Problemernes jantelov: Problemer skal ikke tro de er noget

Foto: Lasse Bech Martinussen

Om hvorfor sociale problemer er så irriterende og hvordan man får dem til at forsvinde.

”Nu ved jeg hvorfor jeg er ugift! Det er fordi jeg er ungkarl” – sådan beskrev Svend Brinkmann på et tidspunkt logikken i den offentlige debat.

Skibsbyggeren Peder Frederik Jensen har været taleskriver for statsminister Mette Fredriksen og er forfatter til bogen ’Det Danmark du kender’ – om netop det Danmark vi tror vi kender, men som er forsvundet fra gade- og mediebilledet. I programmet ’Brinkmanns briks’ på Danmarks Radio P1 d. 2.december 2020, fortalte forfatteren om en elev, der havde genfortalt bogen for sin klasse på et velhavergymnasium i København, og hvor klassens reaktion var: ’der findes da ingen underklasse i Danmark’. Som den 42-årige forfatter bemærkede så var der en underklasse på Vesterbro da han flyttede ind i sin lejlighed som 17-årig, men nu var den væk. Det betød ikke at underklassen var væk, men at boligpriserne på Vesterbro på 25 år var gået fra at være de laveste i landet til at være de højeste, så underklassen var sivet ud af Vesterbro til de langt billigere boligområder på Vestsjælland og Lolland-Falster, hvor de nu var genstand for eksotiske TV-programmer som f.eks. ’På røven i Nakskov’. Når de fattige er væk, tror vi det er fordi fattigdom er udryddet. Vi tror simpelthen der er nogen der har løst fattigdomsproblemerne. Vi kender kommentarerne og holdningerne fra medierne: Der er ingen underklasse i Danmark. De fattige findes ikke i Danmark. Hvis de gør, så har de nok selv valgt det. De fattige er er fattige fordi de tager forkerte valg og ikke hører efter. Nogle mennesker vil bare ikke det bedste for dem selv. Hvis de vælger at flytte væk, så er det nok fordi det er bedst for dem. Eller også har de sociale myndigheder løst problemet ved at finde en billigere bolig til dem. Udtryk for en idé om at der findes personer og myndigheder, der anonymt og skjult løser eller fjerner samfundets problemer. Social privilegieblindhed bygger åbenbart på den opfattelse at sociale problemer enten ikke ér problemer, at der nok er ”nogen” der løser dem, eller at de er uløselige – og i sidstnævnte tilfælde, så er de ikke mine problemer.

Når jeg holder foredrag eller underviser læger, lægestuderende, og andre ansatte i sundhedsvæsnet om kommunikation, empati og patientinddragelse, så er der altid tilhørere, der mener at lægers tid er guld og bør doseres forsigtigt og kun bør anvendes til det klassiske lægehåndværks grundværktøjer: piller og operationer. Sociale problemer er forstyrrende og irrelevante. Når talen falder på patienters ønske om empati, tid til bedre samtaler og mere involvering i beslutninger, så starter debatten altid med en tør konstatering fra flere i salen: ”Dét der har vi ikke tid til”. Underforstået at hvis læger fik tiden, så ville de bruge den på at føre længere samtaler med patienterne og på deres præmisser. Senere bevæger debatten sig tættere og tættere på kernen: ”Skal læger tage sig af alt? – findes der ikke psykologer, der er uddannet til at tale om menneskers problemer?”. ”Vi kan jo ikke gøre noget ved eksistentielle problemer, det er ikke vores arbejde”. ”Sociale problemer må løses i kommunen”. Og konklusionen ender ofte med at ”læger er jo gode til at tale med patienterne, det er jo en kerneydelse i lægearbejde. Måske er der bare nogle patienter der ikke vil høre efter”. Lægers tid er for kostbar til problemer som andre har skabt og undladt at løse. Med andre ord så siger lægerne: Dét har vi ikke tid til, for det har vi ikke tid til. Med inspiration fra Svend Brinkmanns må man konstatere at i de privilegieblinde optik, så er problemer folks egen skyld og de er kun problemer fordi der ikke er nogen der løst dem.

Det må derfor være tid til Problemernes Jantelov: Problemer skal ikke tro de er noget.

1.      Hvis man ikke har tid til et problem, så er der nogen andre der løser det.

2.      Hvis man ikke kan se problemet, så er det ikke et problem.

3.      Hvis man ikke har løsningen til et problem, så er det en andens problem.

4.      Hvis man ikke bryder sig om løsningen på problemet, så er det problemet der er problemet.

5.      Hvis problemet er irriterende, så er den der fremfører problemet der er problemet.

6.      Hvis man har travlt med eksisterende problemer, så må nye problemer vente.

7.      Dem der skaber problemer, er selv skyld i det og dét er ikke mit problem.

8.      Problemer skabes af mennesker med en svag karakter, det er dét der er problemet.

9.      Shit happens, for den der lader shit happen. De kan bare lade være.

10.   Jo mindre man ved om folks problemer jo lettere er de at hjælpe.

 

 

Lærebog Indvandrermedicin: Det du ikke ved får patienten ondt af

Her er link til gratis pdf udgave af min lægebog "Det du ikke ikke ved får patienten ondt af" om tværkulturel klinik og kommunikation i mødet med etniske minoritetspatienter:

Det du ikke ved får patienten ondt af

Alternativt link:

www.ouh.dk/laerebog 

Nogle af anmeldelserne af bogen:

