Ebola: Away from Panick to Planning
The raging outbreak of Ebola virus in West Africa, a strain
never seen in the region, is scary indeed. To see and read about medical
professionals who are supposed to know more than anyone in the society, fall
helplessly in the line of duty is very frightening. And when the media love for
anything drama is added; fear goes off the roof. Ebola is another of Africa’s
brand-killers. And it seems to take the shine away from the story, of a
continent that has been rising unprecedentedly in a post-financial crisis era,
where economic growth is in short supply. Even the recent historic US-Africa Summit
and its outcome were overshadowed by the world-wide panic over the viral
contagion. Two African Heads of States of the affected countries even declined
an opportunity to take pictures with the first
American President of African blood— preferring to stay back to lead emergency efforts against
the disease— a rarity in Africa, albeit.
As if to further add fear. The World Health Organization,
the world’s leading health agency, has declared Ebola outbreak and spread a
global public health emergency— an extraordinary health event, the third in
recent years after swine flu and polio. The organization has further labelled
the epidemic as ‘’out of controlled’’ and most recently observed that the over
2000 confirmed cases and more than 1000 deaths in the three affected countries,
have been ‘’vastly underestimated.’’ Medicins San Frontier, a reputable
international NGO, has signaled no end to the tunnel yet. MSF projects another
six more months to contain the virus. While Ebola has struck panic at the core
of the political, health and social establishment, as a killer, it pales greatly in
comparison with Africa’s health challenges. Without a forward looking approach
to address the roots of the virus, all the firefighting to contain Ebola could
end up harming Africa more than the disease itself. In fact, what justifies the
unprecedented local, national and global (dis) attraction over Ebola.
Price of Herding
The virus seems to have unleashed the animal within us, in
the face of danger: fear, confusion and breakdown. Like ‘’sheep’’, African
governments individually strive to appear as doing something: suspending air travels to key destinations,
even against a WHO’s advice that air travel poses low risks of transmission.
One country issues a suspension, others follow seemingly without questioning. Those
seemingly rational decisions, made by governments, citizens and companies on an
individual basis, when taken together, may end up doing more harm than good— if
no disproportionate action had been taken in the first place.
The cost to Africa as whole is high, and disproportionate on the affected economies. While it is difficult to put an exact estimate, the extent of damages to countries would depend in part on the duration of spread of the disease. Early projection from the World Bank has already revised the growth forecast for Guinea by 1 percentage point ($62million), almost half of what the government spends on health care a year. The Liberian Finance Minister has also revised downward the IMF country growth forecast of 5.9%[1].
The panic and confusion could be more disruptive than the
disease itself. While one cannot put money value to life, the true economic costs
of pandemics are usually way off the mortality figures. For example, the outbreak of a relatively
rare disease like Severe Acute Respiratory Syndrome (SARS) with 8,273 cases as
of 2003, caused just over 800 deaths[2]. But in
terms of damage to the global economy, the figure was more than $50 billion in
less than a year, more than the value of Kenyan economy, the 4th
largest in Africa. While we can only know for sure, whether present policy
responses were overblown two years at least after the end of the outbreak, as
humans there is a natural tendency to overprice the risks of viral
transmission, even for a rare pathogen with statistically low risks like Ebola (MacNeil A, 2012).
While the future
economics cost may be high, does the biology and epidemiology justify the
‘’excessive fear.’’ This is not to underestimate its deadliness.
More than what
In
fact, Ebola as well as other filloviruses are a major public health threat to
Africa and the world. Ebola kills, and
takes away life from patients up to 9 out of 10 times, and does this within a
short period of time, ranging to 21 days. So far, for a modest estimate, more
than 1000 people have died, since the virus surfaced in Guinea in December
2013, and subsequently spread to neighboring Liberia and Sierra Leone and now
Nigeria[3].
But
with only 2300 confirmed cases in the history of filovirus outbreaks until
recently, the share of Ebola in Africa’s disease burden is barely noticeable.
Taking the present outbreak into consideration, of the more than 2000 people
infected, it has taken the disease almost 9 months to kill half of them.
Assuming everything stays constant, and the disease continues with the same
rate of progression, then rough estimates of number of deaths by the end of the
year, may not exceed 2500. I would reemphasize
everything remains equal.
