Lessons Learned from Ebola

~Written by Kelly Ann Hanzlik (Contact: kelly_hanzlik@hotmail.com)

According to the World Health Organization, 28,616 people contracted Ebola and 11,310 lives were lost during the Ebola epidemic. After so many lives lost and the hopeful, but understandably tentative countdown of Ebola free days continues once again in West Africa, it is imperative that we take a moment to consider what we learned from the devastating and tragic epidemic.

I spoke with Dr. Ali S. Khan, former senior administrator for the Centers for Disease Control and Prevention, former Assistant Surgeon General, and current Dean of the University Of Nebraska College Of Public Health. He noted initially, that there is always the risk of importation of cases; that is how it started he reminds us. He elaborated further that the epidemic “changed the response from the WHO and caused a change in political focus by the nations involved that will affect future outbreaks and ensure native capabilities, as well as link them to the global response.” He also noted that new medical counter measures, such as vaccines and related therapeutics, were also the result of the Ebola impact. When asked about what we learned, he did not hesitate. “The first thing was a new vaccine that permits a novel prevention strategy using ring vaccination to prevent spread and new cases. The second is the new monoclonals and antivirals for treatment.” He also noted the better understanding of the viral progression and clinical diseases that will influence options for acute treatment and follow up of convalescents.

Ebola has provided us with a virtual plethora of opportunities to learn about the disease, its treatment and control, as well as the control of other infectious illnesses through our attempts to prevent its spread as well as through our failures, and successes. We gained valuable treatment modalities and tactics that will likely be used in future outbreaks of Ebola, as well as many other infectious diseases.

Ebola taught us other things too. It has been some time since global health has taken center stage. Ebola changed that. During the epidemic, one could not watch the news or go through a day without hearing an update on the latest development in the Ebola crisis. Although other infectious diseases like Plague, Polio, AIDS, SARS, H1N1, Cholera, and now Zika have captured the world’s attention, few diseases have made such an intense impact, nor caused the uproar and fervor that Ebola elicited. Ebola reminded us that global health is public health and affects us all, and as such, deserves to be a priority for national and international focus and funding for everything from vaccine development and research, to capacity for response locally, nationally, and internationally. Global health has teetered on the edge of public awareness, and remained a quiet player in the competition of priorities in national budgets. Today, it is abundantly clear how vital this sector is to each nation’s, as well as the world’s health, safety, success and even its survival.

Another effect from the Ebola crisis was the opportunity to educate people about public health and the transmission of infectious disease. Through education, public health officials were able to promote behaviors that ensured the safety and health of the public. It is stunning that in this day and age, we persist in so many behaviors that put us and those we interact with at risk. The discrepancy in what we say we will do, and what we are actually willing to commit to and take action on, looms large. Persisting low vaccination rates and the prevalence of infectious diseases such as sexually transmitted diseases, measles, pertussis and influenza show this. Ebola offers yet another opportunity to demonstrate the connection between our behaviors and our risks and disease.

Ebola also showed us that many nations continue to lack sufficient financing, infrastructure, facilities, support and medical staff to treat their own populations. Endemic conditions like malaria, and neglected tropical diseases like Guinea worm disease, Yaws, Leishmaniasis, Filariasis, and Helminths, as well as other conditions continue to affect millions globally.  Maternal and childhood morbidity and mortality rates remain deplorable as well. And millions of children around the world continue to suffer and die of malnutrition and disease before they reach the age of five. This is unacceptable, especially because proper treatment and cures for these conditions exist. Ebola also highlighted the need for treatments for chronic non-infectious conditions as well.

Moreover, Ebola clearly demonstrated the enormous need that remains for sufficiently trained medical professionals and healthcare staff to provide adequate care for many populations throughout the world. The loss of so many extraordinary and heroic staff that dedicated their lives to helping others in need under the most daunting and challenging of circumstances was devastating to those whom they served, and must not be in vain.

Additionally, Ebola provided us with yet another chance to relearn lessons about the role of safety in giving aid to others in need. We learned that we cannot just rush in with aid, but must recall the basics that every first responder and medical student must learn:  Ensure scene safety before giving care, and first do no harm. Ebola showed us the necessity to strategize and prepare to give care by utilizing personal protective equipment. It also reminded us very quickly that we could indeed do harm, and worsen the epidemic when we acted without first assessing the situation and ensuring proper protection and preparation.

So, it remains to be seen just how much we will learn from Ebola. Will we learn from our mistakes? Will we take the global view in the future, or the narrow one? Will we truly live by the motto of the Three Musketeers and be "one for all and all for one", or persist in "it's all about me"? Only time will tell. 

