The intensive care unit was filled with children, sometimes five to a bed. In the suffocating heat and at a frantic pace, the medical team worked day and night, seven days a week, to tend to the 198 patients admitted to a hospital with just 80 beds.
What was causing the massive influx of patients to Ankoro Hospital nestled deep in the Democratic Republic of Congo’s (DRC) Katanga province? Measles. A virus for which a vaccine has existed since 1963 and is part of the normal schedule of immunizations for children. Complicated by malnutrition and malaria, most of the children in the ICU struggled to survive. By December 2015, the outbreak had sickened at least 40,000 people and led to nearly 500 deaths.
The Katanga measles outbreak is emblematic of how a combination of inadequate surveillance systems, politically motivated decisions, poor healthcare for local communities, and little response capacity from health systems continues to turn epidemics—outbreaks without the capacity to pose a global threat—into devastating events for communities. The Katanga measles epidemic is just one example. Massive cholera outbreaks that have sickened hundreds of thousands of people in Angola, Haiti, and Zimbabwe over the past decade also illustrate failures in disease prevention, surveillance, and response.
Over the last decade, our organization Doctors Without Borders/Médecins Sans Frontières (MSF) has responded to scores of outbreaks in different countries where internal and external constraints have, in some cases, led to an inability to implement a proper and timely epidemic response. This failure to respond translates into excess mortality directly linked with the disease causing the outbreak. In the case of a measles outbreak, an increase in childhood malnutrition often follows the spread of the virus.
At the World Health Organization (WHO) Executive Board meeting in January, MSF warned the global health body and its member states that without proper investment in preventing and responding to outbreaks of cholera, malaria, measles, meningitis, and a group of often-overlooked diseases spread by viruses and parasites, they are likely to pose an even greater threat to people’s health in the year ahead. Current strategies to prevent major outbreaks of disease show only limited success. Epidemics continue to occur, often with devastating consequences for some less developed countries. Epidemics open up cracks in national health systems, exhaust available resources, and, in many cases, kill large numbers of people.
Tip of the Iceberg
Though the devastating Ebola virus outbreak that killed more than 11,000 people in West Africa has triggered, rightfully, a necessary discussion on epidemic preparedness and global health governance, it is only the tip of the iceberg. The measles outbreak—the second in the past five years in Katanga alone—emerged while much of the world’s attention was still focused on the Ebola epidemic and while numerous public health experts were contemplating how to improve future responses to new and emerging diseases.
The reality is that not all epidemics are viewed equally. The transnational threat posed by a “level four” biosecurity pathogen, such as Ebola, is not comparable with measles and other infectious diseases. Yet local and national outbreaks of diseases such as malaria, measles, and cholera—which are well-known, preventable, and treatable—are still claiming hundreds of thousands of lives every year. One has to wonder how we can expect to defeat transnational outbreaks of emerging and rare diseases when this reality still exists today.
No one can say for certain just how large a problem epidemics of preventable diseases are today. It is not easy to know how many outbreaks are occurring in the world at a given moment. The WHO-coordinated Global Outbreak Alert and Response Network (GOARN) has limited scope, and while there are several sources of information, there is no single validated and real-time database to consult. From the information available publicly, one can conclude that the majority of small outbreaks (with or without adequate responses) are most likely not reported, thereby making it difficult to quantify the real number of outbreaks worldwide or their impact on a population.
Communicable diseases with epidemic potential continue to be the main cause of mortality in children ages one to 59 months worldwide. Sub-Saharan Africa has higher child mortality rates than any other region on the continent, and this is predominantly related to vaccine-preventable and infectious diseases.
According to the WHO, “a disease outbreak [or epidemic] is the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season. An outbreak may occur in a restricted geographical area, or may extend over several countries. It may last for a few days or weeks or for several years.”
Epidemics are often viewed as some sort of failure at a political level, and given the gaps in prevention, this is in some respects true. No one likes to take ownership and acknowledge failure.
