“Once you’ve poured the water out of the bucket it’s hard to get it back again” (Chinese proverb)
Neither the WHO, DANIDA or any other international donors have an excuse for the uncontrollable behaviour of the Ebola epidemic. There is tons of knowledge and donors have had time to pick it up, just as they have had time to act on it.There are five things donors have ignored, overlooked and misinterpreted.
One is that there is extensive evidence that the quality of care in many public hospitals in West Africa has maintained the same unacceptable level for decades.
The second is that the management of global epidemics requires that there is one strong, competent and financially prepared authority and a functioning global network of researchers, laboratories and epidemiologists as well as the necessary political contacts which could force necessary solutions through. WHO should have been be the global health agency, but has been constrained by the larger countries that would rather give money to health programs they have established themselves. Private actors such as the Gates Foundation have with the world’s acceptance taken over many of the tasks that the WHO previously was in charge of.
Thirdly, WHO has restricted its own opportunity to be able to act quickly with its inappropriate career system that rewards anything but skills and WHO has given too much autonomy to the regional WHO offices resulting in low competencies in some offices.
The fourth factor donors have overlooked is that epidemics move with people and if they change behavior so will the epidemic change behavior – with subsequent unpredictable risk environments.
Finally, WHO and the rest of the world overlooked the fact that while Ebola epidemics previously were known as small Ebola epidemics started by game hunters and farmers in relatively isolated rural areas, it could apparently spread seamlessly in slums or post war zones and defenseless fragile health care systems.
The current Ebola epidemic unfolds in a complex environment consisting of a toxic mixture of densely populated cities and slums, populations commuting between rural and urban areas and patients met by completely unprepared doctors and nurses. It is no coincidence that the epidemic continues in the three countries that have invested least in the public health system. Countries that produce the world’s cocoa and rubber – bizarre in a situation where rubber gloves are in short supply.
DID WE LEARN FROM THE SARS EPIDEMIC?
The SARS epidemic should otherwise have given us a lesson. The only luck was that we were able to isolate ourselves out of the SARS epidemic. Fortunately SARS was a sloppy virus that though it was very infectious and a fast killer it was sufficient to isolate patients with symptoms to stop the epidemic.
WHO showed its worth and got blown to alarm and established cooperation between large laboratories. Perhaps the global response was quick and firm because the epidemic became very visible when it landed with jet aircraft and hit right in the middle of a big Canadian city – far from where the epidemic began. Slack hygiene, including among doctors, put hospitals in Toronto to the test during the SARS epidemic, but they got the hang of it. China was slow to recognize the seriousness of the situation but with the WHO’s global alert they ended up being open to external support – Taiwan took too long to establish a national crisis group and had an epidemic amongst other than hospital staff in contrast to the other countries. WHO got yelled that perhaps they were too hot-headed shouting wolf, but in a comprehensive analysis of the SARS epidemic WHO was praised for their quick clear statements based on current and real-time updated knowledge.
There is also strong evidence to suggest that we have seen looking at epidemics in the wrong way – it is not the disease itself that is changing, but our global migration and travel patterns that change. This has implications for how infections spread and where the highest risk of infection is experienced, but it requires that we are ahead, constantly monitoring and analyzing human patterns – even in Africa’s major cities and the most rural areas of the African continent as well as in any country or continent: Europe, China, Russia, Syria, Mexico or India.
INERTIA OF THE WORLD COMMUNITY
It may have also played a role in the current Ebola outbreak that it spread so quickly to some of the most rapidly growing West African mega cities with huge slum areas that are impossible to control also in the case of epidemics. Urbanization and it’s health risks shouldn’t come as a surprise to the global health donor community – but in spite of many alarming reports the past decade it still surprised the international community. That wasn’t very flattering.
The first cases of Ebola in Guinea-Conakry were apparently reported as early as December 2013. In late January 2014, a report of 5 suspicious deaths all with the hall marks of a hemorrhagic fever but that report did not reach the national health authorities until much later. And WHO didn’t react until MSF expressed concern about the situation. It probably caused extra delays and thus a spark to an epidemic that Guinea is a large country with relatively sparse contact with the surrounding countries and a staggering health care system that is lacking confidence among the population. We could have intervened in April 2014 – the necessary information was available but was ignored and circumstances were misinterpreted – but we waited till the little virus with only 7 genes took a flight to Texas and to Spain in September 2014 before we acted.
The greatest worry about the Ebola epidemic, however, has been the apparent inertia of the world community. Even when it became clear that there was a completely different type of Ebola epidemics than in the past, there was virtually no response before the first cases were suspected in Europe and the United States. But in reality there is a much bigger and even more terrifying inertia in the way international donors, including DANIDA, has turned a blind eye to decades of countless research reports that have shown how the public hospital sector in parts of Africa are largely useless or in some cases detrimental to health. Paul Farmer, Professor of Global Health at Harvard University (physician and anthropologist) has estimated in a new article that the mortality rate of Ebola would be down to 10 % if hospitals in West Africa were able to provide ordinary standard of care such as fluid therapy and normal hygienic procedures.
PROBLEMS IN AFRICAN HOSPITALS
And Ebola continues to reveal the comprehensive consequences of decades of failure to invest in health care and education. Now that the epidemic has been raging for a longer period we encounter a new problem: many hospitals in Africa don’t have safe procedures for hospital waste and finds it difficult to dispose of medical waste from Ebola departments. Prior to the epidemic hospital waste was merely dumped behind the hospital, but the Ebola epidemic with its media focus has revealed that the practice is in fact deeply problematic while the staff still don’t know what to do as the disposal problem never has been a donor darling global health challenge.
