We produce and consume disasters whether we
intend to or not. But it's generally not the same groups of people that causing disasters and
those sacrificing. Disasters,
in all their grief, have a capacity to reveal inequalities and injustices of the world (eg.
Katrina did in the US and the earth
quake in Haiti). While we wait for the little Ebola virus to give in
under the pressure from the international community let us see if this disaster
has unearthed hidden disparities in health, ugly faces of the international
community or new lessons for global health that we need to address.
In her speech at the 136th executive board meeting of the
WHO in 2015, President Margaret
Chan said: "Well-functioning health
systems holds together the community
and protects against crises", and noted that
universal and equal access to health
care reduce the effect of social
determinants on health. The current Ebola epidemic
has given its own view on why we should
invest in health. As many other agencies DANIDA,
the Danish governmental development organization does not invest directly in overall
capacity building of health care in low-income countries as a means to ensure development.
But maybe DANIDA, and many others, should consider changing that
position now where the Ebola mist is disappearing. The Ebola
epidemic has given us a rare insight into the devastating effects of
lack of investment in health, education, logistics and research. We were globally stunned when a tiny virus with 7 genes met fertile ground in a country the majority of the world’s population can’t
place on a world map even today. Just as stunned
as esquimoes were when they met the measles virus for the first time in 1951 (after
several previous near-epidemics, that were stopped) at a dancing party in Nuuk or
as the haitians when they met cholera bacteria after the earth quake through
the otherwise friendly UN peace keeping forces.
The ugly side of Global
Health
It's not Ebola, which has
killed so many people to death - it is a cocktail of bad leadership, the absence
of timely international care
unfortunate global mechanisms and the pre-existing failure of health systems
in the weak states where the epidemic spread. And neither should be a
surprise to the global players and
donors. They have known about the
weaknesses of health care in the Ebola-affected
countries for decades, but they have not shown interest in any of the many reports and scientific studies that have documented the
near-collapse of some West African health systems.
The Ebola epidemic started in 2013 in an
area of Guinea-Conakry, previously occupied
by rebels from neighboring Congo, where the forest is cut down and
replaced by endless rows of palm
oil plantations. The military
had, shortly before the epidemic index case, shown some aggressive behavior in the area and there were ethnic disputes involved. A parallel, internationally funded system of
Community Watch Committees (Comités
de Veille, CWC) should
in principle report illnesses and deaths, but members
of the councils were appointed for political reasons and payments were
irregular so the reporting was
sporadic. And that turned out to be crucial in the
beginning of the Ebola epidemic. Parallel reporting systems with external funding will live
their own life outside public health care. The
government enjoyed very little
support in the population, and
the whole effort against Ebola was organized
with a top-down militaristic flavor and without attempts
of social or cultural adjustments
of health messages or funeral rituals, which further increased the population's
reluctance towards the Ebola campaign. Schools and health
centers in the area were not operating, there were no doctors
in the area and that is apparently still
the situation today 1½ years later (KILDE). Peter Piotr’s encounter with the world’s
first Ebola outbreak in 1974 was exactly the same as the present Guiné outbreak.
Some lessons are apparently more difficult to learn and it is
precisely both the problem and
the solution to global health challenges.
Global health has an
ugly side that we need to expose
and deal with.
Cutting down trees and the easy access to bush-meat snacks in
Guinea and Sierra-Leone have been blamed for the outbreak. Sierra Leone’s
forests are forecasted to be completely wiped out by 2018. Especially in the
part of Guinea where the first case in the outbreak occurred seems interesting
from an environmental point of view. Forestation and subsequent demographic consequences
for the population and the restriction of border traffic that affected mainly
female traders has led to a lively ever changing community and it is thought
that fruit bats, thought to be the reservoir of ebola virus have had to find
new habitats thereby changing the interaction with humans. Mining has also had
an effect on changing environments that have forced bats to adapt to new
environments closer to humans. Climate change in the area has led to disappearance of some of the fruits the
bats thrive on.
The epidemic doesn’t
unfold in a tropical distant vacuum. A survey in 4 remote counties in Liberia in August-September 2014 found that 3 of
6 doctors had fled because of the epidemic and most nurses didn’t show up for
work. In 3 counties nurses hadn’t been paid their salaries for three months. Rubber
gloves and sterile gloves, and obstetric equipment was missing at all
facilities. It was not possible to wash hands. Two centers had rudimentary
isolation facilities without access to water. Only 6 of 19 facilities in one
county has access to mobile phone communication .
