(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.

In the late 19th and early 20th centuries, an "open borders" United States absorbed millions of European immigrants in one of the largest mass migrations ever. New research by Stanford economist Ran Abramitzky challenges the perception that immigrants lagged behind native-born Americans in job pay and career growth.
 

BY CLIFTON B. PARKER

European immigrants to America during the country's largest migration wave in the late 19th and early 20th centuries had earnings comparable to native-born Americans, contrary to the popular perception, according to new Stanford research.

"Our paper challenges conventional wisdom and prior research about immigrant assimilation during this period," said Ran Abramitzky, an associate professor of economics at Stanford, faculty affiliate of The Europe Center and author of the research paper in the Journal of Political Economy.

New research challenges conventional wisdom about immigrant assimilation during the bygone era of open borders and mass migration. Photo Credit: Lewis Hine/Library of Congress

New research challenges conventional wisdom about immigrant assimilation during the bygone era of open borders and mass migration.

Abramitzky and his colleagues found the average immigrant in that period did not face a substantial "earnings penalty" – lower pay than native-born workers – upon their arrival.

"The initial earnings penalty is overstated," said Abramitzky.

He said the conventional view is that the average European immigrants held substantially lower-paying jobs than native-born Americans upon first arrival and caught up with natives' earnings after spending some time in the United States. But that perception does not hold up to the facts, he said.

Abramitzky's co-authors include Leah Platt Boustan from the University of California, Los Angeles, and Katherine Eriksson from California Polytechnic State University.

The researchers examined records on 21,000 natives and immigrants from 16 European countries in U.S. Census Bureau data from 1900 to 1910 to 1920.

"Even when U.S. borders were open, the average immigrant who ended up settling in the United States over the long term held occupations that commanded pay similar to that of U.S. natives upon first arrival," Abramitzky said.

In that bygone era of "open borders," Abramitzky said, native-born Americans were concerned that immigrants were not assimilating properly into society – yet, on the whole, this concern appears to be unfounded. "Such concerns are echoed in today's debate over immigration policy," he added.

At the same time, Abramitzky said that immigrants from poorer countries started out with lower paid occupations relative to natives and did not manage to close this gap over time.

"This pattern casts doubt on the conventional view that, in the past, immigrants who arrived with few skills were able to invest in themselves and succeed in the U.S. economy within a single generation," Abramitzky and his colleagues wrote.

Age of migration

America took in more than 30 million immigrants during the Age of Mass Migration (1850-1913), a period when the country had open borders. By 1910, 22 percent of the U.S. labor force – and 38 percent of workers in non-southern cities – was foreign-born (compared with 17 percent today).

As the research showed, immigrants then were more likely than natives to settle in states with a high-paying mix of occupations. Location choice was an important strategy they used to achieve occupational parity with native-born Americans.

"This Age of Mass Migration not only is of interest in itself, as one of the largest migration waves in modern history, but also is informative about the process of immigrant assimilation in a world without migration restrictions," Abramitzky said.

Over time, many of the immigrants came from the poorer regions of southern and eastern Europe.

Abramitzky pointed out that native-born Americans in the late 19th and early 20th centuries were concerned about poverty in immigrant neighborhoods and low levels of education among children, many of whom left school early to work in industry.

Consequently, American political progressives championed a series of reforms, including U.S. child labor laws and compulsory schooling requirements.

Still, some natives believed that new arrivals would never fit into American society. And so, in 1924, Congress set a strict quota of 150,000 immigrant arrivals per year, with more slots allocated to immigrants from northern and western European countries than those from southern and eastern Europe.

But those early-20th-century fears of unassimilated immigrants were baseless, according to Abramitzky.

"Our results indicate that these concerns were unfounded: The average long-term immigrants in this era arrived with skills similar to those of natives and experienced identical rates of occupational upgrading over their life cycle," he wrote.

How does this lesson apply to today's immigration policy discussion? Should the numbers of immigrants and their countries of origin be limited and those with higher skills be given more entry slots?

Abramitzky said stereotyping immigrants has affected the political nature of the contemporary debate.

"These successful outcomes suggest that migration restrictions are not always necessary to ensure strong migrants' performance in the labor market," he said.

China’s maritime pursuits in the East and South China Seas and President Xi Jinping’s announcement of a new Asian security concept have gathered considerable attention in recent months, leading American analysts to critically examine the strategic value of the U.S.-China alliance. Is the United States in a position where the costs outweigh the gains?

In an article by the Global Times, Thomas Fingar, the Oksenberg-Rohlen Distinguished Fellow at Freeman Spogli Institute for International Studies, responds to questions about U.S. alliance management, discussing the origin and United States’ interests behind its relationship with China.

Over the past few decades, when developing its alliance network, did the United States have a clear and comprehensive mission? Does the United States have any concerns over responsibilities or risks that alliances may generate?

The principal purposes of U.S. alliances are deterrence and collective self-defense, as they were when most were established after World War II and the Korean War. They also contribute to stability and security by requiring transparency and confidence-building among members of the alliances, and to limiting the spread of nuclear weapons by reducing vulnerability to conventional attack and enhancing security through extended deterrence. The United States bears a disproportionate share of the costs associated with its collective security and stability in the global order to justify the costs and risks involved.

Compared to America’s transformation (from upholding isolationism to building a formidable alliance system), how should we evaluate China’s non-aligned strategic partnership policies?

The alliances in which the United States participates are one part of the global system that has contributed to the unprecedented peace and prosperity that we­–the world–have today. Other elements include the United Nations, the World Trade Organization and the Treaty on the Non-Proliferation of Nuclear Weapons (NPT) and other control regimes, and all other institutions in the liberal, open and rule-based system developed by the “Free World” during the Cold War and transformed into a global system in the years since 1991. I would describe the difference between the U.S. vision of relationships among states and China’s non-aligned strategic partnerships as the difference between obligations and expectations within a family and those among colleagues and friends.

