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 earthquake through the otherwise friendly UN peacekeeping 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 none of them 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.
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 three 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. 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 picture 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 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 systems, 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 for 60 years ago, or in the early years of the African HIV epidemic when African peacekeeping forces with rocketing HIV prevalence were deployed to rural African 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 in the beginning focused too much on treatment 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 mobilephones 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 up 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.
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 – until 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 it had.
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. 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 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 the 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 Walter Onema says: This thing can happen anywhere.