Lessons, Impact, and the 'Fearonomics' of the Ebola Outbreak in Nigeria

~Written by Sulzhan Bali, PhD (Contact: sulzhan.bali@twigh.org) 

Also published on the DGHI Diaries From the Field Blog

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Passport Sticker with Ebola Symptoms and National Helpline. Photo Credit: Sulzhan Bali, PhD

24th of July.

The day Macchu Picchu was discovered in 1911.

The day Apollo XI returned to the Earth after the first successful mission of taking humans to the moon in 1969. 

Yet, in Nigeria, that day in 2014 will always be marked as the day Patrick Sawyer—the index patient of Ebola—died and set an outbreak in motion in one of the most populated cities in Africa. Patrick Sawyer was a Liberian-American citizen and a diplomat who violated his Ebola quarantine to travel to Nigeria for an ECOWAS convention. His collapse at the airport, coupled with an ongoing strike by Nigerian doctors in public hospitals, landed him at a private hospital in Obalende, where he infected eight other people. 

Patrick Sawyer’s death marked the beginning of an Ebola epidemic in Lagos, a city of 21 million. Lagos is a major economic hub in Africa and one of its biggest cities. An uncontrolled Ebola epidemic would have a far-reaching economic impact beyond the borders of the city, its country, and even its continent.

A recent study has shown that Ebola virus remains active in a dead body for more than a week. Add to this that the body is most infectious in the hours before death, and it is a "virus bomb" waiting to happen if handled incorrectly. West Africa, especially Nigeria, has a strong funeral culture. This Ebola-infected Liberian diplomat’s body was transported and incinerated in accordance with the WHO and CDC protocol. This feat was achieved despite immense political and diplomatic pressure to return the body for funeral rites. It represents one of the many cases of collaboration and "clinical system governance" that are at the heart of the successful containment of Ebola in Nigeria. It is one of the many stories that I'm hoping to highlight in my research on the role of the private sector in Nigeria’s successful Ebola containment.

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One of Many Ebola Information Posters Around Lagos. Photo Credit: Sulzhan Bali, PhD

As part of my research, I am looking at 10 different economic sectors to understand how the Ebola outbreak impacted the private sector and how the private sector dealt with the challenges that the Ebola outbreak posed. My hope is that this research will lead to lessons for the private sector on how, in times of an epidemic, they can help the government to mitigate the disease’s economic impact. I also hope that the resulting report will help governments engage with the private sector more effectively in times of emergencies.

With many outbreaks, especially of highly fatal diseases such as Ebola, fear is the biggest demon. This fear has led to the crippling of economies of Ebola-affected countries. This fear has cost Sierra Leone, Guinea, and Liberia 12 % of their GDP in foregone income and unraveled the years of progress made by these countries. However, this fear is not just a phenomenon limited to West Africa. I had a very personal encounter with this fear recently, when I was quarantined for a few hours in the United States (despite Nigeria being declared Ebola free since October 2014). 

It has been a humbling experience so far, as I try to understand how this fear and the hysteria around Ebola can lead to significant behavioral changes—some of them necessary but some extreme. Everyone I speak to has a story to share. Some people tell of how they bought more than two bus tickets to prevent sitting next to other people. Others tell of hospitals resembling "ghost buildings" as people avoided hospitals and doctors like the plague. Many tell of the "Ebola elbow-shake" that replaced the usual handshake or hug. The reality is that although the Ebola outbreak infected 21 people in Nigeria, it actually affected the lives of 21 million people in Lagos alone, in one way or another. I have come to realize that there is a thin line between precaution and hysteria. Maintaining the equilibrium between the two is the key to controlling the disease and mitigating its economic impact.

As I wrap up my interviews, a few questions resonate with me time and time again from these sessions.

“Are we prepared for the next time?” 

“Ebola is back in Liberia. What can we do to prevent Ebola from coming back to Nigeria?” 

 For the doctors who died in Nigeria’s fight against Ebola:

“Can we truly say our country is a safer place after their sacrifice?” 