Pædiater Alexandra Kruse i Dagens Medicin 22. januar 2021

”Ny bog om etniske minoriteter i sundhedsvæsenet gør os alle klogere. Bogen indeholder et overflødighedshorn af sundhedsfaglige problemstillinger, kommunikationsudfordringer og eksempler på ulighed i vores sundhedsvæsen fra et langt lægeliv dedikeret til mødet med den fremmede patient i Danmark. For de, som har appetit til at gå om bord i den store, tætskrevne bog, bliver sulten stillet, og mere til.”
Læs anmeldelsen her 

 

(Gunhild Bjarnasson, Pædagogisk leder)

”Kan også anbefales til andre faggrupper. Det giver et godt og lærerigt indblik i kultur og sprog og hvor vigtigt det er for at forstå. Så hvis du ikke er i sundhedsvæsenet, kan du springe det tunge lægesprog over. Dyk ned i de mange cases, det giver stof til eftertanke og mulighed for at gøre det bedre i praksis. Tak for det Morten Sodemann” 

 

Et så nødvendigt mesterværk på området (Telse Hübertz, mph, sygeplejerske)

Tak for et længe ventet og vigtigt bidrag. (Helle Tvorup Andersen, jordemoder, international koordinator jordemoderuddannelsen)
  

Praktiserende læger og lektor på Københavns Universitet, Lise Dyhr:
”Bogens styrke er de mange patientcases om det danske sundhedsvæsens møde med etniske minoritetspatienter. Bogen har fokus på vores blinde pletter og beskriver værktøjer til at imødegå disse”
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 Pædiater Alexandra Kruse i Dagens Medicin 22. januar 2021:

”Ny bog om etniske minoriteter i sundhedsvæsenet gør os alle klogere. Bogen indeholder et overflødighedshorn af sundhedsfaglige problemstillinger, kommunikationsudfordringer og eksempler på ulighed i vores sundhedsvæsen fra et langt lægeliv dedikeret til mødet med den fremmede patient i Danmark. For de, som har appetit til at gå om bord i den store, tætskrevne bog, bliver sulten stillet, og mere til.”
Læs anmedelsen her

 

 Solidaritet 15.01.2021:

“Allerede titlen: ”Det du ikke ved……” placerer en opfordring og et ansvar på dig. Og hvem er det ’du’ så? Det er lægen, det er behandleren, det er sundhedssystemet, det er alle os, der har ansvaret for, at den etniske minoritetspatient bliver behandlet efter alle lægekunstens regler”

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‘Medicinsk lærebog i omgang med patienter fra andre kulturer er en imponerende øjenåbner’ 

Læs anmeldelsen her

 

 

Dagens Medicin d. 11.12.2020

”Opgør med fordomme og halvdøve ører: Læger skal være bedre til at lytte”.

NY BOG: ‘Det du ikke ved får patienten ondt af’ er titlen på overlæge Morten Sodemanns nye bog. Bogen er baseret på hans årelange erfaringer med en patientgruppe, de etniske minoritetspatienter, som typisk ender på hans bord, når alle andre specialister har opgivet at hjælpe.

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Dagbladet Information 24.11.2020

”Flygtninge og indvandrere opfattes ofte som »åh nej-patienter«. Det vil ny bog gøre op med”.

Flygtninge og indvandrere kommer ofte skævt ind og ud af sundhedssystemet og er udsat for flere fejl og forsinkelser end etniske danskere. Nu har læge Morten Sodemann skrevet en lærebog om sine erfaringer med minoritetspatienter i håb om, at de fremover kan få en bedre behandling i det danske sundhedsvæsen.

Læs anmeldelsen her 

 

Interview i P1 Orientering om bogen 25.11.2020
Afsnit Flygtninge og indvandrere er ofte udsat for misforståelser i sundhedsvæsenet. Det vil overlæge gøre op med i ny bog

Hør interviewet her

  

Den er uhyggeligt velskrevet. Opregner en overflod af hårrejsende eksempler. (Anders Langscheidel Rasmussen, lektor, narrativ medicin).

 

Bogen er spændende og med en god blanding af case eksempler og undersøgelsesfund. Den har nogle lærebogskvaliteter på universitetsniveau med et højt vidensniveau, som ikke er så almindeligt mere. (Ask Elklit. Professor i psykotraumatologi).

 

Denne bog imødekommer et stort behov på mange niveauer! (Helge Kjersem, tidligere hospitalsdirektør og tidligere leder af Indvandrermedicinsk klinik på Hvidovre Hospital)

 

Sundhedsvæsnet har i den grad brug for den her bog – en bog alle burde læse. Denne patientgruppe kan ikke altid puttes i de vanlige instrukser og forløbsbeskrivelser som vi har på de forskellige afdelinger (Negin Jafar, gynækolog).