But the problems in hospitals in Africa are deeper and have their roots far back in time. In a large study of district hospitals in low-income countries, 76% of emergency patients were exposed to clearly insufficient clinical assessment, suboptimal treatment and total lack of monitoring. Most doctors and nurses had insufficient knowledge about most diseases and their treatment and had unacceptable clinical practices even for common diseases. Existing guidelines were not followed, medications given in the wrong doses and used in largely obsolete therapies. Fear of Ebola has resulted in a 53 % reduction in hospital visits in Guinea because of fear of contracting Ebola, according to an Oxfam report this week and Sierra Leone has only 2 doctors per 100,000 inhabitants. Children are not vaccinated and don’t go to school in Liberia.
THE LACK OF QUALITY CARE
A Dutch researcher with extensive knowledge of hospitals in Africa wrote in 1997 an article on hospitals in Africa titled Why we need more of what does not work as it should, “if there is no investment in the hospital sector in Africa at all levels, there will be lack of hospitals in Africa within 10 years”. The Ebola epidemic has shown that he was painfully right, but it’s no fun to get right in such a terrible way.
Politically fragile post-conflict countries with collapsed health systems find it very difficult to turn research to practice without outside support and input. There is a continuing high hospital mortality in African hospitals, and it continues even after discharge from hospital. The huge investment in primary care has not changed the hospitals’ mortality rate which has remained high since 1986 in West Africa. The reasons are economic: lack of education, lack of equipment, lack of medicines and a consequent low morale among employees. There is a large indirect loss of human resources in the health sector in Africa through productivity loss. Poor or improper use of skills / knowledge, high absence- percent, lack of management support and no supervision. The low laboratory quality is also an obstacle to increasing hospital quality.
Corruption, favouritism and preferential treatment for family members is widespread. But it has proved possible to reduce mortality by providing physicians with small incentives, medical kits and broad supervised training. And just by motivating doctors to follow current guidelines a lot would be achieved. Even in Liberia they managed to lower mortality at a privately run teaching hospital by supervision and training. It is well documented that the long haul with broad basic supervision and training at all levels and securing medicine and equipment supply is the only way forward and there is no need for short-term disease-specific programs. Unfortunately it is not the strategy DANIDA and other donors have chosen.
We have failed to see what has being going on right in front of our noses in health care in some areas of Africa: donors have insisted on their own agenda and supported everything else than research, hospital equipment and maintenance, medical training and nursing schools. Now donors pay a small moral price while their policy inflicts a heavy toll on the lives and economy of a range of West African countries leaving a health care system that is even more demoralized and mistrusted than it was before Ebola started raving.
Disasters do not happen and unfold in a vacuum with their own biological rules – disasters unfortunately develop in a global environment among human beings and under the existing terms and conditions. Horror movies about epidemic disasters always begin with a politician or a top researcher, with assumed crushing calm, insisting that he is in control of the situation, while scientists are risking life and limb along with doctors and nurses to get an overview of the threatening world pandemic.
A team of American researchers came with that statement in Sierra Leone in April 2014 – Ebola cases have re-emerged for the third time in the country last week. Any frequent moviegoer now the politician and the researcher in the disaster movie are not in control of anything, but it usually takes a long film before the scientist realizes that something is totally wrong in the lab and then he has to convince the obstinate politician that something has to be done. In fact, it took much longer – from December 2013 to September 2014 to go through the real epidemic horror movie. That’s no excuse. DANIDA elected, despite widespread criticism from scientists 10 years ago, to stop aid to the health sector in Africa. That was no excuse then and it’s even less of an excuse now. The church in the United States that put up the sign in the picture may be very right in a different way than they had imagined.
EXPECT THE UNEXPECTED
All the previous Ebola epidemics unfolded in rural areas and we kept thinking of Ebola as a thrilling, rare, tropical virus that would kill fast and be stopped fast. Nobody in the international Global Health community had imagined that it could pop up anywhere, not just in rural areas.
Dr. Felix Kaducu, head of Gulu referral Hospital in Northern Uganda that was struck by an Ebola epidemic in year 2000, had the following message to West Africa and international organizations: don’t expect the Ebola virus and its victims to show up where it’s most convenient – it never does, so expect the unexpected and be prepared.
The other important experience from the Uganda 2000 Ebola outbreak was that in the beginning it took 14 days (!) from blood samples from suspected cases were drawn and sent to the South African reference laboratory until the results came back. Only when a local lab was established did the clinicians get the results quickly enough to start treatment and calm down community fears of Ebola – time that would allow Ebola to spread silently.
We still haven’t learnt. Just as we keep intervening against terrorism based on what we have already seen and terrorists keep inventing attacks in ways we haven’t seen, we need researchers that can look around corners and analyze possible and impossible scenarios and that requires research investments both in the countries where emerging events are frequent but also in areas where we don’t expect new public health threats to arise – because they will eventually. Ebola is the most recent example. SARS was the previous. Do we need more examples?
INVESTING IN HEALTH IN DEVELOPING COUNTRIES PAYS OFF
The Lancet’s latest commission: Global Health in 2035: a World Converging within a Generation proves conclusively that it pays off to invest in health in low-income countries. The Lancet’s editor Richard Horton points out that this was shown in the 1993 development report without it being taken seriously enough. The World Bank remarked to the latest Lancet report that this time it is time for higher aspirations and greater investment in health.
Or as Sierra Leone’s President Ernest Bai Koroma himself noted: “What is required was required yesterday”.
Meanwhile, hospital equipment worth millions of dollars is waiting in the port in Freetown, Sierra Leone – waiting for someone to find out who constitutes the “Emergency Operations Center”, which must consent to medical devices for treating Ebola patients can be released from duties that require huge amounts of an import permit. The water fell out of the bucket – can we manage to get just some of the water back in the bucket?