The above text is reposted with permission from the Global Times. A version of this text ran as an excerpt written in the Chinese language, which can be accessed here.

Standing upright, then slowly clasping both hands and drawing them up to shoulder height, Kevin Won next kneeled on the floor. Bending forward, he bowed his head toward his silent audience.

Won’s demonstration of the Sebae, a traditional bow performed for elders during South Korea’s lunar new year, may have seemed out of place during a warm, sunny day on Stanford’s campus. But the intricate display was in perfect context during a cross-cultural conference for secondary school teachers from the United States to learn about Korean society, as well as providing a forum to directly engage with Korean teachers and students.

Despite Korea’s growing relevance worldwide, there has been little development of Korean studies below university-level, leaving a vacuum for misunderstanding, including stereotypes, to form at an early age. The conference – now in its third year – aims to shift this reality.

For three days in late July, twenty-four teachers from across America participated in a variety of activities and seminars intended to give them new perspectives and teaching strategies.

Gary Mukai, director of SPICE, welcomes participants.

The conference was co-organized by the Korean Studies Program (KSP) at the Shorenstein Asia-Pacific Research Center (APARC) and the Stanford Program on International and Cross-Cultural Education (SPICE), both in the Freeman Spogli Institute for International Studies. The two groups work together to convert research on Asia into material that is suitable for younger students.

“Our mission is to make Stanford scholarship accessible to all,” said SPICE director Gary Mukai, who has been with SPICE for over 26 years. SPICE and Shorenstein APARC, under the direction of Gi-Wook Shin, a professor of sociology, have coordinated curriculum development for key projects on Korean history and perceptions of wartime history in Northeast Asia. 

A cadre of scholars and practitioners from Stanford and other universities and organizations offered talking points and actionable ideas for instruction. Among them was David Straub, the associate director of KSP, who lived in Korea for eight years as a senior U.S. diplomat. 

The United States and Korea have a very close relationship, but lack equal dialogue, explained Straub. America is still “number one” for Koreans, as such, Koreans know more about the United States than Americans know about Korea. This imbalance can lead to misunderstanding. Straub took the teachers through the recent history of U.S.-Korea relations, which is often narrowed to the context of the Korean War. 

Two teachers work together on a curriculum exercise comparing political cartoons.

Since 1945, South Korea overcame extreme poverty and effectively established a democratic society, a transition that was uncommonly quick and relatively smooth, and one that now supports a global powerhouse of trade and culture.

Throughout the conference, SPICE staff demonstrated ways for educators to bring Korea, and greater Northeast Asia, into their classrooms. They gave the teachers a chance to practice student lessons. In one exercise, the teachers deciphered sets of political cartoons and compared news headlines from Japan, China and Korea, using material from SPICE instructional materials. 

Each activity was carefully prepared to guide teachers to examine their own preconceptions. Greater cultural awareness can come when both teachers and students are “more critical consumers of information,” said Rylan Sekiguchi, a SPICE curriculum specialist, in his presentation.

While curriculum is important, establishing rapport seemed an essential part of the conference. A key component to a successful cross-cultural workshop is creating a community, “and looking around the room, I think we’ve done that here,” said Mukai, in an address to participants at a reception.

Also in attendance was a delegation of 11 Korean teachers and students from Hana Academy Seoul, a private high school in Korea with a unique structure and curriculum. The school’s name comes from the Hana Financial Group, which established the school in 2010, and is also the supporter of the Stanford conference. The Korean students gave presentations that covered a wide range of topics, including an analysis of teenage life and the public education system in Korea.

(Left to right): Students Nayoon Kim, Kevin Won, Seung-hyun Kim and Sarah Chey presented on Korean culture and society.

Six students from Hana Academy Seoul performed Samulnori, one of Korea’s most popular genres of music. The musical group, known as Da-Seu-Reum, showcased their talents while wearing traditional, brightly colored outfits. Afterward, the students became the teachers – when they invited the American teachers to come up and play the instruments. 

Three students were also honored for their research and participation in the Sejong Korean Scholars Program (SKSP), a distance-learning opportunity for 25 high school students across the United States to engage in an intensive study of Korea for a semester. SKSP is dually led by SPICE and Shorenstein APARC, and sponsored by the Korea Foundation.

“I feel very honored to attend, and have learned a lot about U.S.-Korea relations,” said Won, who is from Korea and attends The Taft School in Connecticut. “But mostly, I am just glad my presentation went well.” 

Won, a relative newcomer to public speaking, explained Korean holidays and how to perform a traditional bow. After demonstrating the correct posture and sequence to the audience, he asked for, and easily received, teacher participation. 

Kelly McKee, a teacher from Illinois, tries playing the Buk, a drum used in Samulnori, with direction from a Hana Academy Seoul student.

“From the impeccably credentialed presenters to the wonderful pacing of the presentations, I thoroughly enjoyed my three days here,” said Eladio “Lalo” Martin, a humanities teacher at Cesar Chavez Middle School in Watsonville.

“This conference, by far, is the best I’ve ever attended,” he added. Martin has been teaching for more than 18 years, and says he looks forward to returning to Stanford.

“The speakers have been fantastic,” said Kelly McKee, a social studies teacher. “They’ve shared in-depth expertise on topics like Korea’s special economic zones and North Korea – areas you can’t find in professional development workshops elsewhere.”

McKee, who works at Lake Forest High School in Illinois and is a leader of a student exchange program to Shanghai, says she plans to supplement her Korea unit with what she has learned. As the availability of Asian studies curriculum continues to grow, she says the future certainly looks bright.