The Ebola epidemic has been described as a stew of
fear. On the one hand the
Western world fears the strange
and dangerous diseases that come from the tropics where bloody tears and dreadful pains accompanied by extreme fevers mixed with
Western fear of the mysterious and dangerous tropical Africa, with blood sucking giant bats flying around
at night and bush meat sold on any
corner. On the other hand Liberians
and Guineans can’t help doubting
and fearing what lies behind the sudden tremendous interest white people are have in their well-being ...
.where were they,
their interest and charity before Ebola started? It gives a lethal unpredictable stew of fear where the
spices are distrust and fear..
Many other factors have, until recently, contributed to
the lack of outbreak control. The Ebola
epidemic showed the
impact global mechanisms can have on the local level. The International Monetary Fund's demands for public spending cuts and user fees in health
care and education in conjunction
with an uncontrolled increasing privatization
of health care has led to the decay
of public health centers and
hospitals that lack public
confidence. Lack of wages for doctors and nurses, the financial crisis and rising food prices
have pushed public officials to have more jobs and
to charge unofficial fees for services that should be free. To the majority of doctors' career opportunities and access to training / specialization is
non-existing. Collapsed public universities without associate professors, high
tuition fees and privatization of university education have contributed to reduced health research capacity.
Swing
door poverty
Recently, an independent think tank that studies corruption demonstrated that corruption
in public administration has been, if not the cause itself, so at
least a significant part of the blame for the non-functioning
healthcare systems in the Ebola struck countries.
Paul Farmer, physician,
anthropologist, and expert in Global Health has
recently said that one of the
reasons that the Ebola-affected countries have been
let down is that
we ourselves, in high-income
countries, are the
enemy. We think in a uniform set of explanations and our solutions are not thought
through, while most of the funds allocated
to Ebola eradication stay in high-income countries as taxes and administrative fees for universities and
aid organizations. A recent UN survey estimated that only
40 % of Ebola funds end in the affected African countries. Farmer called it the epidemic that never should have happened and
that it was not a
natural disaster but "the terror of poverty".. Poverty resulting from disease is a huge global problem, and 200,000 people become incurably poor each year due to
health problems and it is believed that over 1 billion of
the world's population is moving into swing door poverty
due to disease (Chronic Poverty Report 2014: One trillion at risk from 'revolving
doors' of poverty). The current
ebola epidemic has been followed by an epidemic of orphaned children and
irreversible poverty.
IMF role disputed
The International Monetary Fund (IMF) has
also been accused of causing the miserable state of health care in Sub-Saharan
Africa. A new study from 2015 shows
that IMF in
sub-Saharan Africa has been instrumental in
governments investing more in health
than previously. But the clear conclusion is that it is taking place in countries that spent little or nothing on health
care and the little increase caused by IMF has therefore not had
the effect that was intended or even wished. The picure
is not clear and there is a hefty
ongoing debate about the IMF role
among academics.
Many have tried to excuse the situation in Sierra
Leone with a protracted civil war. The focus, however, has in the past six years has been more on why
the Ebola-affected countries have not invested more in health care. The explanation is, apart from those already mentioned, that although the economy in some countries actually increased by 6-8%, for example Sierra Leone only succeeded to collect 11% of public expenditure through taxes. Large international companies lured by low
corporate tax subsequently organizes
tax evasion in great style. Sierra Leone spends about 25 million US dollars
a year on health care,
but provides 10 times
as much: 245 million US dollars, in tax
exemptions for
international companies. And
now firms are reluctant to come back - the
basic economics, agriculture and health care
system is broken.
For comparison it may be mentioned that the International Monetary union has determined that the three Ebola affected countries together have lost over 2
billion US dollars in
total revenue until now due to Ebola
epidemic.
The way the Ebola epidemic spread has contributed to a second and more terrifying variegated aspect of what
even low-income
countries must
prepare for. Over 65%
of the Earth's
population now lives in
cities and most live in disorganized slums without administration, sanitation, health care or education.
The huge population density makes suburban
slum areas an epidemic
paradise, no bar for Dengue and Chikungunya viruses
requiring mosquitoes for transmission,
but also for more wild and rare viruses such as Ebola, which infects from person to person. There has not previously been Ebola virus in West Africa and not in urban
areas as was the case
with the current epidemic. The epidemic spread rapidly across borders and from remote rural areas to large
urban slum-like suburbs where there is a normal health with built-in reporting of cases of disease. West African health care was prepared for neither the pattern nor the speed of the
epidemic. It turned out to
be such a difficult task to put potential patients in quarantine
that governments tried to put the military in action - leading to conflict escalation between population and authorities. Some parts
of Guinea are still struggling with mistrust that Red Cross workers are continuously
confronted with. Several
experts discussed the
Ebola epidemic in a panel on the
recently DAVOS
conference and it was agreed that what surprised the most was how quickly the epidemic spread and how quickly the weak health, and
international aid organizations,
lost their grip on the epidemic because it all went so quickly. Ebola epidemics are always explosive in the beginning, but the speed of this one was difficult to understand because it played out in a different context than we were accustomed to and therefore completely unprepared for. The basic level of quality in health care in the
affected countries was
simply too low – and far away from what WHO and
other organizations anticipated. Even the simplest hygiene routines were not routines and standard fluid
therapy was far from standard. The bad news is that so it was before Ebola epidemic – and it was no secret. Even the health authorities in
Sierra Leone admitted that they thought health
care workers were better informed – but they weren’t
which is a bit late to realize when the epidemic has filled the hospital wards.
