Thursday, October 2, 2014
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Responding to Ebola

NEW YORK – The horrific Ebola epidemic in at least four West African countries (Guinea, Liberia, Sierra Leone, and Nigeria) demands not only an emergency response to halt the outbreak; it also calls for re-thinking some basic assumptions of global public health. We live in an age of emerging and re-emerging infectious diseases that can spread quickly through global networks. We therefore need a global disease-control system commensurate with that reality. Fortunately, such a system is within reach if we invest appropriately.

Ebola is the latest of many recent epidemics, also including AIDS, SARS, H1N1 flu, H7N9 flu, and others. AIDS is the deadliest of these killers, claiming nearly 36 million lives since 1981.

Of course, even larger and more sudden epidemics are possible, such as the 1918 influenza during World War I, which claimed 50-100 million lives (far more than the war itself). And, though the 2003 SARS outbreak was contained, causing fewer than 1,000 deaths, the disease was on the verge of deeply disrupting several East Asian economies including China’s.

There are four crucial facts to understand about Ebola and the other epidemics. First, most emerging infectious diseases are zoonoses, meaning that they start in animal populations, sometimes with a genetic mutation that enables the jump to humans. Ebola may have been transmitted from bats; HIV/AIDS emerged from chimpanzees; SARS most likely came from civets traded in animal markets in southern China; and influenza strains such as H1N1 and H7N9 arose from genetic re-combinations of viruses among wild and farm animals. New zoonotic diseases are inevitable as humanity pushes into new ecosystems (such as formerly remote forest regions); the food industry creates more conditions for genetic recombination; and climate change scrambles natural habitats and species interactions. 

Second, once a new infectious disease appears, its spread through airlines, ships, megacities, and trade in animal products is likely to be extremely rapid. These epidemic diseases are new markers of globalization, revealing through their chain of death how vulnerable the world has become from the pervasive movement of people and goods.

Third, the poor are the first to suffer and the worst affected. The rural poor live closest to the infected animals that first transmit the disease. They often hunt and eat bushmeat, leaving them vulnerable to infection. Poor, often illiterate, individuals are generally unaware of how infectious diseases – especially unfamiliar diseases – are transmitted, making them much more likely to become infected and to infect others. Moreover, given poor nutrition and lack of access to basic health services, their weakened immune systems are easily overcome by infections that better nourished and treated individuals can survive. And “de-medicalized” conditions – with few if any professional health workers to ensure an appropriate public-health response to an epidemic (such as isolation of infected individuals, tracing of contacts, surveillance, and so forth) – make initial outbreaks more severe. 

Finally, the required medical responses, including diagnostic tools and effective medications and vaccines, inevitably lag behind the emerging diseases. In any event, such tools must be continually replenished. This requires cutting-edge biotechnology, immunology, and ultimately bioengineering to create large-scale industrial responses (such as millions of doses of vaccines or medicines in the case of large epidemics).

The AIDS crisis, for example, called forth tens of billions of dollars for research and development – and similarly substantial commitments by the pharmaceutical industry – to produce lifesaving antiretroviral drugs at global scale. Yet each breakthrough inevitably leads to the pathogen’s mutation, rendering previous treatments less effective. There is no ultimate victory, only a constant arms race between humanity and disease-causing agents.

So, is the world ready for Ebola, a newly lethal influenza, a mutation of HIV that could speed the transfer of the disease, or the development of new multi-drug-resistant strains of malaria or other pathogens? The answer is no.

Though investment in public health increased significantly after 2000, leading to notable successes in the fights against AIDS, tuberculosis, and malaria, there has recently been a marked shortfall in global spending on public health relative to need. Donor countries, failing to anticipate and respond adequately to new and ongoing challenges, have subjected the World Health Organization to a debilitating budget squeeze, while funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria has fallen far short of the sums needed to win the war against these diseases.

Here is a shortlist of what urgently needs to be done. First, the United States, the European Union, the Gulf countries, and East Asian states should establish a flexible fund under WHO leadership to combat the current Ebola epidemic, probably at an initial level of $50-$100 million, pending further developments. This would allow a rapid public-health response that is commensurate to the immediate challenge.

Second, donor countries should quickly expand both the Global Fund’s budget and mandate, so that it becomes a global health fund for low-income countries. The main goal would be to help the poorest countries establish basic health systems in every slum and rural community, a concept known as Universal Health Coverage (UHC). The greatest urgency lies in Sub-Saharan Africa and South Asia, where health conditions and extreme poverty are worst, and preventable and controllable infectious diseases continue to rage.

In particular, these regions should train and deploy a new cadre of community health workers, trained to recognize disease symptoms, provide surveillance, and administer diagnoses and appropriate treatments. At a cost of just $5 billion per year, it would be possible to ensure that well-trained health workers are present in every African community to provide lifesaving interventions and respond effectively to health emergencies like Ebola.