 

Godt og vigtigt fokus på at ændre tilgang og holdning til "besværlige" patienter. (Konfliktmægler)

 

Tænker at alle i sundhedsfag kan lære af denne bog. (Sygeplejerske og lektor på en sygeplejeskole)

 

Weekenden er aflyst - hvis nogen mangler mig, så vent til mandag. Jeg har en spændende bog af Morten Sodemann jeg skal have læst (Karina Andersen frivillighedskoordinator, region Syddanmark)

 

Morten var en af de første, der satte fokus, hvad der sker når sundhedsprofessionelle skal kommunikere sygdom og behandling på tværs af kulturer. Der er helt sikkert noget at lære for farmakonomer og farmaceuter også. Vil glæde os til at læse den. (Pharmakon)

 

Det er så vigtigt at lytte til patientens viden og fortællinger - vi kan lære meget af indvandrermedicin! (Josine Elvekjær Legêne, forskningsleder på Videnscenter for Brugerinddragelse i Sundhedsvæsenet)

Meget nyttig og længe ventet bog (Helle Tvorup Andersen, Professionshøjskolen University College Nordjylland)

 

Mange tak for link til bogen. Den burde være pligtlæsning ikke bare for sundhedsfagligt personale, men også for politikere, meningsdannere, medier og sociale myndigheder. Vi er langt fra holdninger og synsninger, og tæt på fakta, dokumentation, reel viden. (Susanne Langer tidl medlem af Regionsrådet i Hovedstaden)

 

Det vigtigste er ikke hvilken sygdom patienten har, men hvilken person der har sygdommen, skriver landets førende ekspert inden for indvandrermedicin og global sundhed. En fantastisk case-baseret lærebog til det danske sundhedsvæsen. Glæder mig til at læse den. (Øzlem Cekic. Tidl. Folketingsmedlem. Brobygger og foredragsholder).

 

Spændende bog der giver stof til eftertanke.  Tak for det. (afdelingssygeplejerske på klinik for ældresygdomme)

 

Det bliver fantastisk og spændende læsning (Katja Sejer Nielsen. Projektleder Social Sundhed - brobyggere i sundhedsvæsenet)

Intet nyt fra Vestegnen

Det er nu femte gang siden marts at der er udbrud i mediernes fokus på COVID19 blandt etniske minoriteter i særlige boligområder. Imens rejser Corona virus rundt fra kommune til kommune og sætter lus i skindpelsen på alt og alle. Sumpe skal drænes, ministre skal ofres og indvandrere skal spærres inde. Smittetrykket er højt i de kommuner i København, hvor der bor forholdsvis mange med minoritetsbaggrund. Journalisterne spørger, for 5. gang, hvad er det sker på Vestegnen? Og svaret er, for 5. gang, det samme: ingenting. For der sker det der altid sker under epidemier. Dem der har mindst indflydelse på deres arbejdsplads er de samme der er uden indflydelse på deres boligforhold. De har også korte uddannelser og en hårdt trængt økonomi, der ikke levner plads til gæstetoiletter, hjemmearbejdsdage eller selvisolation. De har frontliniejobs med høj smitterisiko og ansættelsen er midlertidig. Mange har oplevet at det var umuligt at blive hjemme fra arbejde fordi arbejdsgiver og kolleger fandt det uacceptabelt at sygemelde sig pga. lidt forkølelse. De bor sammen med flere i samme hushold, typisk med bedsteforældre og børnebørn under samme tag. Forskningen viser at kortuddannede har sværere ved at omsætte hygiejne råd til deres egen hverdag. Oprindeligt boede minoriteter og etniske danskere i samme kommuner og boligblokke, men majoritetsbefolkningen er langsomt sivet væk og har efterladt minoriteter i hvad de fraflyttede nu med foragt, betegner sociale ”ghettoer”. Der er intet ”sket” på Vestegnen udover at de er blevet efterladt tilbage på egnen mens resten flyttede.

De sidste 15 år har den velfærdspolitiske indsats, og retorik, overfor socialt sårbare, flygtninge/indvandrere ændret sig markant. Skiftende regeringer har i serielle overbud indskrænket mulighederne for social mobilitet og øget fattigdommen blandt etniske minoriteter. Muligheden for at skabe sig en identitet og en fremtid i Danmark er blevet et Sisyfosprojekt med skrappe symbolpolitiske krav til opholdsgrundlaget. Kommunernes integrationsteams blev for 10 år siden nedlagt landet over, sammen med tværkulturelle de rehabiliteringsteams. Nu hed det sig i at der ikke længere var tale om flygtninge men om socialt sårbare, som kunne gøre brug af kommunernes eksisterende tilbud til socialt udsatte. Politisk blev sprog til en integrations politisk kampplads, hvor materialer om det danske velfærdssamfund, sundhed og sygdom nu kun måtte findes på dansk sprog. Boligforeninger udgiver kun materialer på dansk og da H1N1 pandemien truede (tidligere kaldt ”Svineinfluenza”) fravalgte sundhedsmyndighederne at oversætte informationsmateriale om smitterisiko og hygiejneråd fordi man ikke fandt det nødvendigt. Sundhedsstyrelsen nedlagde samtidigt sin gruppe af eksperter der beskæftigede sig med etniske minoriteters sundhed.

I lægers uddannelse blev tværkulturel psykiatri fjernet fra specialeplanen (Sundhedsstyrelsens dokument over hvad der arbejdes med i Sundhedsvæsnet og hvem der har opgaven), ligesom feltet Indvandrermedicin, som er tværkulturel medicin, kun figurerer som en opgave, der i kompleksitet rangerer på det laveste specialiseringsniveau svarende til at behandle blærebetændelse og forkølelse.

