was elected in June, 2013. However, little would have been possible without U.S.-Russia cooperation."

In a June 2 interview in the Tehran Times, Hecker said that the only way forward for Iran's nuclear program is transparency and international cooperation. He suggested that the country follow the South Korean model of peaceful nuclear power.

"In my opinion, South Korea will not move in a direction of developing a nuclear weapon option because it simply has too much to lose commercially. That is the place I would like to see Tehran. In other words, it decides that a nuclear program that benefits its people does not include a nuclear weapons option," he told the interviewer.

Hecker said that it is not in Russia's interest to have nuclear weapons in Iran so close to its border.

"Washington, in turn, needs Moscow, especially if it is to develop more effective measures to prevent proliferation as Russia and other nuclear vendors support nuclear power expansion around the globe," Hecker said.

In February, the Iranian government republished an article by Hecker and Abbas Milani, the director of Iranian Studies at Stanford University. The story ran in Farsi on at least one official website, possibly indicating a genuine internal debate in Tehran on the nuclear subject. Hecker and Milani described such a "peaceful path" in another essay on Iranian nuclear power.

Hecker is working with Russian colleagues to write a book about how Russian and American nuclear scientists joined forces at the end of the Cold War to stymie nuclear risks in Russia.

Media Contact

Siegfried Hecker, Freeman Spogli Institute: (650) 725-6468, shecker@stanford.edu

Clifton B. Parker, Stanford News Service: (650) 725-0224, cbparker@stanford.edu

Lexie Ross, research assistant to CISAC co-director David Relman, accepts the 2014 Director's Cup on behalf of all Stanford athletes. The biology major who graduates later this month is also a member of Stanford's NCAA national champion women's water polo team.

Listen to her short acceptance speech and learn about the Marble Monday tradition established by her team. Read the Stanford Atheltics story about Stanford claming its unprecedented, 20th consecutive award as the top intercollegiate athletic deparmtent in the nation. To honor the success, Stanford elected for the first time to have a student-athlete accept the award on behalf of the university.

U.S. Army Col. Tracy Roou is a senior military fellow at CISAC this year. She is researching security cooperation with challenging governments and preparing for her next assignment in the Office of the Secretary of Defense for Policy. She recently met with former Secretary of Defense Donald Rumsfeld in Washington, D.C., at the headquarters of the Rumsfeld Foundation. They discussed military cooperation as a tool of foreign and defense policy. Here, she shares her thoughts about that meeting and what it meant to her personally as a military officer, as well as to her research.

CISAC has given me the platform to learn from two former U.S. Secretaries of Defense, William J. Perry and Donald Rumsfeld. They happen to be the first and the last secretaries of defense to visit Uzbekistan, where I recently served as defense attaché. Their deep insight into the complicated world of policymaking and the military’s ability to provide capabilities and build relationships as a tool of foreign policy in the former Soviet Union, has added greatly to my understanding of strategic thinking in that part of the world.

The chance to meet with Rumsfeld to discuss military cooperation with challenging governments was an incredible opportunity for my research, but also a true honor and a highlight of my Army career. I was well aware of his reputation as a tough interview. The meeting started with his questions about me, my career and family, and my year at CISAC as a U.S. Army War College Fellow. After I described the depth of expertise at CISAC and Stanford about strategic thinking and military policy, he jokingly asked why I needed to meet with him.

It was clear that Secretary Rumsfeld still keeps an intense battle rhythm. But he was gracious, generous with his time and open to all of my questions. A large bust of Winston Churchill sits in the corner of his conference room, where we met for an hour.

Our session covered many areas, but mostly focused on the former Soviet Union and U.S. military cooperation in that region. In the context of foreign policy with challenging governments, Rumsfeld said: “Linking U.S. diplomacy and the military – even when powers will try to pull them apart – is very important.”

Rumsfeld has been back in the news, with a new documentary about his work and leadership in public service, especially overseeing the Iraq War. Though some are saying he was evasive and impenetrable in the documentary, “The Unknown Known,” I found him to be open and engaging when discussing U.S. foreign policy in the former Soviet States and Russia, which is the focus of my research.

Few remember that as a young U.S. congressman, Rumsfeld was a co-sponsor of the Freedom of Information Act, a landmark tool granting American citizens and reporters the ability to push for government transparency. With his memoir, “Known and Unknown,” his declassified papers give insight on many tough policy decisions with challenges to the to the government, many of which can be found on his website, The Rumsfeld’s Papers.

I learned that the Rumsfeld Foundation helps young leaders in government, business and academia in Central Asia and the Caucuses better understand the concepts of a market economy, a civilian-led military and a free and open government. The foundation helps microfinance organizations working with the world’s poorest people and it grants fellowships to graduate students interested in public service.

“I had spent a lot of time in Central Asian Republics and felt that they did not have a good connection among themselves, nor did they have much connection or awareness of the Unites States,” Rumsfeld says in a video on his foundation website. “So we’ve established a fellowship program to bring over 10 or 12 Central Asian fellows, mid-career people so that they’ll develop relationships and go away with a better understanding of what the United States of America is all about and the kind of opportunities that free systems offer.”

Following our meeting, I was given a tour of foundation offices, which are filled with photographs and presidential letters of various periods in his life in public service, starting as a U.S. Navy pilot. As I left, I noted the two cabinet chairs from his two terms as secretary of defense sitting at the entryway.

I came away from my meeting with Rumsfeld with the realization that our 13^th and 21^st secretary of defense is as nuanced and complex as many of the policy and security issues he tackled in his extraordinary career. At the end of our meeting, he agreed to a photograph together, next to the Churchill bust, as well as another meeting.

In his book, “Rumsfeld’s Rules,” he refers to a quote by Churchill: “The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.”