This extract was compiled from the Brenthurst Foundation Special Report 11,312 Unnecessary Ebola-related Deaths: Building Citizen Trust in Health Systems (by Helen Epstein with contributions by Janusz Paweska and Wilmot James), Johannesburg, 13 June 2016.
Why are we not better at preventing these epidemics? Why do we lurch from crisis to crisis and lapse into complacency in between?
Based on the proceedings of a conference of public health and security experts held at the Carnegie Council on Ethics in International Affairs (and supported by Bard College, the Ford Foundation and Brenthurst Foundation) on 31 March 2016 in New York City, Helen Epstein authored the Brenthurst Foundation Special Report titled 11,312 Unnecessary Ebola-related Deaths: Building Citizen Trust in Health Systems which was released on Monday 13 June 2016.
Epstein reviews what went wrong and what went right with the responses to the epidemic. In summary form, she notes that the WHO inexplicably declared a “health threat of international concern” very late in the day and that three of the most severely affected countries may have had economic interests in resisting the declaration. Local health systems were in a dreadful state and emergency response health professionals were thin on the ground. Local financial systems could not process aid, philanthropic and private donations rapidly, sometimes not at all, and local communities were suspicious of their governments’ intentions and responded to health warnings too late.
Problems continued after international assistance arrived. The Liberian government replaced an ineffective involuntary quarantine with a proper Incident Management System (IMS) that focused on 5 tasks: (1) providing safe transport, isolation, and treatment of patients with suspected disease followed by laboratory testing and contact tracing; (2) ensuring safe burials; (3) promoting infection control throughout the health care system; (4) providing clear and effective communication to affected communities and the general population; and (5) strengthening the national incident management structure to support the response.
But electrical outages and other infrastructure problems caused equipment to malfunction. Particularly vulnerable were the diagnostic machines, which overheated due to high ambient temperature and problems with the power supply. Dysfunctional air-conditioning units made work in the bio-containment chamber and other lab areas highly uncomfortable, especially for those wearing full gowns, which posed the threat of human errors and safety risks. Other potential risks to laboratory staff included unsafe packaging and inappropriate primary containers for blood and buccal swabs from suspected Ebola patients. Labs had to be closed several times for technical reasons.
What is to be done?
First, the global community has redoubled efforts to develop an Ebola vaccine. A vaccine had been in the works for over a decade before the outbreak, but lack of funding and a general assumption that outbreaks were small and easily contained meant progress had stalled. Since then, numerous clinical trials have been initiated or completed, and a phase 3 trial has demonstrated efficacy for Merck’s candidate Ebola vaccine known as rVSV-ZEBOV.
The Global Alliance for Vaccines and Immunisation (Gavi) has agreed to stockpile 300,000 doses of pre-licensed rVSV-ZEBOV and Merck has submitted an application to the WHO for use in emergencies and will apply for full licensure soon. Johnson & Johnson and GlaxoSmithKline also have promising Ebola candidate vaccines in clinical trials.
But vaccines alone won’t eliminate the Ebola threat – let alone the threat of other epidemics. More data is needed on the safety and efficacy of these vaccines; the regulatory processes in African countries needs to be expedited, and African public health leaders must plan for how the vaccines will be used. All of these activities, along with the refinement of the vaccine itself need to be prioritised, and it is hoped the international community won’t drop the ball just because Ebola no longer seems as scary as it was in 2014.
Second, a greater emphasis on epidemic preparedness in Africa in general is needed. Dealing with future epidemic crises will require an alert, capable and adaptable disease control and prevention system. In February 2014, President Barack Obama established the Global Health Security Agenda (GHSA) that aims to prevent avoidable epidemics – whether naturally occurring or caused by intentional or accidental release of micro-organisms, detect threats early, and respond rapidly. The GHSA is a collaboration of more than 50 nations and international organisations to reduce biological threats worldwide.