Without
a doubt, Ebola is truly horrible, but on mortality scale, there are many dozens
of other diseases that kill far more people in Africa. Ebola does not future on
the top 100 killers. By the end of the year, preventable cholera would have
killed almost 100000 people, that is, 50 times more Africans than Ebola since
it emerged in 1976. How about AIDS, TB, Malaria? According to the global burden of disease
estimates, in every four months, Sierra Leone sees around 650 deaths from
meningitis, 670 from tuberculosis, 790 from HIV/AIDS, 845 from diarrheal
diseases, and more than 3,000 from malaria.
Yet
even when measured against this worst outbreak in affected countries, Ebola has
been responsible for just 2 percent of all deaths in Sierra Leone. It killed no
one in the country in the months and years before that, and assuming this
outbreak is controlled soon, years will pass before it kills anyone again. Besides
spread, the current outbreak is not exceptional in terms of mortality rates,
too. While the numbers of people who eventually die from the infection compare
to those that survive in the present outbreak averages 64%, it pales in
comparison to the 90% deaths in the Congo 2002-2003 outbreak, the Zaire 1995
and 1996 fatality rates of 79% and 88% respectively. Fatality rates can go as
low as 25%, like the outbreak in Uganda in 2007-2008.
Even
when the way in which the disease propagates is taken into consideration, Ebola
is a relatively controllable disease. The public health tools are well known an
effective: like avoiding fluid and contacts with infected persons. The viral
infection is not as infectious as flu, which spread through air.
Broken
system
I
could hear a scream!!! Cholera, TB, HIV and Malaria have effective treatments and
even the cures are available. True. So
what? How many people have access to them? Do we have a capable system to take
the often free and subsidized drugs to where
they are most needed?
Health
care systems in Africa continue to suffer from chronic neglect. While public
spending on health care has improved, thanks to donor funding, when compared to
what is needed, African governments are shockingly underinvesting in healthcare
delivery for their populations. Guinea allocates only 7% of the government spending
to health, far below the 15% target agreed by African leaders in Abuja. And the
quality of allocation of funding leaves much to desire: Urban areas are far
more privileged over rural areas. In fact, in 2000 during the Ebola virus outbreak
in Gulu, Uganda, 71.3% of the population lived more than 5 km from the nearest
health facility. But the percentage was only 0.7% in the capital city, Kampala
(MacNeil A, 2012). While health budget
have almost remained flat, spending on military has grown by 9% almost doubling
the annual growth rate of Africa.
Corruption in the healthcare sector is also rife[4]. Basic
health care infrastructures are lacking. Health workers lack motivation.
Health care workers are among the most
marginalized category of professionals in Africa. While political assassination
is often one-off events in Africa, doctors and nurses are endangered on a daily
basis due to their poor working conditions. The already limited health workers
are therefore pushed out of the continent to Europe and America where their
skills are valued more. Even when health workers raised their voices,
politicians rarely care. Nigerian doctors are on strike for the last two months
because of low salaries[5]. And the
consequences are dire for the population. For example, Africa accounts for 24
percent of all diseases in the world but only has 3 percent of the world’s
health workforce. Guinea, the epicenter of the outbreak has only 331 laboratory
workers to cater for its 10 million people, approximately one staff for every 30000
people. Little wonder that, the outbreak is suspected to have occurred earlier
than December and was only reported four months after, when it could have been
easily contained[6]. In neighboring Liberia, before the outbreak
there were only 150 doctors for its 3.5 million people. As a consequence,
health services are therefore exclusionary lending themselves to corruption, as
patients—in particular those who can afford— do anything to get care[7]. More
than 50 percent of Sierra Leoneans doctors work abroad.
And for those that elect to stay and serve
their motherland, they have to accept what could best be described as difficult
working conditions. Lack of basic equipment, protective gloves and even
sterilize needles. They may even end up unwillingly
in harm’s way, paying the ultimate price with their lives, which is barely
recognized as a footnote in the history of failed health policies. For example,
WHO estimates that for every 100 patients admitted to a hospital in Africa, 10
of them will acquire additional illnesses from the care provided by the health
establishment. Abandoned by governments, hospitals in Africa have become hubs
for disease transmission. More than 81 health-care workers have died and 170
infected, according to WHO.