Declaring an outbreak can be also be delayed by reasons as simple as not anticipating an epidemic or not recognizing the disease. In some cases—areas with endemic cholera or malaria, for example—there is an “acceptable” seasonal rise in case numbers, or there may be late recognition of epidemic thresholds where there is ongoing, year-round transmission. Outbreaks affecting hard-to-reach or remote populations are also difficult to identify and respond to appropriately.
The alarm is usually triggered either by analysis of trends or formal and informal notification of an increased number of cases. From that moment, an investigation needs to take place to confirm—or rule out—the existence of an outbreak. Once this is done, the local Ministry of Health must declare an outbreak and action will be taken. This timeline is sometimes not straightforward, however, and several steps may happen at the same time. An emergency response may be launched without official confirmation or without a declaration of an outbreak by the health authorities.
Having the outbreak identified and declared is only the first step on the path to controlling it. Adapting the response to the specific moment of the outbreak is sometimes impossible, as there may be no epidemiological curve due to poor surveillance or no possibility of calculating attack rates due to a lack of reliable population figures.
The fact that the Katanga epidemic went undeclared for months is hardly surprising. A systematic review of infectious disease outbreaks in 22 fragile states between 2000 and 2010 identified long delays from onset to detection, as well as further delays from detection to investigation, confirmation, declaration, and control. This can translate into up to five months from the first case outbreaks to the start of control measures.
The study also found that just one of the 56 epidemics reports consulted for the review was issued by the national authorities; the rest were issued by external organizations. This may indicate that national ownership of surveillance, alert, and outbreak control is weak, and reinforces the hypothesis that small outbreaks go underreported and most likely unnoticed.
As a result, an unknown number of people—largely young children—are invisible casualties of large epidemics that should otherwise be preventable. An MSF study of measles-related deaths during the 2010-2011 Katanga outbreak estimated that deaths linked to the epidemic could be up to ten times higher than the number of deaths reported by health authorities.
By Motorcycle and Canoe
When measles or other epidemics are allowed to rage without adequate local and international responses, it makes it all the more challenging to put out the fire. This is a symptom of poor surveillance, lack of willingness to report epidemics, and inadequate capacity to respond to epidemics once they have been identified. The Katanga outbreak offers a telling example of these challenges for epidemic response.
A province nearly the size of Spain and with more than 10 million inhabitants, 24 of Katanga’s 68 health zones have been affected by the measles epidemic that started in early 2015. To try to stop the outbreak, MSF and Congolese Ministry of Health teams working through the province vaccinated more than 962,000 children aged six months to 15 years. MSF teams also provided medical support to nearly 30,000 children with simple or complicated cases of measles.
Our MSF colleagues have described this ongoing battle against measles as the equivalent of fighting a forest fire blindfolded. The epidemic is declining in Katanga province due to their efforts, but measles cases are being reported in most other provinces in DRC, risking triggering a new outbreak.
Measles is highly infectious, and to prevent its spread, it is necessary to immediately launch vaccination campaigns once an outbreak emerges, and additionally, to ensure free care to patients to prevent mortality and complications. Yet Katanga province is home to some of the deepest jungles and most isolated villages on the planet. Roads are virtually nonexistent and bridges are often washed out. Throughout the vaccination campaign, MSF medical teams were forced to abandon their vehicles, bringing coolers in hand to ensure the vials remain within the appropriate temperature range, and take to motorcycles and canoes to reach certain villages.
Getting supplies in is even more challenging. For several months, the main road that links this area with other cities had been cut off because of construction work. And fuel shortages meant that trains no longer reached the area. As a result, supply chains were no longer functional, and health centers were suffering unprecedented shortages of medicines. The few drugs that were available cost more than most people could afford, leading people to not bring their sick children to health centers for treatment. Those that braved the journey arrived at MSF-supported hospitals often after five to six hour journeys on motorcycle taxis with their ill children in tow.