In the US, the Department of Defence (DOD) leads the effort. (The department’s) public health and humanitarian assistance programmes, including various labs and bio-surveillance programmes, but through the GHSA … will be more co-ordinated. In Liberia, DOD was able to respond quickly, provided engineering support, medical training and lab assistance. It also built 10 additional Ebola Treatment Units, as well as a mobile medical facility specifically to treat healthcare workers. The Department’s logistics hub in Senegal helped the Liberian government, other US agencies and the international donor community to mobilise their own resources. Among DOD’s most important contributions was building the confidence of the Liberian government (which) was struggling to recruit health workers, many of whom were frightened of contracting the disease.
Now that the epidemic has subsided, DOD is working to strengthen national bio-surveillance and disaster management in West Africa and beyond through its Co-operative Biological Engagement Programme, or CBEP. DOD’s Chemical and Biological Defence Programme is also working with the National Institute of Health and CDC on Ebola vaccine and therapeutics trials in West Africa. And the Africa Command’s African Partner Outbreak Response Alliance programme, or APORA, is training military medical leaders in 11 West African nations in leadership, transparent communication, defining military roles, identifying regional capabilities and addressing gaps. Africa Command’s West African Disaster Preparedness Initiative (WADPI) recently trained approximately 800 African military health workers in the development of Ebola preparedness and response plans; chemical, biological, radiological, and nuclear incident prevention and management; hazardous materials decontamination and crisis communication. Plans are in the works for more such courses across the African continent.
The involvement of DOD in beating Ebola in West Africa marked a change in the discourse on health and security. In security circles there is talk of the Pentagon’s increasing involvement in health, and in the increasing involvement of health organisations like CDC in security affairs. Because defence establishments tend to have higher budgets, the former sees their new role as an opportunity, whereas some in the health community see the encroachment of security organisations on their turf as a threat. No doubt some balance will emerge, but this is new territory for both disciplines and professions. Diplomats must recognise that infectious disease outbreaks are increasingly seen as security issues that call for more than humanitarian charity. At the same time, we must be worry about military support, necessary and welcome though it was in West Africa. As the US learnt when it attempted to use soldiers to deliver food aid in Somalia in the early 1990s, retooling armies for humanitarian purposes carries grave risks if troops are seen to be taking sides in local conflicts. Human rights are also too easily suspended in settings where they never had much force in the first place.
Under the GHSA, the African Union has since signed a Memorandum of Agreement (MOU) with the US Government to establish the African Centres for Disease Control and Prevention (A-CDC) which will focus on surveillance, emergency preparedness and response and strengthening International Health Regulations which govern reporting, transport, trade and communications in the event of a health emergency. The A-CDC will be supported by Regional Co-ordinating Centres that will be public health institutes in their own right.
Third, donor governments have spent billions on programmes to control malaria, HIV, tuberculosis and other diseases, but relatively little on supporting the health care systems – the doctors and other personnel, the supply chains for drugs and supplies, the infrastructure and equipment, the information systems and the governance structure – that perform the daily work of keeping populations healthy. For years, public health experts have decried the concentration of resources on a small set of killer diseases, sometimes to the detriment of the health systems that would make programmes to fight those diseases sustainable. But health systems don’t only depend on donor largesse. They also require political commitment from national leaders and the communities they govern.
The neglect of health systems, especially in Africa, has partly resulted from the retreat from the public sector that followed the end of the Cold War. Only when disaster strikes does the international community recognise how important a well-functioning public sector is.
In Liberia, the Health Ministry did warn locals early on about the dangers of Ebola, and urged people to report suspected cases. But many people, perceiving the government of neglecting their needs and engaging in corruption, did not heed this advice. A well functioning and robust health system that met local citizens’ needs before the crisis hit would have inspired greater trust and effected faster behaviour change in response to warnings; local nurses would have been adequately paid, and would not have needed to moonlight to earn extra money, which is how many became infected; and hospitals and clinics would have been adequately staffed and equipped to handle the early cases when they were few in number before the epidemic spiraled out of control.