The structures that should be in place, healthcare and
government, was largely absent. That was the international organizations not prepared for -
they assumed they were there, and
functional, but they were also wrong on this point.
Looking at accounts from previous Ebola outbreaks it looks as if the global
community and local governments keep repeating the same mistakes and keep
ignoring previous experiences: the 2000 Ebola outbreaks in Gulu developed
within weeks while previous outbreaks had taken months to develop,
some outbreaks spread to towns even then so the present urban epidemic was not
the first time as has been pointed out. The Gulu outbreak was eventually
stopped by: calling in
WHO expert teams immediately instead of waiting for a broader international
appeal to have its (slow) effect, setting up the first field lab, government
involvement and hospital
isolation of cases and suspected cases accompanied by wide spread public
communication that was supported
by public officials and ministers and therefore had more public
strength. None of these well documented experiences were used in
West Africa. Many of the mistakes that
were made during the
earthquake in Haiti have
also been repeated in 2013 in West Africa. And for
that matter the same
kind of mistakes that
were made when
measles sailed to Greenland 60 years ago, or in the early years of the African HIV epidemic when African peacekeeping forces with rocketing HIV prevalences were deployed to rural
Africa border areas, and when an already collapsed health system in Haiti met the Nepalese cholera
that came with the UN forces. Global health has no brain, but it ought perhaps to have one – preferably a huge one with a rapid powerful
executive memory function.
An
epidemic of misunderstanding
It was a delaying factor that unsafe funerals and
a theoretical risk through game meat was given too much attention in the information that was sent out. People were told they
had to go to treatment centers if they were
sick, but at the same time
they were told that there was no treatment and in many places there were no treatment centres contrary
to the official information. In many places patients/suspected cases were rejected for treatment or admittance.
It has been shown that the population in situations of such
ambiguous health information and widespread fear from past experience are used
to take matters into their own hands - whether the international NGOs think it is smart
or not, it's on their terms only right to find their own solutions when public health care
doesn’t. Even MSF regretted that they focused too much on treatment in
the beginning compared to communicating the right information to the
population. Health messages must, as
always, be adjusted to local conditions,
traditions and beliefs. This has now been demonstrated again,
but too late.
A new study in The
Lancet analyzing the epidemic it was
shown that infection associated
with funerals and the spread of infection in hospitals was only a problem at the beginning of the epidemic – as a
whole 82% of infectious cases took place in the community and 72% between family members.
There were a few families who did not cooperate in the beginning of the epidemic, and it sparked the epidemic that health authorities were
unable to control the behaviour of these families. When
control over the situation was gained hospitals
and temporary tent
clinics started to play a key role
in stopping the epidemic: the isolation of suspects
and sick patients works in
any epidemic as it has always done. Small scale studies indicate
that training of local assistants detecting new cases and equipping
them with mobile
phones appears to be effective, together with the temporary
isolation tents. Transparent
body bags for safer funerals has
also been shown to be effective both in
stopping infection chains and in regaining public trust in health care and
authorities. Recent resurgence in Ebola cases in Guinea has been linked to two unsafe
funerals underlining the importance of continuous health information and good
reporting systems on the ground. There are also established open-source data collection platforms
for Ebola control that combine mobile
data with google earth etc. Given the lack of data
that provides an overview this could fill the information gap
in remoter areas.
Even in the US the extent of exploitation
by the media and politicians contributed to mass hysteria and continuing fear.
Communication was so bad that anthropologist dared to call it “an
epidemic of misunderstanding”. It allowed people to fixate on
“projectile vomiting, diarrhea and blood coming out of eyeballs instead of
reality. The Dallas’ outbreak never
reached epidemic proportions, although the media coverage tried to convince the
population
.