Early
warning systems for detecting and reporting the emergence of pandemic are also
broken, too. In a recent review by WHO, on the minimum core public health
competencies to meet the International Health Regulations, a global system of
rules for alerting and responding collectively to global health threats, Africa
lags far behind all other regions. Only 45% of human resources for health
targets were met as compare to a global average of 66%. Health targets at the
port of entry were missed with only 23% of the agreed measures was in place
compared to 54% globally (World Health
Organization , 2012).
Africa
has shortsightedly underinvested in providing health care in an accessible and
effective manner to its citizens, in particular the poor. And for that, the world seems
to be paying a heavy price.
Whose security
With no cure available, all what is left is containment of
the virus. Already limited health resources in Africa, have been diverted to
providing surveillance and response. While this is critical, it is not clear
the extent to which health care systems will benefits in lasting ways that could
start to address the chronic obstacles to providing care for all African.
But as it stands, the bottom millions of Africans who are
driven into poverty every year because of health care expenditures, will
further find it difficult to access the limited numbers of doctors, buy drugs
or even go about their daily struggles to earn just more than a dollar a day. Many
health professionals are too busy worrying about their own safety at the moment,
than provide health care to the many other illnesses afflicting Africans. For
instance, the Kikwit, DRC, Ebola outbreak in 1995 resulted in the infection of
80 health care workers and the closure of Kikwit General Hospital for non-Ebola
related activities, severely limiting the availability of medical care to the
population of Kikwit (200,000), as well as surrounding areas (al (Khan et al., 1999)
Nevertheless, for one thing, Ebola has introduced in an
increasingly unequal African society, a frightening reality: the random nature
of death. The poor have almost same chance of dying of Ebola like the rich,
everything being equal. And for once, African
elites don’t have the option to buy their way into safety and protection
through flying abroad for treatment—while abandoning a crumbling health care
system they have neglected for so long through chronic under investment. Added is the
inconvenience of not being able to fly freely, abroad.
But for the millions of poor, the fear is not Ebola, but the
weight of a crumbling and distant health system, which only is noticed when the
mess of its mismanagement threatens the comfort of the elites. They have lost
trust in their healthcare system and governments and therefore reluctant and
suspicious to seek critical care against Ebola from their health care
professionals. Even foreign healthcare workers have been chased away by
communities.
The Ebola fear extends even beyond Africa, too.
Globalization and interdependency have together turned Africa’s sneeze into a
cold-causer for the West. Because of the security threat, strengthening the
global surveillance system is becoming a top priority for donors. The
possibility of terrorists playing
with an Ebola-like bug, has invited national security institutions into the
search for antidotes. While the US Military has no biological weapon program,
it is investing heavily in research against new and emerging viruses, which
could threaten the health of its troops. For example, the US Military together
with a private company have developed an experimental antiviral therapy, ZMAPP,
provided to the two American health workers infected in Liberia.
Information about the biology and epidemiology of Ebola is
crucial to finding a cure. In fact, it is a global public good for humanity. But the ability to conduct research on
infected Ebola samples is limited to only high containment laboratories found in
Europe and America. Extensive funding has been channeled to research in the
last decade and progress has been made in understanding the biology and
potential likelihood of finding a cure or vaccine against the deadly virus ( Dias et al, 2010). Yet what is the use of
this information, if the vaccines or potential treatment options developed will
remain unfordable to those who need them the most.
The tendency to put intellectual
property rights over human rights is a dividing line between Northern and Southern
countries. How to balance the global public good nature of information on the
pandemic viruses originating from Africa with global access to vaccines and
other health commodities generated from the viral samples collected remain
unclear. While Africa may not have to go down the Indonesian way by using Ebola
virus samples as a bargaining tool, the international health crisis provides an
opportunity to shape the global health security for the benefit of African
peoples[8].
While all the global attention on Ebola has already started translating into much needed funding for health[9], it remains unclear whether this is going to plug critical gaps in the performance of health systems. In particular, building sustainable health systems that are people centered as opposed to diseases. The track record of disease based interventions in Africa has in many ways been counterproductive for long-term strengthening of health system. The disproportionate allocation of donor funds to HIV/AIDS has led to internal brain-drain in most African countries. The already limited health workers continue to exodus in droves away from public hospitals to work with international organizations and NGOs funded disease programs that offer better wages, than what the government could pay (Abdul, 2013).
