Gostin L. Tackling the Ebola Epidemic. JAMA Forum Archive. Published online August 19, 2014. doi:10.1001/jamahealthforum.2014.0033
The Ebola virus epidemic in West Africa is now out of control, but it shouldn’t have come to this. Ebola virus disease (EVD) is a preventable disease, but the current epidemic is challenging efforts to contain it. Previous outbreaks that have occurred since the virus was first detected in 1976 have been confined to rural areas. This time, EVD has reached the urban landscape, with people and animals congregating together. Extensive travel across land borders and by air is furthering its spread.
Lawrence Gostin, JD
The most affected countries—Guinea, Liberia, and Sierra Leone (with recent spread to Nigeria, which currently has a dozen cases)—are ranked lowest in global development and do not have the basic infrastructure to contain the Ebola epidemic. Even with international help, it will take at least 6 months to bring the crisis under control, according to Médecins Sans Frontières/Doctors Without Borders. For now, Ebola is spreading unchecked because of such factors as fragile health systems in resource-poor countries, cultural practices, and deep-seated distrust.
Being treated or working in a hospital in affected states is hazardous. Health professionals are the most susceptible: they typically care for infected patients without personal protective equipment and infection controls; they lack training in differential diagnosis of and treatment for EVD; and they are underpaid. Patients, too, perceive that hospitals in the affected countries are unsafe places that offer little effective treatment. Consequently, patients with Ebola-type symptoms stay away, and those who need treatment for myriad health problems—from AIDS and malaria to cancer and heart disease—remain untreated in the community.
The persistence of traditional burial and other cultural practices in West Africa also make it more difficult to contain Ebola. Loved ones come in close contact with the deceased, including ritual touching and bathing. Burial practices create the conditions for transmitting EVD, which then can be spread throughout the community. Another practice, consuming bush meat, which might include animals that are reservoirs for Ebola virus, is a traditional source of food, especially for poor Africans, providing life-sustaining protein. Women, as the traditional caregivers, are more likely to contract the virus than men.
Further challenging attempts to contain the spread of Ebola are common misperceptions, such as the belief that aid workers from medical groups were spreading the disease. Public education has been neglected and governments have curtailed accurate news reporting about the crisis. Epidemic control requires trust and an informed public, so risk communication is fundamental to controlling Ebola’s spread.
Also related to the issue of trust has been the use of scarce experimental therapies. More than 20 Ebola outbreaks have erupted in sub-Saharan Africa, yet the world was unprepared for the current tragedy, with no licensed vaccines or treatments. (This lack of readiness would not have surprised Albert Camus. As he wrote in The Plague, “Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads.”)
An experimental drug called ZMapp, which has neither been proven effective nor tested for safety in humans, was available in scarce amounts and was administered to 2 US aid workers and, reportedly, to a Spanish priest. The last remaining doses have now been delivered to West Africa, but the initial perceived preference given to white foreign workers fueled a sense of injustice. Although selecting who should get the untested treatment is an agonizing choice, it’s my opinion that priority should be given to African health workers, who die of Ebola in far greater numbers than do foreign workers. In any case, it is vital that allocation decisions be made fairly and transparently. The decision to treat the foreign workers was made behind closed doors without community consultation. Going forward, high-resource countries should create public-private partnerships to ramp up development and rigorous evaluation of vaccines and treatments.
Adding to the distrust that hinders attempts to control the epidemic is local populations’ fear not only of Ebola but also of the militarization of the disease. Countries have erected cordons sanitaires (guarded lines preventing anyone from leaving), but are using ancient methods to enforce the quarantine. In West African hot spots, armed troops have established blockades, closed roads, and banned travel beyond the guarded perimeter.
As a result, the populace is finding it hard to obtain food and other basic necessities. Targeted travel restrictions may be necessary, but there is a smarter way to go about them, through humane care and incentives. Governments should provide people with nourishing food, health care, and psychosocial support. Transmission hot zones can’t be ignored, but neither can the needs and human rights of communities.
Fragile health systems are at the root of the problem, and bolstering them is a key to fighting Ebola and preventing another uncontrolled outbreak. Affected countries are unprepared for Ebola’s complexities; they are unable to provide all their people basic health services, much less the requirements of an Ebola response, including full body protective gear, specially trained health workers, isolation units, and advanced laboratory capacity with higher biosafety capabilities. Building strong health systems would rebuild the most basic community asset: trust. Looking ahead, the international community should mobilize to provide sustainable funding scalable to needs.
This crisis represents a manifest failing of the international community, particularly its wealthier members, which ought to have been generous in supporting surveillance and response capacities obligatory under the International Health Regulations (IHR). The World Health Organization (WHO), the World Bank, and the United States Agency for International Development, among others, have made notable pledges of support. But what the region needs now is an assurance that these funds will be ample and sustainable.
To address this need, I propose an emergency, and then an enduring, “Health Systems Fund” administered by WHO (with participation of local governments and civil society) and supported by high-resource countries. Considering the funding needs, an immediate (emergency) down payment of $200 million is needed for the affected countries and their at-risk neighbors. The money should be spent to strengthen health systems. Building on recent pledges of support, these additional funds could reward and motivate frontline health workers, ensure humane conditions in communities subjected to cordon sanitaire, and establish surveillance and response preparedness.
This fund would be surprisingly affordable, with this initial installment of funding representing only 1% of international health assistance. Growing the fund over time into a multibillion dollar funding channel for lower-income countries would finally make it possible to mobilize the resources envisioned in the IHR, as well as the growing global commitments to universal health coverage. Eventually, the fund might be merged with the Global Fund to Fight AIDS, Tuberculosis and Malaria into a new Global Fund for Health.
It is in all states’ interests to contain health hazards that may eventually travel to their shores. But beyond self-interest are the imperatives of health and social justice: a humanitarian response that would actually work, now and for the long term.
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