Samtidig prøver myndighederne om det stadig er rigtigt at ”Hvis du altid gør det du altid har gjort så får du det du altid har fået”. De samme informationer om hygiejneråd sendes ud over befolkningen på den samme måde og i den blinde tro at de så anvendes efter hensigten. Spørgsmål om hvad der nærmere forstås ved ”hold afstand”, ”selvisolation” eller ”nærmeste familie” overlades til den enkelte. Min nærmeste familie er på 12 personer, mens flere af patienterne i Indvandrermedicinsk klinik angiver at den nærmeste familie er 60-80 personer. Social afstand er en social konstruktion og der er flere videnskabelige studier, der påviser betydelige etniske forskelle i hvor stor social afstand af, eller hvornår man er ”for tæt på hinanden”. Det første studie er fra 1925 og betragtes stadig som en grundlæggende studie på området, så det er ikke ny viden. Det er heller ikke ny viden at jo større hushold man bor i jo større risiko, er der for at smitte hinanden.

Regeringen og myndighederne prøver at løse et problem de ikke forstår. Etniske minoriteter over hele verden, og på Vestegnen er mere end dobbelt så udsatte for smitte end andre befolkningsgrupper. De bor over hele verden i samme typer boligkvarterer med de samme dårligt ventilerede lejligheder. Velfærdssamfundet ligger som det har redt og der er intet nyt fra Vestegnen. Det nye er desværre at det nu er tydeligere hvordan dette årtis konstante indhug i velfærdstiltag og i de tværkulturelle kompetencer i kommuner, regioner, ministerier, styrelser og sundhedsuddannelser påvirker ulighed i sundhed og dermed folkesundheden. Vi var ikke forberedte på COVID19, men vi kendte alt til ulighed i sundhed - uden at gøre noget. Det er ikke nogen nyhed på Vestegnen. Man kan ikke tillade sig at bede om tordenvejr og så brokke sig over at det også regner.

Corona hærger der hvor der skabes mulighed. Social ulighed, desinformation, symbolpolitik og bevidst uvidenhed gør det muligt for pandemien at sprede sig for at efterlade en slagmark af skyld, skam og forvirring. Der er intet nyt fra Vestegnen. Dét burde være nyheden.

Ulighed i sundhed: Vi tæller træerne men gemmer skoven

Ulighed er som at ryge: vi ved det er dyrt og helbredsskadeligt og vi har ikke råd til det, men på én eller anden måde er vi afhængige af det. Vi ved vi bør holde op, vi bilder andre ind at vi til enhver tid kan holde op, for vi har gjort det utallige gange før. Som rygning er ulighed blevet en vane for os, en del af hverdagens små spændende udfordringer eller småforhindringer - en risiko man løber ved at leve. Man indrømmer gerne sin svage karakter som ryger og fattigdom er vel nærmest en karakterbrist? Men ulighed koster samfundet over 50 mia kroner om året.  At gøre noget ved ulighed i sundhed er ligesom rygestop: der er masser af hjælpemidler, men de virker ikke hvis man ikke alvorligt ønsker at stoppe med at ryge.

Løsningen på ulighed i sundhed skal ikke findes i sundhedsvæsnet – sundhedsvæsnet ser derimod ulighedens konsekvenser i sundhedsvæsnet. Løsningen skal findes i det samfund og de politiske vilkår som sygdomme skabes i og som sundhedsvæsnet er tvunget til at sende patienterne tilbage til.

Ulighed i sundhed handler om at der er en meget stærk kobling mellem kort uddannelse, ingen eller usikker beskæftigelse og sygdom. Dårligt helbred fører til kortere uddannelse. Kortere uddannelse fører til lavere behandlingskvalitet. Usikker beskæftigelse fører til lavere indkomst. Lavere indkomst øver følsomhed for medicinpriser og fører til svingende medicinindtag. Svigende medicinindtag fører til sygdomsforværring og flere komplikationer. Store medicinudgifter kan føre til irreversibel fattigdom, hvis der samtidig er store bolig- og transportudgifter. Kortere uddannelse fører til dårligere rehabilitering efter sygdom. Børn der vokser op i fattigdom med mange negative sociale oplevelser, får kortere uddannelse og er i øget risiko for at blive syge som voksne. Det forunderlige er at det er lykkedes et velfærdssamfund som det danske at skabe ulighed i forebyggelse af sygdom, risikoen for sygdom, adgang til behandling, behandlingskvalitet, genoptræning og overlevelse efter f.eks. kræft og hjerte-karsygdom.

Investeringer i social velfærd kan øge den sociale mobilitet men hvis ikke ulighed i levevilkår mindskes, så bliver social mobilitet lige risiko for at opnå ulige levevilkår og et dårligt helbred. Hvis ikke ressourcer til skole og sundhedsvæsen fordeles mere efter behov og mindre i forhold til efterspørgsel kan den onde cirkel mellem kort uddannelse, dårligt helbred og manglende/usikker beskæftigelse ikke brydes. Sundhedsvæsnet koster 114 mia kr/år og udgifterne er steget ca. 43 % på 17 år. Sundhedsvæsnet sluger pengene til netop de investeringer i velfærd der kunne beskytte os mod sygdom: Uddannelse, social velfærd & sund opvækst.

Et par aktuelle eksempler på ulighed i sundhed:

·        Medicinpriser svinger uforudsigeligt og presser lavtlønnede patienter og patienter på overførselsindkomster fordi deres udgifter ikke kan afdæmpe udsving. Medicin koster det samme for millionæren som det gør for kontanthjælpsmodtageren.

·        Der er ulighed i kræftscreening (underliv, brystkræft og tarmkræft). Jo kortere uddannelse og jo mere økonomisk svagt stillet jo færre bliver undersøgt.