New paradigm: prepare for the unexpected
Despite many years of global investment in preparedness against major epidemics, so were the countries most often hotbed of new
epidemics, totally unprepared. They were unprepared for the unexpected. Lessons from previous Ebola epidemics, like in year
2000 in Gulu, Uganda it was a clear lesson that Ebola cases can pop anywhere
and that should be part of the preparedness planning. In Guinea, Sierra
Leone and Liberia they were unable
to change gear because there were too
few doctors, their health management
structures were fragile with poorly trained staff
lacking confidence. Hospitals in Europe have gradually learned to deal with any new outbreaks of disease through good routines, but it does not mean that it is the same experience that is needed, for
example in West Africa's slums or in remote mountain villages.
Nor does it mean that low-income countries, have the resources to
undertake such training of doctors and nurses and/or the
motivation or capacity to prioritize this over childhood vaccines, HIV-treatment, malaria
eradication, tuberculosis case finding or mother-child health. There
is no money for it
all and low income countries do not feel obliged to prioritize
by global interests or standards.
The international players knew this, but it has not
previously led to the establishment of an
international emergency unit to be
engaged in unexpected epidemics
in unexpected areas.
There have been reports of weak health systems in many of the now Ebola affected
countries for nearly 30 years. The
towering infant mortality in
countries has partly
been attributed to poor treatment of
newborns, poor medical
training, miserable hospital
facilities and lack of routines for the most common
diseases such as malaria, diarrhea and pneumonia. Maternal mortality is towering
in the same countries due to inexperienced midwives and even less experienced obstetricians.
Several studies have documented that while sick children are treated initially within the health care
system, they end up dying at home
after discharge from hospital.
There has also
been criticism of the way funds are allocated to health research.
The excessive focus
on specific fashionable or media-friendly
diseases also characterize research priorities has created a global
research funding bias. It's hard to obtain funding for research on equity in health, improvement in existing
health care or to
ensure smarter use of already
known interventions.
Recent reports have shown that many of the rarer of
the world's infectious diseases are
not very attractive to researchers and
research funds. Most of the rarer diseases such as Ebola, has until now only been interesting to
two research foundations and one of
which withdrew from
the field shortly before the Ebola
outbreak. Those who allocate money
for research funds and members of the scientific committees that evaluate research funding
applications have a shared responsibility that neglected
rare but dangerous diseases are not allowed to fly under the research radar.
Dismantled WHO
Therefore, care must be taken not to dismantle the WHO as the
global health board after their somewhat sluggish Ebola efforts. WHO
is part of the United Nations and
is defined by its member countries that
systematically starved WHO budgets. WHO has been
criticized for not taking its global responsibilities seriously, calling
unruly nations for
peace when there
was a need for concerted global action.
WHO was more of a world leader during
the SARS epidemic, but it was
perhaps due to the fact
that the epidemic required China’s
involvement combined with the fact that the
epidemic very quickly became a visible reality in the middle
of a big city in Canada. That was not the case with Ebola until far into
the epidemic. But again only two weeks after the Texas
Ebola case hit the media the UN security council made the up to then invisible
West African epidemic a global security threat – that was the trick and not
something the WHO could have done, no matter how much funding. WHO has recently been described
as 7 independent and
dysfunctional WHOs. They don’t support or learn
from each - especially about disasters such as Ebola. Even now in the present disastrous situation WHO is
bound by the influence of national sovereignty: With the resolution of the WHO board in January 2015 they have committed the world's countries
to follow existing rules and regulations on
international health, so it's nothing
new and there is no financial
commitment at national level
. As long as WHO pretends
that diseases such Ebola can be fought in each country
separately we will have re-emerging Ebola epidemics -
national sovereignty is meaningless
when diseases are
indifferent to borders. WHO's career
system must be tightened up
academically and WHO
should be strengthened with the
technical and financial resources required to tackle
unexpected epidemics and the associated training
in the countries that need it. That was the clear
message from 95 internationally
recognized researchers in the prestigious journal
The Lancet (Strong
comment from 95 scholars globally).
The government of Guinea-Conakry had not done much for
the population in the remote border
area where the first cases
ensued. Sierra Leone had failed to invest in health care and instead spent money
on tax exemption for mining and rubber
companies and Liberia had not paid for
doctors and nurses in six months but when they decided to go
on strike to get paid the population
got enough of it
all and the anger over the Ebola epidemic response was focused on the staff – instead of the health authorities or the government.
Margaret Chan seems
to be more than right: a weak
health care system dismantles society. Chan has also pointed
out that modern health systems
in Africa, must be
prepared
for what can not be prepared for or predicted. No one had foreseen that
the Ebola epidemic within a few
months would kill so many national doctors
and nurses. Converted to a US
context would have been equivalent to
an epidemic that within three months killed
70,000 American physicians while authorities was passively watching passively..