And for myself:

“How will your report help Nigeria?”

These are the questions that keep me going. Although my report may not be able to answer all of the aforementioned questions, I do hope it will at least get policy makers, students, and advocacy groups talking about how countries can be better prepared for the next big outbreak and how public-private collaboration can lead a country out of an epidemic and on a path of recovery.

To end on a positive note, 24th July, 2015 also marked one year since the last polio case in Nigeria—an achievement that clearly shows what collaboration in global health can achieve.

(To learn more about my research or to contribute/collaborate in my study, please contact me.)

Civil Unrest and the Global Polio Eradication Efforts

~Written by  Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.

Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.

Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.

Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.

This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.

References:

http://www.cdc.gov/polio/updates/

https://news.vice.com/article/afghanistan-confirms-new-polio-cases-as-pakistans-outbreak-reaches-grim-milestone

http://www.theguardian.com/society/2014/sep/07/us-nearly-600-measles-cases-this-year-cdc

http://time.com/27308/4-diseases-making-a-comeback-thanks-to-anti-vaxxers/

http://www.polioeradication.org/

http://www.washingtonpost.com/blogs/worldviews/wp/2012/10/17/taliban-polio-vaccines/

http://www.bbc.com/news/world-asia-26121732

http://www.npr.org/blogs/goatsandsoda/2014/07/28/330767266/taliban-in-pakistan-derails-world-polio-eradication

Values and Global Health Governance: Lessons from the Ebola 2014 Outbreak

~Written by J. La Juanie Hamilton, PhD Candidate (Contact: lajuaniehamilton@gmail.com)

Twitter: @jasminogen

Values are critical in shaping the global health (GH) dialogue and landscape. Values and the actions that arise from them (virtues) underlie the policies that ensure universal access to necessary health services, adequate responses to health emergencies and resource allocation. Similarly, the values of health governing bodies can create chasms between people and their health necessities. This truth has been unfolding poignantly on an international level during the handling of the Ebola virus disease (EVD) outbreak in West Africa. 
 

What values did the actions or inaction of the international GH community endorse in handling the current EVD outbreak? Although the uniqueness of the outbreak in terms of location and challenges in diagnosis should be considered, many experts agree that the greatest force contributing to the rapid spread of EVD was inaction (1-4). In June 2014, signs that EVD was spiraling out of control throughout Guinea were flashing brightly but the response from the international community remained slow. The exception was Doctors without Borders (MSF), whose staff was already on the ground, helped to diagnose the first case and pleaded for a more robust response from international health governing bodies (3). 
 

Criticisms of health regulatory bodies grew stronger when EVD entered rich countries, which appeared to produce a marked increase in global support efforts. It is hard to say unequivocally, whether this heightened interest and commitment was inevitable or whether the cases in the US and Europe were the impetus. But it is fair to say that many mistakes were made in terms of prioritizing EVD eradication and surveillance. It may also be accurate to say that major economies responded when EVD was perceived as an immediate threat to their economy. This, I believe, is inevitable in a GH system that is built upon a market-driven approach.
 

Can a GH agenda that is framed around economics prioritize the eradication of emerging diseases and neglected diseases of poverty? Although there are compelling arguments for why high-income countries should help to combat EVD and similar diseases, it is unlikely that great achievements will be made without a values shift (5). 
 

A market driven approach inherently prioritizes the need of a few versus the need of many. This model enables the interests of major economies to outweigh the greater good of the whole, if left unchecked. The most important consequence of this approach is that it undermines international health regulatory bodies, whose actions and budgets are heavily influenced by larger economies. This is a problem which, when combined with poor health systems, harmful microbes and permeable borders will inevitably lead to threats in local communities and global security. More importantly, with the movement of people forming a major characteristic of this era, the market driven approach is an unsustainable value upon which to build GH interventions. 
 