·        Der er social ulighed i adgang til og i effekt af rehabilitering. Der findes ikke nationale standarder for genoptræning og hver kommune har sin fortolkning. Uligheden gælder både i chancen for at blive henvist, at starte på genoptræningen og at fuldføre den.

·        Patienttransport er et tilbud der er afgørende for mange økonomisk mindre velstillede, psykisk syge og gangbesværede. Men motivationen til at bruge muligheden varierer fra sygehusafdeling til sygehusafdeling. Ofte er reglerne komplicerede og ulogiske og det er langt lettere for sygehusansatte at afvise muligheden end at sætte sig ind i reglerne, der desuden er forskellige i psykiatrien og somatikken. Men det betyder at nogle patienter, oftest enlige, ensomme, psykisk syge eller socialt udsatte, ikke kommer til kontrol, forundersøgelser eller operationsvurdering. Dét er en skjult ulighed i behandling men den registreres ikke som sådan. Regionerne har tilmed nu strammet reglerne for patienttransport, så dårligst stillede mest sårbare patienter med største behov får nu endnu sværere ved at få glæde af sundhedsvæsnet.

Ulighed udspiller sig ofte i samspil med mange faktorer på én gang og ofte spiller faktorerne hinanden stærkere end de ellers ville have været. Coronakrisen viste i alle sammenlignelige europæiske lande, herunder Danmark, at risikoen for at blive smittet med COVID-19 var størst blandt dem der havde mindst indflydelse på deres arbejdsplads og deres boligsituation. Den viste også at der var en højere risiko for at blive meget syg af Corona-virus og dø af infektionen hvis man tilhørte en etnisk minoritet, som netop oftere end andre har ansættelse i de såkaldt kritiske funktioner i frontlinie som f.eks. butiksansatte, plejehjemsassistenter, hjemmehjælpere, taxachauffører og samtidig også dem der pga lav indkomst kom fra husholdninger der var dobbelt så store som mere velstillede. Samtidig påviste en norsk undersøgelse at dem der havde sværest ved at forstå og at efterleve myndighedernes hygiejneråd, var dem med kortest uddannelse.

Det bliver endnu mere komplekst når man ser lidt dybere bag tallene. I USA fandt man at selvom man korrigerede for faktorer som social status, erhverv, brug af offentlig transport, boligforhold, privat sundhedsforsikring, overvægt og kroniske sygdomme, så havde afro-amerikanere end meget højere dødelighed Coronavirus end andre amerikanere og man mener derfor årsagen må være en kombination af lavere behandlingskvalitet i sundhedsvæsnet (forskelsbehandling) og kronisk stress.

Man skal forstå ulighedens mange virkemidler og man skal forstå de politiske og sociale årsager til at ulighed reproduceres. Man skal forstå hvor sårbarhed kan opstå når flere faktorer forstærker hinanden. Man dør ikke af sin korte uddannelse eller usikre ansættelse. Man dør af konsekvenserne. Og konsekvenserne kan være forskellige steder i landet og i forskellige befolkningsgrupper. Velfærdssamfundet bør kende konsekvenserne og reducere deres indflydelse på de mest sårbare. Men det kræver at man politisk faktisk ønsker at gøre op med ulighed i sundhed.

Ulighed er ubekvemt og det kræver mere af os, end vi er villige til at yde, at ændre på det. Politisk er det opportunt at tallene er farveblinde. Vi tæller måske nok træerne, men vi gemmer skoven. Det tog sin tid at få tallene for de etniske minoriteter frem i Danmark og i England blev tallene fjernet fra den officielle rapport. Ofte gemmes uligheden væk og hives kun frem hvert 10. år i en skåltale, nu skal vi også tage os sammen. Men nu har corona pandemien uventet hevet den frem fra skabet og pudset den af og dét tvinger os endnu engang til at tage stilling til om vi faktisk vil holde op med at ryge eller om vi bare skal prøve igen med noget mere nikontinplaster? Vi kan jo altid holde op med at ryge, ikke?

 

Kilder

https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30264-3/fulltext

https://www.statnews.com/2020/06/15/whos-dying-of-covid19-look-to-social-factors-like-race/

https://ec.europa.eu/migrant-integration/news/covid-19s-impact-on-migrant-communities

 https://www.theguardian.com/inequality/2020/jun/13/leaked-report-says-racism-and-inequality-increase-covid-19-risk-for-minorities

https://www.bmj.com/content/369/bmj.m2264

Diderichsen, Finn. "Sårbarhet–ett begrebb till bruk för båda jämlik hälsa och hållbara samhällen." Socialmedicinsk tidskrift 95.6 (2018): 621-626.

https://politikensundhed.dk/debat/art7821515/Manglende-nationale-standarder-for-rehabilitering-giver-ulighed-i-sundhed

 

Safran svøben

Bertolt Brecht funderer I Motto to Svendborg Poems, 1939

In the dark times

Will there also be singing?

Yes, there will also be singing.

About the dark times.