Regrettably, in the war between the affected countries’ healthcare systems and Ebola, the virus won. In Liberia, for example, nurses, doctors and other health personnel were approximately 30 times more likely to be infected with Ebola than the general population. The country’s health system, already unstaffed, lost hundreds of workers, with grave consequences for the future, even though Ebola itself has been all but eradicated. This Ebola-related shock to the healthcare system is predicted to result in a 111% increase in maternal mortality to 1,347 deaths per 100,000 live births – the second highest in the world, after Afghanistan. The aftershocks of Ebola are also projected to increase infant mortality by 20% (from 54 to 64 per 1,000 live births), and under-five mortality by 28% (from 71 to 91 per 1,000 live births).
A strong, resilient healthcare system that could deal with crises like Ebola must have a strategic health information system and surveillance networks that monitor its status and impending health threats; address a broad range of health challenges, enhancing public trust in normal times so that new threats could be recognised and addressed more rapidly, in co-operation with the population; and contain novel health threats while delivering core health services, so as not to propagate instability throughout the system.
To operate effectively will require excess capacity that could be mobilised quickly in times of crisis. This in turn will require long-term investments in infrastructure and health worker training, as well as capability for emergency measures such as isolation units.
Truly resilient health systems would also bring together diverse actors, ideas, and groups to share information and co-ordinate activities under the guidance of a designated focal point that would also handle the crucial and delicate task of communication with the public. Such a system would be constantly adapting to long-term epidemiological and demographic change. When health crises did occur, such adaptability would enable lessons to be learnt quickly, so that short-term performance is improved. Too often the humanitarian response to health emergencies has a short half-life, leaving little benefit for the larger health system after the crisis. The ability to adapt depends upon strong and flexible leadership, a good data system and the capacity to use it, as well as responsive bureaucracies.
In Liberia, this will mean hiring and training thousands of new, properly remunerated health workers to be deployed around the country, converting Ebola Treatment Units and Community Care Centres into health facilities and improving the nation’s health infrastructure generally, including systems for maintenance, transportation and referral and construction of new health facilities. Liberia will also need a National Public Health Institute, an improved surveillance and response system and public health laboratories.
Important as these initiatives are, even more work is needed at the higher level of governance, democracy and human rights in Africa. We still don’t know what made the West African Ebola epidemic different from the previous 24 Ebola epidemics, all of which occurred in African countries lacking a network of CDC Global Health Security institutes, and many of which had even worse healthcare systems than Liberia’s, Sierra Leone’s or Guinea’s in 2013.
However, some experts have pointed to particularly poor relations between the governments of the three countries and their people. While popular discontent with national leaders exists in many African countries, including those that have been better able to cope with Ebola in the past, Guinea, Sierra Leone and Liberia all have recent histories of bitter civil conflict, and allegations of high-level corruption appear almost daily in the press. This has reawakened popular suspicion concerning the integrity of the leaders of these countries and fuelled the spread of rumours through the social networks upon which most people typically reply for news and information.
It was this particular political mood that some maintain contributed to the particular catastrophic situation in West Africa by delaying behaviour change. If so, the implications of this reality are subtle. It doesn’t mean that all countries with unpopular governments are vulnerable to outbreaks of Ebola. Indeed, it is very unlikely that, if Ebola were to break out again in West Africa, people would respond as they did in 2013. But it does mean that in addition to applying global measures such as a more robust emergency preparedness system for Africa and improved health systems, more care must be taken to understand the particular political climate of each country, and if possible, implement programmes to foster democracy, human rights, impartial justice and intolerance of corruption, and inspire greater trust in government.
Such changes will not occur overnight, but the international donors can help accelerate progress by standing with those fighting against corruption and defending human rights, especially in those countries that rely on them for foreign aid. DM
Photo: A Liberian man walks past an Ebola sensitisation mural in Monrovia, Liberia 06 October 2014. EPA/AHMED JALLANZO
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