Finally, high-income countries must continue to invest adequately in global disease surveillance, the WHO’s outreach capacities, and life-saving biomedical research, which has consistently delivered massive benefits for humanity during the past century. Despite tight national budgets, it would be reckless to put our very survival on the fiscal chopping block.

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  1. CommentedVal Samonis

    The biggest deficit is in collaboration among Africans themselves (from different countries). Ebola may force some necessary changes in that; better that way of change than no change, if tertium non datur!

    Val Samonis
    Toronto

  2. CommentedStephen Pain

    One of the biggest problems with dealing with viruses is the general biological conception of what a virus is. A virus is seeking to unlock a door to complete a biological process which was programmed millions of years ago. One might liken it to the programme of a washing machine that had a function in the context of washing. After breaking away it initially sought reentry or reintegration into a washing machine - if it did then it would complete its function. We see in water birds that the avian influenza completes its cycle/function with little harm. In a terrestrial bird it is unable to complete the cycle and becomes virulent and dangerous killing its host. If you think of what happens if you put a washing machine programme in a car, you will see how dangerous it could be. What we should look at is not a war against viruses but seek ways of assisting them complete their initial functions. We should also seek to change agricultural practices so that overpopulation is prevented also in the human context. Hospitals must be more distributed and smaller. Large hospitals are equivalent to battery chicken farms in terms of potential risks.

  3. CommentedShan Jun Chang

    This Ebola outbreak has received a lot of media coverage largely because it's precisely the sort of disease that people can imagine spreading to blight our bounteous and plentiful lands, and this terrifies them. From what I could tell, the general attitude of people in response to news of the American and Spanish aid workers being repatriated home for treatment was something along the lines of "God don't bring it here! Confine it to Africa, where it can go on killing lots of people, just like malaria and malnutrition, other things which are confined there and which as such we don't really care about". And that is why it's probably going for Mr Sachs to get his "global disease-control system", however much it costs, than for him to deal with AIDS, malnutrition, cholera, and many of the other pressing problems that the developing world faces.

  4. CommentedAndrew Brown

    Health supply chains need human resources; the missing link for universal health coverage

    Thank you Dr Sachs for your article ‘Responding to Ebola’, where you challenge the developed world to engage seriously in Universal Health Coverage through a more aggressive approach to health systems strengthening. Within your article you focus on the need for more appropriately trained community health workers and the health commodities they need to complete their work. This is especially so for the current Ebola outbreak. This focus on clinical cadres often overlooks the enabling systems and associated cadres required to enable clinical cadres to do their work, for example health supply chains.

    The Third Global Forum on Human Resources for Health (HRH) was held in Recife, Brazil, in November 2013. The aim of the forum was to seek ways to accelerate progress towards attaining the millennium development goals (MDGs) and how to better achieve universal health coverage. Although significant gains have been made since the 2006 World Health Report, a lack of focus on the human resources required to run public health supply chains sustainably, is a significant oversight that may be preventing further progress.

    Up to a third of the world’s population has limited access to essential medicines, and the health supply chain workforce is crucial if the health-related MDGs are to be attained.1. Of the eight MDGs, four explicitly involve medicines or medical commodities and their availability at the primary care or service delivery point level.2.

    Without access to and appropriate use of quality medicines and health commodities, health systems lose their ability to meet the treatment and prevention needs of the patients and clients they serve. The International Pharmaceutical Federation (FIP) Global Pharmacy Workforce Report (2012) focuses attention on the lack of human resources in this sector, making a link between a lack of pharmacy personnel and inequalities in access to medicines. Sub-Saharan Africa is of particular concern with an average of less than one pharmacist noted per 10,000 population.3.

    Since the first Global Forum in Kampala in 2008, the focus of the HRH movement has been on the doctors, nurses, midwives and community health workers (CHWs) needed to provide healthcare interventions. There has been little consideration given to the human resources required to sustain the public health supply chains that are needed for healthcare personnel to be effective. A March 2013 Lancet article by Singh and Sachs provides an example of the insufficient focus in this area.4.

    Singh and Sachs contend that scaling up the education and recruitment of CHWs is an intervention that would have a small comparative cost and help significantly address the existing health burden.4. This idea has merit, but the full effect of such an intervention will only work if an appropriate enabling environment exists, including the availability of medicines and medical commodities in the right place at the right time. Proposals made by Singh and Sachs acknowledge the importance of the WHO health system building blocks including ‘medical products’, while also stressing the underlying assumption that each CHW is provided with medications and diagnostics.5. This assumption requires more systematic and sustained attention. The supply of medicines and medical commodities is not a straightforward process in many developing countries.

