Winston Churchill famously said, “never let a good crisis go to waste”. The Ebola crisis in West Africa is not a good crisis. It is a terrible catastrophe. Yet there is a lesson in Churchill’s words that must not be lost in this crisis. The current outbreak probably arose in Guinea in December 2013 and quickly spread to neighboring Sierra Leone and Liberia and was introduced into Nigeria by a single air traveler. These are some of the poorest countries in the world, with poorly developed or dysfunctional health systems hardly capable of withstanding a major health crisis. The gross national income (GNI) per capita of Guinea, Liberia and Sierra Leone ranges from US$580 to US$1,340 and per capita health expenditure ranges from US$67 to US$200 per year, according to the World Health Organization. While Nigeria has had only a few cases and appears to have contained the outbreak, the thought of Ebola spreading in a country of 169 million people with densely populated cities is indeed terrifying. A group at Harvard was privileged recently to meet with the ambassadors to the U.S. of several of the affected countries and from neighboring nations concerned about transmission to their countries through the auspices of the Harvard Humanitarian Initiative. The dialogue centered on the perceived needs of the countries and how the faculties of Harvard University and Boston University and our colleagues in the affiliated hospitals could be helpful.
Ebola is a truly frightening viral disease that attacks the immune system first, then the vascular system, and then the whole body, ultimately leading to a miserable death in 40-80 percent of its victims. Its symptoms – fever, pain, nausea, and diarrhea – are difficult to distinguish from many other infectious diseases, like malaria and enteric diseases, that already occur in these countries. The virus then progresses until it eventually causes hemorrhaging and organ failure. Additionally, the animal reservoir is unclear, but fruit bats and primates are the most likely possibilities. Its saving grace is that it is transmitted only by direct contact with people suffering from the disease or their bodily fluids and not, like influenza or SARS, by the respiratory route. But Harvard scientist Pardis Sabeti and her team are finding that the virus is already changing genetically to adapt better to its human hosts. An additional reason for optimism is that past outbreaks in East Africa, beginning in 1976 in the Democratic Republic of the Congo and Sudan, and later outbreaks in 2008 and 2012 in Uganda, were curtailed in a matter of a few weeks or months. However, they affected only rural villages that could be ringed off. The current outbreak is more extensive and far more widely spread than any of the previous ones. At the time of writing, the WHO indicates that there have been over 13,000 positive and suspected cases and nearly 5000 deaths. By any measure this is a frightening figure. More frightening is the fact that over 400 health care providers have been infected and 216 are known to have died. WHO admits that all these figures are underestimates of the real magnitude of the crisis, since only a portion of those infected are reported or recorded.
How the Epidemic Can Be Stopped
While much of the recent press coverage has been preoccupied with a few experimental drugs or vaccines that are being developed and whether or not they should be given to a few patients, the reality is that there are currently no drugs or vaccines proven to be safe and effective against Ebola. For this epidemic, there is no magic bullet. Needless to say, the financial incentives for the pharmaceutical industry to develop such interventions for intermittent outbreaks that occur in poor countries are not appealing. There has been some support for the research as part of the biosecurity and homeland security programs and there are some promising candidates, but it is ethically challenging to test them in humans, since the disease is so deadly that there cannot be an untreated control group. However, some creative epidemiological designs have been created to allow new interventions to be tested on limited numbers of people, which will enable their effectiveness to be evaluated.
What are the tools that have successfully been used in the past to stem previous outbreaks of Ebola and other infectious diseases in resource-poor settings? They are the common sense public health principles that have been developed over a century to deal with infectious disease outbreaks and supportive medical care. The public health strategy includes:
- Detect cases of the disease. Because the symptoms early on in Ebola are similar to multiple other illnesses in the affected countries it is necessary to validate the clinical impressions with laboratory tests wherever possible.
- Isolate suspected cases. Separate suspected cases from patients with the disease from healthy people to restrict transmission.
- Provide Personal Protective Equipment—Masks, gloves, fluid-proof or disposable gowns, and eye protection must go to health care providers.
- Follow strict protocols to protect everyone involved with patients. Ensure stringent hand-washing, minimal uses of needles, taking all precautions to prevent infection. It is a tribute to the care provided by Medecines sans Frontieres (Doctors without Borders), which has been dealing with Ebola and related infectious diseases for decades in the poorest places, that none of their health care personnel has developed Ebola disease.
- Provide supportive care. Provide fluids and nutrients aimed at keeping the patients alive until they develop a sufficient immune response to recover. The disease is not easy to treat. Specific medical interventions can be given if there is intravascular coagulation or if there is hemorrhaging, but the basic treatment is to keep the body’s systems functioning.
- Identify contacts of known cases and quarantine the contacts or villages in which Ebola is reported. That requires not only that entry to and exit from such areas is controlled, but also that the people under quarantine are treated humanely and provided with supplies of food, water, and other items necessary to carry on their lives as normally as possible.
- Exercise extreme care in disinfecting bodies, contaminated fluids, linens, and all clothing of ill or deceased patients.