Realm of Ideas
But beyond strengthening health system, Africa needs to
assert its voice in the global health security space, where her presence has
barely been noticed, besides begging for support. What does global health
security means for Africa? How should international support for global health
security works for Africa? Unfortunately, African governments seem too busy
chasing funds while the West frames the problem of global health security,
select the tools for tackling Ebola, and even decide what mechanisms and values
should govern global health security. In fact, a rough google scholar search
shows only two African journal articles on global health security. Majority of
the articles are from the West and rest from Asia
To be fair, African countries together with BRICS at the
World Health General Assembly, WHO’s intergovernmental forum, have resisted the
use of the word global health security in WHO’s work. But besides grandstanding, they have failed
to engage in norms-setting discourses which are shaping the global health security
agenda. Some western countries unable to push global health security within
WHO, have opted for a bilateral approach. A Global Health Security Initiative
was launched in 2001, by the US, EU, Canada and Japan as an informal
international partnership of likeminded countries to strengthen health
preparedness and response globally to threats including pandemics. The US has
launched its own agenda for global health security, which includes among other
goals strengthening global norms around rapid and transparent reporting and
virus sample sharing. The participation
of African countries is key to the initiatives.
While Ebola remains virulent more than ever, Africa needs to
go beyond short-term, ad-hoc emergency and panic ways of working, to a forward
looking approach which addresses the roots of health insecurity. The global
scare of Ebola could be an opportunity to assess the cost benefit of global
health surveillance system, and distribution of its costs: who relatively bears
the largest burden and how to compensate for it, before committing to any global
health security initiative that may end of undermining already weakened health
systems in the long-run. This would require ensuring an incentive mechanism for
producing vaccines and anti-viral therapies against Ebola which could correct
for the ability to pay by African countries, where Ebola remains endemic.
Given that the burden of disease of filoviruses like Ebola is
very low, without public funding, there’s little incentive for pharmaceutical
company to produce a vaccine, to immunize millions of Africans which could cost
over a 1 billion dollar of investment and takes more than 15 years. Even when
the vaccines are available for free, it is unlikely that all those most in need
of it would get it, due to health system bottlenecks.
In fact, Ebola is a wakeup call to our leaders, shaming them
to take concrete actions to fix our broken health system.
To move forward,
Africa would need to come up with a common position on global health security.
What values should guide an African owned global health security agenda? What
are the priorities and mechanisms for its effective implementation? A High Level Continental Forum on Global Health Security could be a platform to start talking about those issues. The African
Health Strategy up for revision next year could provide an opportunity to bring
the health systems strengthening agenda with that of global health security,
and doing so in a way that reflect Africa’s long-term needs and capacities.
[5] Recently the Nigerian President sacked the former
central bank government for announcing the disappearance of $20billion in oil
revenue over an 18 month period. This is nearly equivalent to the total amount
of money spent on health care in Nigeria a year. more than two times what the
government spends on health a year
[7]
Every year WHO estimates that about, 150 million people are pushed into extreme
poverty by health care bills majority of which are in Africa
[8]
Unlike H5N1, Ebola virus is not very valuable,
transmission risks is statistically very low, as such the virus would rarely
spread widely to have a significant global impact like the highly pathogenic
airborne H5N1 flu virus.
[9] The World Bank has announced a $200million emergency
fund to country worst affected. This comes on top of $100million earmarked for
Ebola by World Health Organization. WHO has further calls for an additional $75
million to plug the gap in funding. Bilateral partners like US and EU have also
pledged additional support.
Works Cited
Works Cited
Abdul H Mussa, J. P. ( 2013). Vertical funding,
non-governmental organizations, and health system strengthening: perspectives
of public sector health workers in Mozambique. Human Resources for Health,
11:26.
Khan et al. (1999). The reemergence of Ebola
hemorrhagic fever, Democratic Republic of the Congo, 1995.Commission de Lutte
contre les Epidemies a Kikwit. . J Infect Dis 179: Suppl 1S76–S86.
Dias et al(2010). Effects of the USA PATRIOT Act and
the 2002 Bioterrorism Preparedness Act on select agent research in the United
States. Proc Natl Acad Sci U S A 107: 9556–9561.
MacNeil A, R. P. (2012). Ebola and Marburg Hemorrhagic
Fevers: Neglected Tropical Diseases? PLoS Negl Trop Dis 6(6): e1546.
World Health Organization . (2012). International
Health Regulations (2005) SUMMARY OF STATES PARTIES 2012 REPORT ON IHR CORE
CAPACITY . Geneva: WHO.
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