埃博拉疫情早有预警

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.)

在利比里亚、塞拉利昂和几内亚肆虐的埃博拉疫情已经造成至少1万人死亡。公共卫生机构的惯常思维是，埃博拉病毒的流行是一种新现象，在2013年前没有在非洲西部出现过。（有一个例外，1994年在科特迪瓦出现过一例反常病例，当时一名瑞士的灵长类动物学家在对黑猩猩的尸体进行解剖后感染了病毒。）

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.

这种惯常思维是错误的。我们最近偶然发现了《病毒学年鉴》(Annals of Virology)上的一篇文章，令我们颇为惊讶：“研究结果似乎说明，需要将利比里亚纳入埃博拉病毒流行区。”文章作者强调，将来，“利比里亚卫生机构的医务人员应该意识到，他们可能会遇到活跃病例，因此应该做好准备，避免疾病在院内传播。”

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

让我们感到不安的并非文字本身，而是写下这些文字的时间：这篇论文发表于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.

作为上个月拟定利比里亚后埃博拉时期恢复计划的团队成员，我们系统地查阅了自1976年首次在非洲中部发现这种病毒以来的有关埃博拉疫情监控的文献。我们得知，撰写上述报告的德国病毒学家分析了一些冻存血样——于1978年到1979年间取自433名利比里亚人。他们发现，其中26人（即6%）体内携带埃博拉病毒抗体。

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.

另有三篇发表于1986年的论文显示，在利比里亚西北部，距离该国与塞拉利昂及几内亚边境不远的地方，埃博拉抗体的携带率分别为10.6%、13.4%和14%。上述文章，以及那些发表于20世纪80年代的被遗忘的有关邻国塞拉利昂和几内亚的埃博拉抗体携带率的报告都说明，可能存在一些人所说的“避难所”，也就是持续携带潜藏的埃博拉病毒的人体。

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).

公共卫生领域有一条格言：“通往无所作为的道路上铺满了研究报告。”命运弄人的是，去年确认几内亚第一例检测结果为阳性的埃博拉病例的实验室——巴斯德研究所(Pasteur Institute)——正是《病毒学年鉴》的出版方。然而，这家研究所在2014年4月发表的报告称，“该分区并未被认为是埃博拉病毒的流行区。”

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.

造成这一问题的部分原因在于，这些论文都不是由利比里亚科学家合写的。研究人员采集样本，带回去，然后在欧洲的医学期刊上公布惊人的研究结果。那时候，几乎没有利比亚里人受到实验室或流行病学研究方法的培训。就算到了今天，利比里亚的医生下载一篇论文可能要花费45美元（约合280元人民币），几乎相当于半周的薪水。

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.

这个故事并不罕见。事实上，1986年开展的抗体研究的受试对象是世界上最大的橡胶园的工作人员（当时美国使用的40%的乳胶产自该橡胶园）。在最近这轮埃博拉疫情爆发期间，从马及比县的那些诊所——橡胶手套及其他防护装备的缺乏导致护士死亡后，诊所被关闭——看去，橡胶树不断延伸，一望无际。我们在利比里亚的这个地区获取重要医疗信息的方式，与西方国家获取他们所需的橡胶的方式别无二致。

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.

塞拉利昂和利比里亚近期进行的内战使得医护人员难以确认疫情的爆发。这两个国家的公共卫生实验室均未良好运转；拖了好几个月的时间埃博拉病毒才被确定为罪魁祸首。因此，该地区本已稀缺的医生和护士无法进行有效的医疗服务。

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.

在迄今为止所有被确认的埃博拉疫情中，这种疾病都主要是在护理患者或掩埋尸体的过程中传播的。所以，1982年的论文提醒人们注意医院和诊所内部的感染。情况正如德国科学家所预测的那样：利比里亚捉襟见肘的卫生设施成为了软肋。埃博拉沿着它们向全国乃至更广阔的地区扩散。

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.

据我们所知，利比里亚卫生部在职的高级官员中，没人听说过前述抗体研究的发现。在利比里亚勇敢地支持抗击埃博拉活动的国际组织，包括联合国机构和外国医疗团队，它们的高层官员也没听说过。

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.

如果有人撰写这种传染病的历史，我们缺乏准备的无数个地方都会被计入其中，从盖凯杜和蒙罗维亚，到日内瓦和达拉斯。但我们谁都不能凭良心说没有过警告。

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.

埃博拉病毒早就来到了这里。人手不足、设备匮乏的医院和诊所肯定会加剧，而非阻止一场大规模的疫情爆发。主要受害者将包括医护专业人士。如果那些病毒学家的发现，能和训练利比里亚人开展研究、辨认并阻止疫情、提供优质医疗护理的长期行动结合在一起，结果或许会有所不同。

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.

我们都有朋友或同事在这场疫情中病倒。但被传染者的命运却反映出了奇特的悬殊差异。10名感染了埃博拉的美国人，全都被用飞机送到了美国的专科医院，那里有极好的临床护理。其中九人已康复，我们祈祷剩下那名患者也能尽快地完全康复。而上月，利比里亚城市地区有记载的最后一次大规模连锁传染刚刚开始，其中一个集体病例中的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.

这场骇人的卫生危机的持久影响之一，是必须为全球卫生救护建立新的架构，着重建设当地有效应对这类危机的能力。在预防埃博拉等威胁，以及预防失败后提供的医护服务的质量方面，公平必须成为一个不可或缺的目标。只有这样，我们才能丢弃国际卫生的橡胶种植园模式，利用必须与这些努力联系在一起的相关科学研究。