Da den myggeoverførte Gul Feber virus (Kaldet ”Safran svøben” pga. den ledsagende gulsot) hærgede i Louisiana i Sydstaterne i 1796-1905 gik der et bekvemt rygte om at sorte slaver var naturligt immune overfor Gul Feber virus, og dét argument blev brugt til at støtte at slaverne naturligvis skulle det hårdeste arbejde med at dræne sumpområder, fælde skove og arbejde i markerne. Helt bizart var prisen på en beviseligt immun slave 50 % højere end for andre slaver – de blev ”essentielle”, fuldstændig som i dag, hvor renovationsarbejdere og serviceassistenter er blevet livsnødvendige i nu pludselig kritiske funktioner. Immun betyder i ældre forstand at man ikke skal betale skat. I Louisiana blev immunitet vigtigere end social klasse og mænd fra Nordstaterne skulle bevise at de var immune før de kunne få arbejde i Sydstaterne. Immunitet blev til at borgerskabsprøve og mange forsøgte at smitte sig selv for at få en adgangsbillet til det sociale borgerskab. Corona pandemien har på samme måde vendt op og ned på hvem der er brug for når krisen kradser. Sundhedsvæsnets skyggesider blev oplyst i coronaens skær. Dem der var mest behov for var dem der måtte tage den hårde tørn, men også dem der endte med at trække det korteste strå.

Social ulighed holder ikke fri bare fordi der er en pandemi. Det har tilsyneladende overrasket både politikere og journalister at der er ulighed i sundhed. Fattigdom er stadig ikke en karakterbrist hvilket mange ellers er enige med Margaret Thatcher i: ” Der er ikke længere fattigdom i Vesten, så hvis du er fattig, fordi du ikke kan afpasse din økonomi, så er det en fejl i din personlighed”. Corona-pandemien har med al ønskelig tydelighed vist at dem der hverken har indflydelse på deres fysiske arbejdssituation eller på kvalitet og størrelse på deres bolig, har den højeste risiko for at blive smittet og syge. Mens resten af Danmark trak sig tilbage til hjemmearbejdspladser i boliger med gæsteværelser og tilhørende separate toiletter eller i deres sommerhuse langt fra smitterisiko, så kørte taxa- og buschauffører stadig intetanende og ubeskyttede rundt med kunder. Kassemænd- og damer sad i timevis på arbejde mens dem der havde råd, tømte rødvin, toiletpapir og coronavirus op på kassebåndet. Alle dem der ikke havde mulighed for hjemmearbejdsplads og tog en for holdet, blev kortvarigt til helte, men da de pludselig optrådte i statistikkerne over de mest smittede blev de gjort til syndebukke, der gjorde grin med myndighedernes råd og de blev beskyldt for at have en svag karakter. Coronavirus satte strøm til uligheden, men den satte også strøm til fordomme og selvtilstrækkelighed.

En dansk butik meddelte på et skilt i døren at de havde lukket pga. ”China Virus Covid ”. I tre ord kobles et land og et folk direkte med noget både fremmed og farligt. I Kina smider folk sten efter biler med Wuhan nummerplader og der graves bogstaveligt talt grøfter udenfor landsbyer for at forhindre ”fremmede” (smittede) i at komme ind. COVID19 er den perfekte metafor for de negative sider af menneskeheden, når den står overfor nye trusler. Der er en sær kobling mellem forestillingen om sygdom og forestillingen om det fremmede. I skyggen af epidemier venter der ofte andre mere lumske epidemier, både infektiøse (som mæslinger, tuberkulose og kolera), men også konspirationsrygter, katastrofetanker og andre sociale epidemier som rygter om, hvem der er årsagen til, og bærer af, epidemien: ”de fremmede”. Columbus fik skyld for at bringe syfilis med sig til Amerika – og da han vendte tilbage til sit hjemland, blev han beskyldt for at tage syfilis med tilbage fra de indfødte i Amerika. Syfilis blev kaldt den kinesiske syge af japanerne, Morbus Germannicus af franskmændene, ”Franske kopper” af englænderne og ”Napolisyge” af Florentinerne. I Italien blev sygdommen kaldt ”Mal francese”, og i Frankrig hed den ”Mal napolitain”. Jøderne fik skylden for den sorte død, pest, i 1300-tallet, irerne fik skylden for kolerasygdommen i New York, og italienerne fik skylden for at bringe polio til Brooklyn. Kineserne fik skylden for SARS og sammen med latino-amerikanerne fik de også skylden for den i starten benævnte ”Svineinfluenza”, som den arabiske verden mente måtte være en amerikansk virus beregnet til at udrydde arabere. Ebola har hidtil holdt sig til det Afrikanske kontinent, så dén virus har afrikanerne selv skyld i. Alle ved virus kom fra Wuhan, men i al ubemærkethed har forskningen vist at den formentlig kom fra Guandong og at den har været under vejs gennem længere tid. Wall Street Journal skrev d. 3. februar at ”Kina er den rigtig syge mand i Asien”. Flere landes medier har leget med tvetydige overskrifter om ”den gule fare”, asiatisk udseende personer er blevet overfaldet i Europa og flere med ikke-kinesisk asiatisk baggrund har følt det nødvendigt at fremhæve at de ikke var kinesere. Senest er overvægtige blevet et yndet skyldsobjekt, fordi de er blevet udråbt som en særlig risikogruppe i verdenspressen.