All of these factors exacerbated the epidemic. New cases of measles appeared every day across the province, but the number of organizations involved, and the means allocated for responding to the emergency, have never been sufficient. This example speaks volumes to the existing gaps in the global health regulatory system.
A Global Health Security Framework?
The global health regulatory system has evolved over the past two centuries as medical science began to gain a greater understanding of the epidemiology of infectious diseases. The cholera epidemics that overran Europe between 1830 and 1847 prompted intensive efforts to address gaps in public health, leading to the first International Sanitary Conference in Paris in 1851. Eventually in 1948, the WHO Constitution entered into force and in 1951 member states adopted the International Sanitary Regulations, later replaced by and renamed the International Health Regulations (IHR) in 1969.
These regulations were primarily intended to monitor and control six serious infectious diseases: cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. In the early 1990s, the resurgence of some well-known epidemic diseases, such as cholera in parts of South America, plague in India, and the emergence of new infectious agents such as Ebola, resulted in a resolution at the World Health Assembly in 1995 calling for the revision of the regulations.
In May 2001, the World Health Assembly adopted a resolution, “Global health security: epidemic alert and response,” in which the WHO was called upon to support its member states in strengthening their capacity to detect and respond rapidly to communicable disease threats and emergencies.
Finally, in 2005, the World Health Assembly endorsed the IHR second iteration, which aims “to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” The IHR require countries to report to the WHO those disease outbreaks and public health events that have the potential to cross borders and threaten people worldwide. In reality, economics and trade interests, rather than the imperative to prevent disease-related deaths and suffering, would be the driving force behind a global public health architecture.
As of 2013, only 20 percent of the WHO’s member countries achieved compliance with the core capacities outlined in the IHR. One of the foundations of the IHR is to strengthen national disease prevention, surveillance, control, and response systems. This lack of capacity, combined with underlying limited access to health care for many populations, further increases the probability that outbreaks will continue to occur without being noticed and responded to.
Surveillance is a central element of IHR compliance. But public health surveillance (including outbreak detection and planning capacity) alone is meaningless without a capacity to deliver direct care to affected populations. The effectiveness and efficiency—lower costs—of outbreak response improve as patients are rapidly cared for. In a similar way, offering direct care to patients is a critical condition to establish confidence and trust in communities, and to prevent hostile reactions to epidemic control measures.
Unfortunately, the revised IHR rely only on state sovereignty—countries ensuring their capacity and willingness to conduct surveillance and respond to disease outbreaks and progress is measured by self-assessment, not by an external evaluation of any kind. The IHR do not address enough international response mechanisms and populations concerns when countries are ill-equipped or unwilling to act.
Countries willing to declare and respond to an epidemic according to prescriptions of the IHR must find incentives in the global health security system, and not only the prospect of economic, political, and financial fallouts, as seen in the closure of borders, interruption of trade, and decline in funding that initially accompanied the declaration of the Ebola epidemic in West Africa. This lack of incentives is evidenced by the consistent hesitation of local authorities to proactively detect and declare epidemics.
Indeed, the development of an efficient and robust emergency response, supported by the international community as required, is an integral part of the strengthening of national health systems. The capacity to respond to emergencies is a key indicator of the quality of health systems. Epidemics and other health emergencies will continue to occur. Without undermining the importance of prevention and the development of long-term goals, emergency response needs to be prioritized and should not be put in competition with long-term goals.
Malaria is a good example of the deadly consequences of weak health systems. The parasitic disease is endemic in 97 countries around the world. There were an estimated 198 million cases in 2013, with 90 percent of malaria deaths occurring in Africa. On average, only two in every 100 cases of malaria reported are the results of outbreaks, but one in every four deaths is outbreak-related.
Even though progress has been made in malaria control programs and the total number of cases and deaths has dropped significantly in the past few decades, malaria is still among the top five causes of mortality for children in several African countries. In addition, unexpected high seasonal peaks and outbreaks have been reported in recent years in the Sahel region and DRC, with high mortality rates.