- Inform and mobilize the community. Village leadership can greatly help understanding of the need for isolation and quarantine and dispel rumors. If the outbreak enters cities, which Ebola has not previously done, community engagement becomes very challenging.
Currently, the infection is increasing exponentially and is largely out of control in Sierra Leone and Liberia. The hope is that these strategies that have worked in the past to contain outbreaks and epidemics are likely to work in the current situation, particularly if significant transmission in major urban areas can be contained. That will require a huge influx of supplies, protective equipment, trained personnel, and advisors from abroad. The effort can be accelerated if modern tools such as computers and real time reporting enable the health care workers to follow the changes and movements of the disease. Cell phones and all available media should be used to provide messages that inform and motivate the populations.
The Barriers to Controlling the Epidemic
Capacity. When the Harvard Humanitarian Initiative asked ambassadors what their needs and priorities were, they were unanimous in citing two critical immediate needs: essential supplies for protecting their health workers and families of the sick, as well as training. Clearly there is a critical need for protective personal equipment, isolation facilities, laboratory facilities, drugs for supportive treatment, and disinfectant that are lacking in the overwhelmed health systems. But the overarching message was the need for “training, training, and training.” While protective equipment is necessary, the key to protection when working with any dangerous infectious agent is the training, discipline, and concentration of the health care worker or scientist. Before the epidemic, the data indicated that Liberia had only 51 physicians and Sierra Leone had only 136 physicians, many of whom were not going to their clinics. The recognized need was not simply more outsiders parachuting in and taking care of the sick. They were truly appreciated but are likely to disappear after this crisis subsides. Training local health personnel, nurses, community health workers, and logicians to be able to teach others and ultimately to become self-sufficient is essential in being able to prepare for and cope with infectious diseases, serious outbreaks, and stresses to their fragile health systems.
Travel and migration: The differences between this and prior outbreaks have been the facility of crossing the borders between the three countries most affected and the ability to travel by air to almost any country in the world. Identifying people who are unaware that they have been infected can be valuable, and screening for fevers has recently been instituted in many of the neighboring countries for people entering from the affected countries. There is a need at present for outside help and experts as well as the establishment of hospitals, but many of the experts in infectious diseases and engineers have other jobs and will be able to stay only short times. A ban on travel, currently being urged by some political leaders, would make it impossible for them to return home after their duty tours have concluded, in addition to discouraging others from taking up the fight and volunteering, which would be entirely counterproductive.
Fear: The disease itself can be frightening to behold, and fear of the disease and vast amounts of misinformation and rumors have impeded the control of the outbreaks. Desperately needed hospitals are being closed because of refusal of health staff to work for fear of their own safety. Contacts of patients, rather than seeking care at health centers, are dispersing, hiding from fear, which only contributes to the spread. Foreign health workers are being accused of introducing the disease. False remedies are being peddled. The governments have begun to provide public service messaging and information through the media and also through social networks, but trust in government messages is not always high. Credible information from trusted leaders in the communities will be required to change behaviors, particularly in dealing with the severely ill and deceased. One important aspect of that is not only to have messages that emphasize the danger posed by the disease, but the success stories of patients who survived the disease. Letting the people see that Ebola is not a death sentence and that the earlier it can be diagnosed and treated, the better the outcomes, are the positive stories that need to be told.
Coordination: One of the great dangers in any disaster or catastrophe is the well-meaning but uncoordinated efforts of multiple non-governmental organizations. For a dangerous infectious disease outbreak, not every aid worker is sufficiently trained or experienced. The critical need here is for more people with the appropriate knowledge to be engaged. There needs to be coordination between the government workers, the NGOs, and international organizations like WHO, with the focus on providing the training and protocols to enable the local workers to be safe and efficient. Coordination of aid, including requests for material to care for the patients, for isolation facilities, and for laboratory capacity, is essential to avoid needless duplication and life-threatening shortages. The case of over 10,000 relief agencies flying into Haiti after the earthquake is instructive. Most arrived with little experience in dealing with the country or with cholera. They actually confounded the problems there rather than helping to solve them. There needs to be a structure for coordinating the aid efforts here and in future outbreaks. The deadly nature of Ebola may restrict the number of organizations working there such that coordination between all actors will be challenging.
Strengthening the Health Systems
All of the ambassadors who participated in the roundtable discussions indicated how unprepared their national health systems were for this crisis and how overburdened they were with the ordinary health problems of malaria, HIV/AIDS, diarrheal diseases, maternal mortality, and childhood under- and malnutrition, among other issues. All recognized that their health systems were deficient and struggling The term “health system” means very different things to different people, but the one thing that we must recognize is that health systems are enormously complex.
What is a “health system”? The health of populations is affected by many more sectors of the economy of countries than just the health sector (e.g. transport, education, commerce, finance). WHO has defined health systems as “including all the activities whose primary purpose (italics mine) is to promote, restore, or maintain health. Health systems have three fundamental objectives: 1) improving the health of the entire populations they serve; 2) responding to people’s expectations and providing client satisfaction; and 3) providing financial protection against the costs of ill-health and catastrophic illness.