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There are many points worth considering (schematic above). Major questions moving forward should consider creating a GH model that is more oriented toward equity, security and creativity. Resolutions that create a space in which poor nation states help to set the GH agenda without being threatened by the loss of aid from larger economies must be discussed. Additionally, addressing ways in which the GH dialogue can be re-framed to include stakeholders that currently operate based on virtues stated above should be considered. For example, is there a way to ensure a more official decision-making role for organizations like MSF?

What is next for GH governance and what will the values shift towards? EVD 2014 is a strong indicator of the limits of theoretical values, political indifference and passivity in achieving health and well-being for all. But the stories emerging from West Africa provide an opportunity for EVD 2014 to serve as a “meaning making” event in GH. It provides an impetus for changing priorities from passive verbiage of values of human dignity to a model of creativity, equity and accountability which proactively contextualizes GH policies, innovation and interventions. 

References
1. Gostin LO and Friedman EA 2014 Ebola: a crisis in global health leadership. The Lancet, 384; 1323-1324. 
2. Cohen J 2014.Ebola vaccine: Little and late. Science, 345 (6203): 1441-1442. 
3. Ebola: Massive Deployment Needed to Fight Epidemic in West Africa: http://www.doctorswithoutborders.org/news-stories/press-release/ebola-massive-deployment-needed-fight-epidemic-west-africa
4. Farrar JJ and Piot P 2014. The Ebola Emergency-Immediate Action, Ongoing Strategy N. Engl J Med 371(16):1545-1546.
5. Rid, A., & Emanuel, E. J. (2014). Why Should High-Income Countries Help Combat Ebola? JAMA, 312(13), 1297-1298.

Infectious Diseases Come from Animals? - Zoonotic Transmission

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com)

For those people who have been following the Ebola outbreak relatively closely or who have been doing their own research into Ebola, you may have heard that scientists think Ebola is introduced into the human population through fruit bats and/or the butchering of bush meat. 

This concept of infectious diseases passing between animals and humans is not new and is called zoonotic transmission. Now Ebola is a virus, but other disease causing agents such as bacteria, parasites and fungi can also be spread between animals and humans. While you may not have heard of zoonotic transmission before, I bet you’ve heard of some zoonotic diseases. Examples include anthrax, Lyme disease, Avian influenza, plague, malaria, dengue, West Nile virus infection, and rabies. The WHO says there are over 200 zoonotic diseases known to us thus far. I also bet you didn’t know that about 75% of recently emerging infectious diseases affecting humans are of animal origin and approximately 60% of all human pathogens are zoonotic. (I just learned these facts as well and am sufficiently surprised the numbers are that high). 

So how in the world does someone get a zoonotic disease? Well, for instance, anything transmitted by mosquitos or ticks are zoonotic diseases, so take proper precautions to prevent being bitten by all ticks and mosquitos. You can also come into contact with zoonotic diseases through petting zoos, pet stores, nature parks, farms, etc. Our beloved pets can also transmit diseases like salmonella, hookworm, and roundworm. The moral of the story is to make sure you’re washing your hands after handling animals and to be careful about petting every fluffy creature you come across. 

Now I would be missing a big part of the picture if I didn’t investigate some of the human-induced reasons why more and more of the population is in danger of being directly impacted by these “remote” zoonotic diseases. Zoonotic diseases transmitted by mosquitos for example, generally only impact people living in areas where those mosquito species are found. Climate change is allowing for some of these mosquitos to expand their territory, thereby bringing zoonotic diseases to new areas of the world. For example, two mosquito species known to carry malaria are now found at the US-Mexican border. Additionally, our expanding population and changes in how humans are migrating are causing interactions with species we’ve never encountered before through practices such as forest clear-cutting and wetland draining. 

I have no easy solutions to these problems as they stem from much larger human population growth issues. But the good news is that we, as humans, have noticed that zoonotic diseases are a growing issue and have stepped up efforts to stay on top of things. The European Union has passed legislation requiring member states to increase their monitoring of zoonotic diseases and has specific guidelines on how to do that. Self-proclaimed “Virus Hunter” Nathan Wolfe did a TED Talk on how his team and he are working on the frontlines of novel virus detection by using innovative ways to collect specimens, detect, and track previously unknown viruses in humans. (I highly recommend watching the talk even if you’re not really interested in emerging infectious diseases as it provides a practical look into the challenges of doing fieldwork in remote areas where these diseases are coming from.)