Kilde: Politiken. Fotograf: Martin Lehmann

Da den sorte pest hærgede Europa i midten af det 14. århundrede og dræbte ca. 50 procent af de inficerede og en tredjedel af kontinentets befolkning på det tidspunkt, spredtes rygter om, at jøder havde forgiftet brønde for at sprede sygdommen. Når der er store epidemier, smitter frygten hurtigere end epidemien. Man bebrejder en slags indtrængende magt eller de fremmede. I Israel lægger Netanyahu-regeringen nu grundlaget for at kunne bebrejde palæstinensere for spredningen af Covid-19 ved at knytte virussen til overvejende muslimske palæstinensiske israelske borgere, og ministerpræsidenten sagde til en delegation af læger at ”desværre bliver (hygiejne-) instruktioner ikke nøje overholdt i den arabiske sektor”. I Indien har det regerende parti bekvemt kunnet koble en allerede igangværende marginalisering af muslimer ved at give dem skylden for spredning af COVID19. Tommy Robinson, den tidligere leder af den engelske forsvarsliga, der bygger på anti-muslimske fordomme, delte for nyligt en video på det sociale medie Telegram om, at påståede muslimer i byen Birmingham mødtes i en "hemmelig moske" imod regler om hjemmeisolation og forsamlinger og videoen påstod, at det religiøse mindretal planlagde at sabotere det britiske samfund ved at sprede virussen. Videoen blev delt mere end 10.000 gange. Lige så bizart er det at samme COVID-19-pandemien er bekvem for højreekstreme grupper, fordi den passer med en stadig mere populær pseudoteori blandt yderste højre - accelerationisme. Det er en strategi hvis formål er at fremskynde samfundets sammenbrud for at fremme en omstrukturering. Et lækket notat fra det amerikanske sikkerhedsministerium, dokumenterer, hvordan tilhængere af hvidt overherredømme og nynazister opfordrer inficerede medlemmer til at sprede virussen til politikere, politi, militær og mindretalssamfund gennem budskaber der opfordrer covidsmittede tilhængere til at "besøge din lokale moske, besøge din lokale synagoge, tilbringe dagen i offentlige transportmidler, tilbringe tid i dit lokale multietniske boligområde".

Lige nu er Danmarks grænser lukkede for at undgå at fremmede kommer med coronavirus, og der er tale om at stoppe asylansøgere ved grænsen. En dansker i Vietnam kommer i TV-avisen fordi hun sættes i karantæne af myndighederne, men medierne glemmer at hjemvendte danskere også sendes i 14 dages karantæne af danske myndigheder. Tuberkulose bliver opfattet som en sygdom, migranter bringer til Danmark, på trods af at et studie viste, at migranter aldrig smitter etniske danskere. Kina får skylden for coronavirus, der på forsiden af en fransk avis meget tvetydigt blev kaldt ”den gule fare” og den amerikanske præsident har direkte kaldt den for den ”kinesiske virus” og givet Kina skylden for at USA er blevet angrebet. Dét blev man selvsagt kede af i Kina, men samtidig kom der rapporter frem om at de kinesiske myndigheder specifikt søgte at isolere afrikanske migranter pga. ”smittefare”. Et studie af fordomsfulde og stigmatiserende sprog på sociale medier og i google-søgninger fandt at COVID-retorikken rettet mod asiater i USA medførte at spansk-amerikanere i endnu højere grad end asiater fik skylden for corona-epidemien i USA.  I England har nationalister stået i kø for at give etniske minoriteter skylden for COVID-epidemien i landet, samme så man i Italien. Det kedelige modsvar er, at I England har alle læger der er døde af coronainfektion og 50 % af døde sygeplejersker minoritetsbaggrund.

Vi bor alle i det samme glashus, når det kommer til pandemier. At skyde skylden på bestemte lande er som at smide sten efter sit eget hus. Skal vi til at sagsøge USA og Californien for at have fremelsket Enterovirus D68? Arabien har kameler så de må betale for MERS-CoV….selvom der også er kameler i Australien? Og når vi er ved Australien, så er der den særlige Brisbane-influenza-stamme, den må de bøde for? Skal krigshærgede DR Congo så ikke også bære hele ansvaret for ebola-virus? Japan for Japansk Encephalitis? Kenya for Rift Valley Fever? Og hvad med Danmark: Roskilde bør stå til ansvar for Roskilde syge som Fyn må tage skylden for Hantavirus. Nogen skal jo have skylden – bare ikke os selv. Ord betyder noget og den ubevidste kobling mellem smitte og fremmede er sundhedsskadelig for den forplumrer virkeligheden: vi er alle lige fremmede overfor epidemier og mikrober. De var på jorden før os og de vil også være her når det sidste menneske forlader jorden. Men vi har vist at med simple sociale regler som håndvask, afstand og kontaktminimering kan vi leve med dem og hinanden. Næsten halvdelen af jordens befolkning har været underlagt reglerne og mange har lidt store økonomiske og sociale tab, men vi overlevede. Desværre har fremmedhad det strålende i skyggen af Coronaepidemien. Institut for Menneskrettigheder har i en ny rapport påpeget hvor udbredt corona relateret chikane og had er i det offentlige rum (https://menneskeret.dk/nyheder/corona-relateret-had-rammer-minoriteter-offentlige-rum). Fremmedhad bekæmpes med samme metoder som mod Coronavirus, ved at isolere og skabe afstand til det i sprog og handling.

Vi har sunget sammen hver for sig hver dag med Phillip Faber, der på et tidspunkt fik besøg af Smadremanden (Søren Østergaard), der mente at vi skulle smadre coronaerne sammen hver for sig. Men vi kan ikke som smadremanden smadre coronaens konsekvenser hver for sig. Dém skal vi slå ned på sammen.

