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The Ebola epidemic: No effective therapy without proper diagnosis
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For epidemiologists, infectious disease specialists and other public health professionals, the current Ebola epidemic is something of a vindication. The stupefying cost of the disaster — in lives and in dollars — is confirmation that the world should, in the midst of so many competing demands on its attention, renew its commitment to outbreak detection and response.
This feeling is understandable, and discussions of early detection, contact tracing, early warning systems and educating the public have their uses. But this technical, expert focus is also dangerously myopic. It is even, in some ways, symptomatic of the errors that have landed us in the dangerous place we are in today.
The lack of preparation and surveillance and the slowness of the international response are the end-organ manifestations of deeper dysfunctions within the affected countries and within the international public health world. If we don’t understand and address these dysfunctions, we will not only risk prolonging the present outbreak; we will leave ourselves just as vulnerable to future catastrophes. We will be like the rookie physician who, seeing a patient with fever, unstable blood pressure and high white blood cell count, proceeds to mitigate each of these symptoms separately and then wonders why the patient isn’t getting better.
A patient with these symptoms needs to be assessed for underlying pathology, such as sepsis or leukemia, and treated accordingly. What are the underlying problems that we need to understand, and address, to get over this Ebola epidemic?
Emmanuel d'Harcourt
The first is the long-standing crisis in public workforce management in many low-income countries. In the three affected countries, as in a number of other African countries, public employees are paid unlivable wages — and even those are paid irregularly or, in some cases, not at all. As a consequence, health workers take time away from their “day jobs” to take clinical positions in private facilities so that they can feed their families. Another issue is that advancement through the system is seldom based on competence. Individuals with no track record of achievement can rise to high levels of authority, while extraordinarily devoted and competent professionals linger, unrecognized, on the periphery of the system. These problems were directly linked to the spread of the Ebola epidemic in West Africa: the population suspected the disease announcement was a ploy of underpaid public servants, and poor decisions were made by people who probably should not have been in key decision-making posts. There is little point in setting up surveillance systems or conducting training if the basics of sound human resource management are not in place. Donors need to demand — and pay for — reforms in this area before sinking millions of dollars into activities that cannot be sustained without a competent, motivated workforce. One first step would be to formally register all employees of the public health system and guarantee them a regular, living wage. This is a costly measure, but as the Ebola epidemic has demonstrated, it’s much cheaper than the alternative chaos.
A second, even more difficult issue is the lack of trust between the population and government, which is an enormous issue in all three of the principally affected countries, Liberia, Sierra Leone and Guinea. This is an issue widely known and discussed within those countries, but which has received little attention from global public health authorities. This mistrust is the result in part of historical circumstances, but it is maintained by ongoing, brazen corruption — as seen in the midst of the current Ebola epidemic. These violations of the public trust make it difficult for public health campaigns to have any impact. One of the remedies, that of donors and agencies putting in place basic measures to stop corruption, would seem obvious, except that it’s not being done. In Sierra Leone, for example, some officials used crude techniques, such as fake invoices, to divert funds from the Global Fund to Fight AIDS, TB and Malaria. This was just one elementary form of corruption that happened to be documented in shocking detail in a public report. Donors and other agencies need to open their eyes to abuses and take basic steps to limit their occurrence. This will do more to getting the public on board than fine-tuning the language on Ebola prevention posters.
The third and arguably most challenging issue isn’t about the affected countries — it’s about us, the international responders, and the organizations we work for. This starts with the United Nations. WHO representatives for each of the affected countries were suddenly replaced after the Ebola outbreak finally gathered intense global attention. A number of unofficial accounts suggest that, even before Ebola, there had been doubts about whether these representatives were the right fit for the job. Liberia, Sierra Leone and Guinea faced some of the greatest public health challenges in the world, with extremely high child and maternal mortality; public health logic indicates WHO offices there should have been led by the agency’s best staff. The questionable staffing choices are, to a large extent, directly attributable to the political nature of WHO’s management. It makes little sense to continue to bemoan WHO’s underperformance without looking at what we can do to change its governance structure. And the problem doesn’t end with the United Nations: implementing agencies, including donors, also face governance and competence challenges. The governments of the United States, United Kingdom and other major donors, such as the Scandinavian countries, are in a position to do something about the problem. We are, as public health professionals, as well positioned as any citizens to advocate for our governments to make difficult changes. Such advocacy is likely to have far more impact on improving future outbreak response than merely increasing funding to WHO, or proposing technical reorganizations within the agency.
The lesson of the global Ebola epidemic is difficult, but clear. It’s not enough for us to be experts. We need to be citizens, calling on people in power — in the countries involved, in donor agencies, in our own agencies — to make difficult changes. This is much less comfortable than providing technical answers to technical questions. But it’s the only way our patients will get better, and stay better. Isn’t that worth a little discomfort?
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Emmanuel d’Harcourt, MD, MPH, is senior health director of the International Rescue Committee, a global humanitarian aid, relief and development nongovernmental organization founded by Albert Einstein. He can be reached at harcourt@rescue.org.
Disclosure: d’Harcourt reports no relevant financial disclosures.