In 2014, less than half of the population at risk in sub-Saharan Africa had access to an insecticide-treated net in their household, only 62 percent of the suspected malaria patients were tested in public health facilities, only 70 percent of confirmed patients could be treated with ACTs (artemisinin-based combination therapies) that had been distributed to public health facilities, and fewer than 26 percent of children diagnosed received treatment, according to the WHO.
The reported cases of communicable diseases, however, probably represent just a sliver of the problem. Weak surveillance based on passive case finding at health structures in areas where the population has no access to healthcare, without a proper alert system, makes it possible for outbreaks to occur but go unnoticed. Polio is a good example. Despite having one of the more intensive surveillance systems in place under the Global Polio Eradication Initiative, which requires all cases of acute flaccid paralysis to be reported to the WHO, according to the review mentioned earlier, it was found that poliovirus transmission went undetected for more than a year.
In addition, there are outbreaks of diseases with very low fatality rates that are not even within the scope of the Ministry of Health and the WHO alert system (whooping cough, for one). Diarrheal cases not suspected of being cholera are not reported, and it is very difficult to identify lower respiratory tract infections or pneumonia outbreaks in low-income countries. However, both are listed as top-five causes of mortality in children under the age of five.
No “Silver Bullet”
There is no silver bullet to solve the slow response to epidemics. Many factors have led to this situation. These are a consequence of global health priorities, where the overarching policy priority is prevention and health systems strengthening, rather than emergency response.
Rapid urbanization without proper planning, mass population movements, climate change, and resistance to pesticides and available treatments can and will increase the risk of epidemics in the future. Dengue fever, malaria, chikungunya, and viral hemorrhagic fevers are increasingly being reported in unusual geographical locations, and are threatening larger populations, adding to the problem of new and emerging pathogens worldwide.
A start, though, would be increased investments in the capacities for countries to mobilize local emergency responses to epidemics and the international capacity to support these actions. When there are financial choices to be made, emergency capacity seems to be one of the first to be sacrificed by international organizations. This was the case with the erosion of the WHO’s emergency department as member states shifted focus towards chronic non-communicable diseases.
Closing the gap between theory and practical implementation is one of the main challenges for emergency response. Almost all governments have emergency preparedness and contingency plans; however, the holes appear when the time comes to implement them. All aspects of a response can be covered on paper but, in MSF’s experience, this does not always translate into patients being treated or activities being fully implemented. The minimum standards outlined in the IHR are not even being met.
International interest and investment in containing outbreaks with pandemic potential within the borders of nation states where they occur should not be the only guiding force for responses. The current system needs to be reviewed and reformed to respond to the local needs of populations affected by epidemics, even those that do not pose an international threat.
The global health security concept—at the heart of international health regulations – defines protection against a threat as the main trigger for international action. In countries ill-equipped, the system is not prepared to react unless there is a threat. Under this “defensive” logic, the response to Ebola in 2014 failed with a horrific number of deaths in the region, but in the end the system fundamentally worked as it was designed to work—in the primary interest of wealthier countries. When the first cases started beyond the region into Europe and North America, it took only a few weeks to reach high-level decisions to mobilize an international aid effort.
Lincoln Chen and Keizo Takemi expressed this realpolitik of global health priority setting succinctly when they wrote in the Lancet: “What makes Ebola different from the many other epidemics is the fear of contagion that the lethal disease has precipitated among the public, especially in rich countries. When the rich and powerful feel threatened, global political priorities are accordingly redirected.”
For many epidemics, the rich and powerful will never feel threatened. At MSF, we have seen this scenario play out time and again, and translate into the unacceptable suffering of hundreds of thousands from preventable and treatable diseases. Let’s not wait for a new wakeup call. Today we need to prioritize the response to epidemics in a way that ensures adapted and rapid mechanisms of identification and response to outbreaks, big or small.