Ebola: Recovery of Two Americans Sharpens Divisions in Global Health
A surprised press
conference held last month by Emory University Teaching Hospital, stands out as a
rare bright moment in the fight against an uncontrollable Ebola virus outbreak
in West Africa. ZMAPP, an untested serum-based
therapy in humans was successfully administered to two American health workers who were later declared
free from the virus, which has killed more than 1500 peoples. While more trials were still needed to ascertain the effectiveness of the drug, the public announcement
raised hopes for a new front in the fight against the ravaging epidemic.
Besides treatments for its debilitating fever, bleeding symptoms including
palliative care as well as public health measures to contain the disease-- such as quarantining -- no licensed cures so far exist. This most deadly outbreak kills on
average six out of ten patients, one more than all previous outbreaks together since
1976, when the virus first emerged. The number could climb to nine out of ten
patients, at the extreme. The response so far, has been described as ''lethally inadequate'' with the World Health Organization warning that the outbreak
will get worse before getting better.
Besides the ethical and equity challenges in
distributing the limited quantity of the experimental therapies, the remarkable survival and first-rate quality
of treatments provided to the American patients and water-tight public health
containment measures employed, paint in a very stark manner, contours of divisions
in global health, which were already
widening before Ebola and have been worsen by the outbreak. The emergency-only
response by African countries and the international community would fail to bridge those divisions
which will continue in future to manufacture new and remerging epidemics like
Ebola at an alarming rate as well as with frightening impact on a global scale.
Haves and have-nots
Ebola
outbreak and spread are not entirely random. Outbreaks have occurred only
in poor countries, where health systems are broken at best or absent at worst.
A child who survives Ebola in Guinea,-- the
epicenter of the current outbreak— would be lucky to escape premature death from cholera and other preventable diseases before the fifth birthday, and even
more so, extremely lucky to live up to the age of Nancy Writebol (58 years), one
of the American survivors. In Sierra Leone the expectation is far lower, 49
years. Often the mother will not even make it pass childbirth, due to inadequate or
lack of prenatal or postnatal care. This pales in comparison to that of US and
other western countries. Thanks to their excellent health care, a child born
today in those countries may live more than double that the age of peers in the Ebola-affected countries.
The contrast
is even starker. The care received by the infected Americans are worlds apart from that in Ebola-hit countries. Out of the four westerners who have been infected, only one
has died, two have fully recovered and the other making encouraging progress.
While the effectiveness of the unregistered treatments remains unproven in human populations, what is clear: none
of the health workers in the West have been contaminated by the virus, compared to an approximately 25 percent chance of health care workers in Africa to accidentally be contaminated with the virus.
So far, more than 280 health workers have died from hospital-based transmission
of Ebola.
In fact the
superior quality of care provided to the Americans, speaks for itself. For Dr
Brantly alone, there were five world-class doctors and 21 motivated nurses to
care for him. In Sierra Leone, before Ebola, there was one doctor to care for
more than 23000 patients. And now with Ebola, the number of patients would have
gone even higher due to acute shortage of doctors. In Sierra Leone, The New York Times reports of one doctor caring for 90 Ebola patients.
A life in
the West apparently is worth far more than that in Africa. Yearly, the US
spends almost $49668 on each citizen for healthcare, which is 776 times greater
than what is spent on average for citizens in the Ebola-hit countries. The gap
is getting wider, even against rising economic growth performance of over 5% in
the continent. African governments have been stingy when it comes to healthcare, budgets have stayed almost flat (
grown by 1%) over the last decade, with the continental spending hovering
around 9% of overall governments spending, which means as a whole, the continent will likely miss
its own target of 15% of public spending on healthcare (Sambo et al 2013). As a
consequence, most African countries are going to miss the MDG targets for
reducing maternal mortality, and almost all of them will fail to cut the amount
of people without access to proper sanitation, a main transmission medium for
Ebola. The inequities stand out shockingly. Health is the biggest priority in
the West, with over 10% of gross domestic product, compare to less than 5% in
Africa.
Prepayments and pay as you go
An even more
shocking contrast is the mechanism for financing health care. The cost of
healthcare is pooled and shared by the healthy members of the insured
population. The infected Westerners did not wait to pay for their healthcare
after the Ebola-virus attack. They had been paying regularly in advance against
the possibility of falling sick, even when they were healthy and chances of
sickness marginal. The repatriation of the sick Americans was covered by their
prepaid private health insurance. And for the Brit and the Spaniard, their cost
was fully covered by prepaid contribution to their national health insurance
systems. In fact, all of them have drawn on some sort of ''equity'' to get first
rate health care.
In contrast,
health financing mechanisms at the demand-side are very inefficient at worst
and suboptimal at best in Africa. Payments for health services are largely done
at the point of use with catastrophic consequences on the bottom millions of
Africans. While progress has been made in some countries to institute health
insurance, however coverage is mostly limited to workers with formal employment,
leaving behind almost 80 percent of the populations in the informal sector. Expensive
out-of-pocket spending on health care is one of the most effective poverty
traps and easiest route into deprivation[1]. Guinea, as an example, spends $32 per citizen
on healthcare, and out of that amount, almost 90% is from individual payments,
one of the highest in the continent. According to the WHO, two years after Burundi
introduced user fees for healthcare in 2002, four out of five patients in that
country were either in debt or had sold assets to pay for healthcare. Most of
the populations in the Ebola-hit countries spend over 40% of their income after
food purchases to buy medicines and pay for health services. The risks of financial
catastrophe is unmanageable, unjust and unfair.