The important thing to take away from all this information is that zoonotic diseases are almost unavoidable as we humans are interacting with our world, and that world includes all sorts of known and unknown pathogens. By prioritizing innovative ways for early detection we can hopefully learn about potential diseases and create possible remedies before they become global pandemics

Challenges on the Frontlines of Ebola

~Written by Marilyn Perez Alemu (Contact: marilyn.perez@gmail.com) 

Healthcare workers on the frontlines of the Ebola crisis in West Africa are daily putting their lives at risk to save the lives of others. The current epidemic is the largest of its kind in history, exacerbated by a reported 70% case fatality rate. Yet Ebola is a disease that knows no mercy. Since the initial outbreak reported in March, more than 450 healthcare workers have been infected in Liberia, Sierra Leone, Guinea and Nigeria. More than 200 have died.

Despite being faced daily with this reality, as well as the looming stigmatization from their communities and families, healthcare workers continue to provide medical support to Ebola victims for the sake of those who will survive the disease. The initial international response was markedly slow and, as the outbreak intensifies, emerging challenges have severely impacted the ability of healthcare workers to respond to the growing need.

When executed properly, contact tracing is a key method for containing the outbreak spread. Ideally each contact, or person linked to a confirmed or probable case, would be identified by a healthcare worker and monitored for 21 days following exposure, allowing public health officials to track the movement of the outbreak. In theory, contact tracing is an effective method to ensure early detection of infections and immediate treatment, and stem the spread of the virus. Essentially, contact tracing has been called the key to “stop Ebola in its tracks”. And while the process seems simple enough, critical information gaps, limited databases, and an exponential increase in the number of Ebola cases have led to a breakdown in contact tracing in West Africa. With limited infrastructure and many living in remote villages, even finding patients is a challenge. Add that to the fact that people are often uncooperative with tracers, as the fear of going to a health center is something akin to a death sentence. Without the ability to do complete and proper contact tracing, rapid diagnosis and patient isolation is hindered and the outbreak will continue to spiral out of control.

While past outbreaks of Ebola were sporadic and contained within small rural areas, the current outbreak poses a serious challenge in that it has spread quickly to more crowded urban areas in West Africa. In rural areas, population density is lower, community ties are stronger, and transmission prevention measures are presumably easier to implement. Now, in vastly overpopulated urban areas, Ebola transmission has accelerated exponentially and the outbreak has gone beyond the ability to contain it. Control and prevention measures have thus intensified in both innovation and urgency, evidenced by accelerated efforts in vaccine development and experimental therapeutics.

While an Ebola outbreak is caused biologically, an Ebola epidemic is a crisis of poverty and fragile health systems. West Africa is faced with the repercussions of a weak health infrastructure, including scarcity of healthcare workers, limited resources, and poor management systems. It should be noted that these shortcomings preceded the Ebola outbreak, with just 51 doctors to serve Liberia’s 4.2 million people and 136 for Sierra Leone’s population of 6 million. To put this in context, this is fewer than many clinical units in a single hospital in the United States. Having worked its way through the cracks of a fragile health infrastructure, Ebola has effectively brought healthcare to a halt in Liberia, Sierra Leone and Guinea. An added complication is the shortage of resources, including personal protective equipment (PPE) and other control materials, and the lack of straightforward protocols and guidelines. Efforts must increase not only to ensure an ample supply of optimal PPE but also to effectively disseminate information on proper use of the equipment.

At the frontlines of the Ebola outbreak, healthcare workers face a daunting challenge. In Liberia, Emmanuel Boyah, a primary health manager with the International Rescue Committee, recounts the stress and fear of this work. Yet he and many others continue to dedicate themselves to the cause and risk their lives to care for those affected: “I feel that providing services to people during this time, when they’re in need of you, is my call.”