I Kim Larsens sang om hvad der venter os om hundrede år funderer han over om der stadig er prikker på en polka eller striber på en tiger. Man kan have sin tvivl om polkaprikker og tigerstribers bestandighed, men ulighed har vist sig at være temmelig resistent overfor tidens tand.

Udvalgte kilder:

Gonçalves-Sá, Joana. "In the fight against the new coronavirus outbreak, we must also struggle with human bias." Nature Medicine 26.3 (2020): 305-305. https://www.nature.com/articles/s41591-020-0802-y

Ren, Shi-Yan, Rong-Ding Gao, and Ye-Lin Chen. "Fear can be more harmful than the severe acute respiratory syndrome coronavirus 2 in controlling the corona virus disease 2019 epidemic." World Journal of Clinical Cases 8.4 (2020): 652.

Tonya Mosley og Cassady Rosenblum. In Antebellum New Orleans, Immunity From Yellow Fever Was A Form Of Privilege. Could That Happen With COVID-19? https://www.wbur.org/hereandnow/2020/04/17/coronavirus-immunity-privilege-yellow-fever

Who emerged first: humans or viruses?

Should we understand emerging viruses before we bring them to Europe?

In November 2012  the French Institut Pasteur inaugurated a new center:Francois Jacob research center for the study of emerging diseases. The center is named after the Institut Pasteur scientist and 1965 Nobel medicine laureate. The background of the center, it says in the press release is: “In recent decades, we have witnessed growing concern in the scientific community about the emergence of new viruses and bacteria that can lead to widespread epidemics in record time. The Institut Pasteur has decided to step up its capabilities to deal with this new threat by building one of Europe’s largest research centers on its historical site in Paris”.

The cost of the building is 61 million EUROS and as it says in the press material, the François Jacob Center “is fitted with a wide array of state-of-the-art technological equipment and was designed to encourage open, collaborative research. It will eventually house more than 400 leading scientists who will work together in multidisciplinary teams, exploring new approaches to help combat and contain emerging and re-emerging diseases”.

The Pasteur Institute argues that new epidemics cause by viruses like SARS, Chikungunya, H1N1 influenza and dengue emerge every year and very 5 years a new virus threatens to disrupt economy, travel and global health and that some of the viruses have demonstrated an ability to spread faster than news.

While there is no doubt about the severity of these viruses and that they have been a wake-up call to broaden our concept of health there is something wrong with the basic rationale and arguments behind building a 61 million EURO laboratory in a part of the world where the risk of actual human exposure to these potentially dangerous zoonotic viruses is nil. And the consequences that the Institut Pasteur draws based on their perception of a world threatened by emerging viruses is even more of a wild shot. Starting with a lab in Europe to fight a transmission of wildlife/animal viruses to humans occurring in and near rain forests on the other side of the globe is bound to fail. This is the way we have tried for centuries to deal with global health threats since the earliest colonial days and we have never succeeded this way. We have succeded when we applied a broader perspective on health matters in both understanding and intervening against disease and mortality.

As Nathan Wolfe  has demonstrated we need to set up surveillance laboratories, not in Paris, London or Copenhagen, but in the countries where transmission occurs because only then can we identify emerging or re-emerging infections and only then can we intervene timely in the sociological and geographical environment where the transmission threatens to become human and serious (see Origins of major human infectious diseases and Bushmeat Hunting, Deforestation, and Prediction of Zoonotic Disease Emergence).

What Institut Pasteur, and other international research and funding agencies, like to sell is that what we are facing is viruses that emerge are “new” viruses and that they can be detected and controlled by flying blood samples to Paris and possibly controlled later by a vaccine. The fact is that none of these viruses are new or emerging. The only look that way because it is a convenient way for tropical researchers and global health bodies to justify their research and funding. The viruses, parasites and bacteria were here long before we were. We, humans, are the ones to have emerged and we have disrupted a biological environment in certain parts of the world by using former rain forest areas for farming, thereby increasing wild life density and increasing human exposure to wild life viruses that are new to us as humans but not to the globe as such.

We have emerged and created a new equilibrium and new transmission ways for viruses and parasites and to monitor, determine and control this we need to start setting up laboratories in (very-) low income countries as well as in some emerging (!) economies where the majority of human-zoonotic exposure and transmission occurs (see Global trends in emerging infectious diseases).

Virus do not follow the money hence viruses do not live and thrive in Paris where the funding is and the low income countries will never be able to raise funding for the types and quality of the laboratories that are necessary to identify and monitor potential human threats.The priorities of low income countries lie very far from helping high income countries protect themselves against theoretical threats from relatively rare viruses they have never heard of, when they themselves are facing children still dying of pneumonia or measles because of lack of penicillin and vaccines.

So maybe the 61 million EUROS would have been wiser and better spent in Brazil, Burma or Congo so that we could monitor not only virus DNA in blood samples from wild life hunters but also human interaction with wildlife and the socio-economic circumstances that lead to this changing interaction. Something is emerging in the borderland between forest and agricultural land and in the constantly changing borderland of mega cities in tropical and subtropical areas but it is human beings that emerge and not viruses or parasites. If we continue to solve global health problems in laboratories far away from reality, viruses, bacteria and parasites will very soon regain their global position and reestablish the ecology they enjoyed before humans interrupted them for a brief period of time. Global health is about investing where the problems live are not where funding and researchers like to live.

Morten Sodemann

The Ebola fog is lifting - next global epidemic to eradicate: bad global management

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

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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).