It is in stressful situations that we can judge the true performance capacity of health services. While doctors
and nurses died due to inadequate
procedures, equipment and training the epidemic took
a heavy toll on the other routine functions: malaria mortality increased, children
were no longer vaccinated and schools were closed.
And from a larger perspective (re-) emerging
infections are
lurking around in the shadow of ebola.
Hidden curriculum of Global Health
Here, the
international community, including DANIDA, have a new global and moral
responsibility to support and strengthen preparedness
for the unexpected. It requires among
other things the world wide training of a generation of globally competent doctors,
nurses and administrators (Exploring
the Hidden Curriculum of Global Health). Unfortunately, a new survey has
demonstrated why a little 7 gene virus could overthrow the entire global health
community: fewer than
one in 10 universities in
the UK have systematic training in global health. Hence, DANIDA should prioritize
health and global health training as a means and
prerequisite of development, globally
and nationally. A strong health
care system protects against the
crises that will inevitably return – in unexpected
places, forms and patterns. Disease outbreaks that are ignored become epidemics, and just like the financial crisis was downplayed in the beginning, it is expensive
to assume that fragile health care systems in low income countries are prepared
for disasters. The current epidemic was ignored and has left a huge bill in the
affected countries. Whether it is
Ebola, financial crises, rising food prices or natural disasters,
a strong health care system is the best medicine to keep a society working together.
A recent updated model predicts that the
Ebola epidemic will be over in May 2015. But Zanzibar has eradicated malaria -
three times and the last time Margaret Chan was part of the team that claimed
malaria cases had vanished from the Island. That was in 2009, in 2013 malaria
was back again. Let us prepare for the unexpected by building strong health
care that can deal with the real world.
Small
virus far from home
A preliminary ‘Lessons learnt’ opinion published
online in The Lancet on February
10, 2015 has some interesting facts about the West African outbreaks: an
emergency stage 3 was never declared by WHO and it is not clear why. There is only
one (1!) airline on the planet earth that can transport ebola patients! Questions
are raised as to what the most deadly Ebola strain (Zaire) was doing so far
away from its homeland? The West African context somehow added to complexity
it’s argued: very few doctors, civil war/post-conflict stunning of administrations
and health care meaning low trust in government from start, and the extreme
mobility of the population compared to east/central Africa may have contributed
to complexity. As an MSF worker remarks: “If Ebola suspects moves from location
A to location B, suddenly you need to duplicate everything”. The issue of an
epidemic in an urban setting: In rural settings, Ebola moves outwards in small
steps but in urban environment means unpredictability, the realization that the
virus could crop up at any medical facility at any moment as people seeking
help head towards the city from the hinterlands. The initial success in Guinea was
not true: hidden patients kept popping up while official statistics said the
epidemic was over. Because of recent armed conflicts Sierra Leone and Liberia
are used to presence of UN organizations and teams which Guinea was not and
that may partly have led to the confrontations seen in Guinea. By end of 2014
only 50 % of planned treatment centers in Guinea were running. A more outspoken
and top-down approach in Liberia was probably in hindsight better suited for
suburban/urban case detection and quarantines (and a clear support from the
president). The softer and less pro-active approach in Sierra Leone may have
contributed to the continuing epidemic. When Ebola popped up in Liberia MSF
didn’t have more staff – they were all engaged in Guinea and Sierra Leone –
international support was not available at that time. This contributed to a
delayed response and fueled the epidemic in Liberia. When international support
was made available it was mostly a question of organizing, training and
maintaining and overview – help came too late and that complicated the
situation.
Next step: global mismanagement
In 1966 an international
team, the Smallpox
Eradication Unit, was formed under the
leadership of Dr.
Donald Henderson. Subsequently, the
World Health Organization intensified
Smallpox Eradication the global campaign.
The Smallpox Eradication Unit that wiped out the
disease had 10 employees and no fax or internet! Dr. Henderson said in a speech in 1978 when smallpox disease was officially declared eradicated, that the next disease that to be
eradicated was global mismanagement.
We may finally combat Ebola and the countries affected have survived. But they
lost a lot of men, women, parents, health workers and children because the
global community was late – nearly too late to save what’s left. New outbreaks
in new areas, unsafe burials and Red Cross workers still attacked in Guinea
this week. Delayed and not very appropriate health information has been
difficult to sell to people that for many good reasons had already long before
the present epidemic lost trust in their health care system, government and the
international community. Let’s construct a learning brain for global health so
we can prepare for the unexpected. As experienced Ebola nurse Tony Walther
Onema says: this thing can happen anywhere (PIA:
link til interview her).