The underinvestment
translates into poor quality of services. Health
care workers are among the most marginalized category of professionals in
Africa. While political assassinations are 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. More than
50 percent of Sierra Leoneans doctors work abroad. Even when health workers raised
their voices, politicians rarely care. Nigerian doctors were on strike during
the last two months because of low salaries[2].
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[3].
Patients and Consumers
Poverty
comes with neglect. Africa’s endemic diseases like Ebola affect mostly its bottom millions. As such the patients do not form
a viable consumer base enough to motivate pharmaceutical industry to invest in innovative drugs and treatments for them. The WHO has put together a
list of 17 neglected poverty-related diseases (NTDs), Because those diseases
exclusively affects populations in developing countries, interests from the global research
community is very low, and support from African governments is sadly
inadequate. According to one study, about 1393 new chemical entities introduced
between 1975 and 1999, only 16 targeted NTDs
(Patrice Trouiller, 2002).
On a global
scale, research for health in Africa remains marginal. In 2012,the global total
investment in health R&D – both public and private sector— roughly stood at
$240 billion, with 89•5% ($214 billion) coming from high-income countries, 7•9%
($19 billion) from upper-middle-income countries, 2•6% ($6•2 billion) from
lower-middle-income countries, and only 0•1% ($0•2 billion) from low-income
countries (John-Arne Røttingen, 2013). Ability to conduct research on infected
Ebola samples is limited to only high containment laboratories found in Europe
and America.
But Ebola is
unlike any other neglected disease, albeit no licensed cure exists since it
emerged more than three decades ago. The imperative to overcome market failure
has attracted increasingly significant public finance. 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 provided substantial funding to the private company that developed
the experimental antiviral therapy, ZMAPP, provided to the two American health
workers infected in Liberia.
Intellectual property and human
rights
How the
combination of public and private partnership would translate into affordable
or universal access to potential therapies remains unclear. While
market failure has been a main reason behind the neglect, the unprecedented global
attention and renewed interest by the pharmaceutical industry, pose an intellectual
property right challenge in future.
Tekmira, a Canadian company developing an experimental Ebola drug (TKM-Ebola)
has seen its stock swing wildly in the last two months, on the back of the news
that US regulators have lifted safety restrictions for clinical trials to
progress. Short term profit-oriented investors have pushed up the company’s
stock price evaluation to more than 270% in August[4]. The company has received almost $140-million from
the U.S. government.
It appears
the patent race is not only limited to therapeutic products. Diagnostic procedures
and even viral strains are subject to patent. A rough search of the World
Intellectual Property Rights database reveals almost 242 patents already on
different aspects of the virus[5]. All the
applications for exclusive monopoly seem to come from the West. Even the virus
itself is under patent. For example, the U.S. Centers for Disease Control owns
a patent on a particular strain—not the type involved in the current outbreak—
of Ebola known as “EboBun,” (with a patent No. CA2741523A1)[6] awarded
in 2010.
It seems the market value of the viral materials
and disease will likely rise, as pharmaceutical companies rush to bank on the
growing potential to maximize profits in future. In this game of profits,
patients carrying the virus are a valuable raw material pool. Companies could
extract the virus from them, file a claim to have invented the virus, and file
monopoly rights for the exclusive use of the viral material and products
derived from them.
While the possible
treatments and cures available remain statistically and clinically unproven in humans, pharmaceutical and Western governments likely have commercial and political interests to talk-down expectations. Besides the logistical challenges to scale up the
experimental treatments, rolling them out would however come up against ethical,
equity, intellectual property, human rights challenges as well as health
systems barriers. If those experimental drugs are proven to work, in the
current outbreak, would those drugs be provided for free to the bottom millions African at
risks of infection? Would there be enough functional health systems to take the drugs to all those who need them? How would the pharmaceutical companies make a return on their investment? The answers would either close or fortify already existing walls in
global health.
Moving
forward, the Ebola outbreak provides an opportunity to renew efforts towards universal
access to health care for Africa (UHC). The UHC is part of the proposals
for an inclusive long-term goal for health that will succeed the MDGs which
will expire next year. As a people rather than disease-centered approach, UHC
aims to address the ''cause of causes'' of sicknesses and ill health and in doing
so, it would significantly contribute to reducing the gaps in global health. A path Africa must fast track in order to prevent Ebola and other pandemic viruses from taking full advantage of the gaping holes in its health systems, now and in future.
Works Cited
- John-Arne Røttingen, S. R. (2013). Mapping of
available health research and development data: what’s there, what’s
missing, and what role is there for a . The Lancet.
- Patrice Trouiller, P. O. (2002). Drug development
for neglected diseases: a deficient market and a public-health policy
failure. The Lancet, 359(9324):2188–2194.
- Sambo L, Kirigia M and Orem J (2013) Health
financing in the African Region:2000–2009 data analysis International
Archives of Medicine 2013, 6:10 Page 2 of 17 http://www.intarchmed.com/content/pdf/1755-7682-6-10.pdf
[2]
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
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