Components of any health system would include: i) agenda and priority setting; who does it and based on what evidence; ii) financing and resource allocation; iii) health workforce and human capacity; iv) governance; v) access to and provision of health services; vi) scale-up and equity of those health services to reach all segments of the population; vii) logistics and sustainable acquisition and delivery of medicines and medical supplies; viii) the differing roles of the private and public sectors in health care, including traditional healers and local drug shops; and ix) metrics and evaluation of needs, deficiencies, quality, and improvements of the health system itself. Each one of these components is a major challenge for the wealthiest industrialized countries; they are an even more daunting challenge for the overstretched health personnel in developing countries. How does a ministry of health achieve these lofty aims and mechanisms within budget constraints of US$67 to US$200 per capita expenditure on health? And how can the limited resources be allocated to provide the most health benefits to the people? In this context, it was made clear to us by the ambassadors how devastating the outbreaks of Ebola have been for their countries, not only on the patients and their families, the health system itself, but their entire economies. The World Bank has estimated that the rates of growth will already be reduced by half or more. For the three countries that have been growing their economies in the last few years, Ebola has been a real setback, and if not controlled, could be a catastrophe for all of Africa.
The Teachable Moment
“As someone who has worked in global health for over forty-five years, my biggest disappointment has been the failure of the leadership of developing countries to make health and health systems a priority within their countries and in their requests to the international community for development assistance.”
Donald Berwick, a colleague at Harvard, one of world’s great experts on health systems and currently a candidate for governor of the Commonwealth of Massachusetts, has defined “the law of systems” as “a basic principle of systems that every system is perfectly designed to achieve the results it achieves. If we want a greater level of achievement, we must change the system.” Each of the ambassadors of the Ebola affected countries recognized that the health systems in their respective countries were inadequate to the staggering challenges they faced and hoped that we could in some ways help to strengthen their systems.
As someone who has worked in global health for over forty-five years, my biggest disappointment has been the failure of the leadership of developing countries to make health and health systems a priority within their countries and in their requests to the international community for development assistance. There is little reluctance to seek international funds for military assistance or for business investment, but little demand from countries to strengthen their health systems, except in disasters. When they do, extraordinary improvements in health systems and the health of the people are possible. This is nowhere better exemplified than in the enormous progress made in health by Rwanda, a country not facing a current epidemic but with a GNI of US$1,329 per capita, similar to the countries facing the Ebola crisis. Since 1990, under 5 mortality and maternal mortality were reduced by two-thirds, AIDS deaths dropped by 40 percent, life expectancy at birth doubled to 63 years, and basic universal health care was instituted, with 60 percent of the health expenditures derived from external sources.
If there is any lesson from the quotation of Churchill, it is to recognize and take advantage of the opportunity in a crisis. In our dialogue with the ambassadors, one of our messages was that the tragic crisis of Ebola offered an opportunity to request from the international community–any of whose countries could be threatened by Ebola or the next epidemic–not only urgent supplies like rubber gloves, masks, and body bags, but also significant investment in strengthening their health systems. It is important that with the adoption of the WHO-sponsored International Health Regulations seven years ago, a treaty obligation signed by 194 countries, every country vowed to strengthen its health systems in very specific ways to protect its people and those of other countries. It is tragic that aid was not forthcoming to implement that treaty, which should have prevented the current epidemic.
Donor countries and agencies have contributed enormously to improving health in developing countries over the past decade. Development assistance for health has increased from US$6 billion in 1990 to US$31 billion in 2013. A great deal of that assistance has focused on specific diseases–the Global Fund for AIDS, TB, and Malaria; the Global Alliance for Vaccines and Immunization (GAVI); Stop TB; Rollback Malaria; the Partnership for Women, Newborns, and Children; Neglected Tropical Diseases, etc. Each of those contributions requires accountability and devotion of resources within countries to work on the funded disease problems. That entails a lot of reporting separately to each donor and huge transactional costs for the countries. Too little of that development assistance for health has gone to strengthen the national health systems and their necessary components that have to address all of those disease problems, let alone epidemics such as Ebola. Additionally, health systems are enormously complex enterprises. Hopefully, the outbreak will be contained over the course of the next year, but the Ebola crisis is an opportunity for the countries affected, as well as their neighboring countries that may be affected, to formulate the needs of their health systems and request support from the international community. For the international community, the situation is an opportunity to realize the value of investments in strengthening health systems and the price to all countries for failing to do so. It is an opportunity that will quickly fade as the crisis is resolved. The moment to teach the international community how they can strengthen health systems in the resource-poor countries–not just for the present crisis, but for sustainable improvement of health in all developing countries–is now.
The best way to protect the populations of Europe and the US against Ebola is to contain the epidemic in West Africa. The low income countries account for only two percent of global spending, yet they bear about 60 percent of the world’s disease burden. If health is made a priority, the international community can do a great deal to help strengthen the health systems of even the poorest countries. Hopefully this tragic Ebola crisis will remind everyone that in the realm of health, there is no place from which we are remote and no one from whom we are not connected.