    This is articulated well in the new World Bank publication ‘The Labor Market for Health Workers in Africa: A New Look at the Crisis’, where it is suggested that consideration be given to the enabling environment of health workers so that new and existing healthcare personnel are used more efficiently. It is noted that investments in other parts of the healthcare system may be required, such as equipment, supplies or pharmaceuticals.5. When investing in medicines and medical commodities attention must also be given to the human resources required to sustain the supply chain that makes these items available.

    Separate to the human resources for health crisis, there has been a rapid increase in health assistance from multilateral donors, with such initiatives as the Global Fund, the UN Commission on Life Saving Commodities, and the Global Alliance for Vaccines and Immunization. For these investments to have their greatest impact, the public health supply chains accommodating these interventions need to have sufficient capacity and be sustainable. It is important for these and other programmes to give adequate consideration to issues around human resources in public health supply chains. A simple focus on training is not sufficient.

    Human resources are a key performance driver within public health supply chains. The effective management of a supply chain demands excellence in managing its human resources, an area particularly overlooked in resource-poor environments. By proactively managing plans, policies and procedures associated with people, an organization can improve supply chain performance. Such a systematic approach requires the planning, financing, development, support, and retention of the national workforces needed for the effective, efficient, and sustainable management of health supply chains.7.

    Launched in 2011, the People that Deliver (PtD) Initiative is a global partnership of over 80 organizations who have the joint vision of a world where national supply chain workforces are planned, financed, developed and supported in a way that ensures equitable and sustainable access to the medicines and other commodities needed for optimal health outcomes (http://www.peoplethatdeliver.org/). We currently have activity underway in a number of focus countries including Indonesia, Burkina Faso, Ethiopia and Liberia. In these environments we are engaging with country governments to better assess and plan improvements to current HR approaches including better education approaches, improved career pathways and better performance management.

    From the 27th to the 30th of October 2014, PtD will be hosting its 2nd Global Conference on HR in SCM, Copenhagen, Denmark with a focus on the need to strengthen HR in health supply chains as a key enabler of universal Health Coverage. We also call for increased global attention to a systematic approach to health system strengthening where health supply chains are a key component.

    Sincerely,

    Andrew N. Brown (corresponding author)
    People that Deliver Executive Manager
    UNICEF, Supply Division. Copenhagen, Denmark
    executivemanagerptd@unicef.org

    Benoit Silve
    People that Deliver Chairperson
    Bioforce, Lyon, France
    b.silve1@gmail.com

    Erin Hasselberg
    People that Deliver Lead, Technical Working Group
    Supply Chain Management System, USAID
    Arlington, Virginia, United States of America
    ehasselberg@pfscm.org

    Pamela Steel
    People that Deliver Lead, Research Working Group
    Pamela Steele Associates LtD
    Oxford, United Kingdom
    pam@pamsteel.co.uk

    Chris Wright
    People that Deliver Lead, Advocacy and Knowledge Management Working Group
    John Snow Inc., Arlington, Virginia, United States of America
    chris_wright@jsi.com

    Disclaimer:
    The views expressed in this document do not necessarily reflect those of the U.S. Agency for International Development or of the U.S. government.

    References:

    1. WHO, The World Medicines Situation 2011 Medicines Prices, Availability and Affordability http://www.who.int/medicines/areas/policy/world_medicines_situation/WMS_ch6_wPricing_v6.pdf [accessed 31st July 2013]
    2. UN. The Millennium Development Goals Report 2012 http://www.un.org/en/development/desa/publications/mdg-report-2012.html [accessed 31st July 2013]
    3. FIP. FIP Global Pharmacy Workforce Report. 2012 http://www.fip.org/static/fipeducation/2012/FIP-Workforce-Report-2012/?page=hr2012 [accessed 31st July 2013]
    4. Singh, P. Sachs, J. 1 million community health workers in sub-Saharan Africa by 2015. The Lancet, Volume 382, Issue 9889, Pages 363 - 365, 27 July 2013
    5. WHO, Systems Thinking for Health Systems Strengthening http://www.who.int/alliance-hpsr/systemsthinking/en/index.html [accessed 31st July 2013]
    6. Soucat, A. Scheffler, R. Ghebreyesus, T. The Labor Market for Health Workers in Africa: A New Look at the Crisis . Washington DC: World Bank
    http://documents.worldbank.org/curated/en/2013/04/17657443/labor-market-health-workers-africa-new-look-crisis [accessed 31st July 2013]
    7. USAID DELIVER PROJECT, Task Order 4. 2013. Human Resource Capacity Development in Public Health Supply Chain Management: Assessment Guide and Tool. Arlington, Va. http://deliver.jsi.com/dhome/whatwedo/capbuilding/cbhrscm
    [accessed 31st July 2013]

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