Global Health in a 'Restricted' Country - Breaking the Barrier of Stereotypes

~Written by Dr. Sulzhan Bali, Director of Production and HR, TWiGH (Contact: sulzhan.bali@twigh.org)

*Also published on the Duke Global Health Institute Page "Diaries from the Field Blog"

                                            Lagos, Nigeria - a vibrant city

Let’s play a game. Shall we?  I give a word and you think of the first word that comes to your mind.

Nigeria.

Pat yourself on the back if the word you came up with was NOT ‘scam’, ‘419’, or ‘Boko Haram’. Treat yourself to a chocolate if the word that you came up was a positive word (and if you are not Nigerian).

You see, stereotyping comes naturally to our species. Often, our outlook is dictated by the media, news, and hearsay- which although important, often gives us an incomplete singular dimension of the holistic picture.  Unfortunately more often than not that singular dimension dictates our biases.

 I must admit, before I arrived to Nigeria for field-work, I was afraid. Afraid of what awaited me on the other side. After hearing reactions such as “Why Nigeria out of all places?”, “stay careful in Nigeria, scamming is so common”; “Oh no! Isn’t that where Boko Haram is?”, and tales of evacuation, kidnappings, and even carjackings- I had started really wondering whether I should be excited at all? It didn’t help that my field-work country site was considered entirely restricted for safety purposes. No wonder, I was a little nervous as I disembarked the plane.

After I landed, my first experience of Nigeria was a man offering help at the airport for the cart. I didn’t have local currency yet and I needed a cart for my luggage.  I remembered of the innumerable warnings by friends and family to keep my wits about and to trust no one.  Did I take his help? Yes. Did he run away with my bags? No. Over the course of next 2 weeks, I would discover each and every Nigerian that I met to be warm, friendly, helpful, and yes- trustworthy!  

The risk of being scammed or cheated exists in every big city and Lagos is no different. This city of 21 million people is a melting pot of cultures and like any other metropolitan city in the world is like a coin with 2 sides.  My time in Lagos so far has turned my idea of Nigeria that I had upside down. Yes, there is poverty. Yes, development is an issue. So is corruption, weak health system, malaria, maternal mortality, and infant mortality. Yet, there is also will power.  There is optimism. There is an incredible spirit of entrepreneurship, which I am yet to see in another part of the world. Every Nigerian is an aspirational entrepreneur, hustling to be a successful one. People have a safe job along with an entrepreneurial venture. No wonder, that in Nigeria 41% of women between 18-64 years are entrepreneurs- the highest in the world! Unfortunately, Nigeria also ranks among the worst 20 countries in the world for women entrepreneurs. Many of these entrepreneur women are small traders or market women and entrepreneurship is a by-product of necessity due to lack of opportunities in the formal sector. Yet, despite it all, there is no denying the fact that entrepreneurial energy in Nigeria is on a high. There is an impressive desire in almost all Nigerians that I have interacted with to build something of their own. Optimism and innovation have overshadowed the constraints of red tape and lack of infrastructure. Many entrepreneurs in Nigeria are in it to make an impact and facilitate social change. An apt example is EbolaAlert- an organization that I am collaborating with for my study on 'Role of Private Sector in Ebola Response in Nigeria'. EbolaAlert started as a twitter handle at the peak of Ebola Outbreak in West Africa. People across the world were getting their accurate information on the Ebola Outbreak through it. What started as an information-providing platform turned into a Global health influencer that is now launching multiple public health education campaigns across Nigeria in partnership with CDC, Unicef, MSF, and the private sector.

Global health is about collaboration and coordination. It is about dialogue between sectors, organizations, and cultures. To be able to do that successfully, one has to look beyond the biases. Casting away our lens of bias requires looking beyond what we see and hear in media, news, and hearsay which is only possible with a cultural immersion and an open mind. This is why field-work is such an important component of global health.  Nigeria is not perfect. No country ever is. As the biggest economy in Africa and a country all set to reap its demographic dividend, Nigeria has the means and the will to become a great nation. I recently met a few Nigerian young professionals in Lagos. These were Nigerians from across the world visiting for the Young Nigerian Leaders conference to talk about the future of Nigeria. As it happens, Nigeria's biggest assets are its people. Many of who are using lean entrepreneurship, collaboration and ideation to facilitate change in all spheres.  From my vantage point, the whole world is Nigeria's oyster. Restrictions on the other hand, lie only in our mind set. 

No prize for guessing which is the first word that comes in my mind when someone says Nigeria.  It is 'entrepreneurship'. 

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.

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.”

Politics and Medicine

~Written by Mike Emmerich, Specialist Emergency Med & ERT Africa Consultant (Contact: mike@nexusmedical.co.za) 

https://twitter.com/MikeEmmerich

"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

Politics is defined as "organised human behaviour", thus we can postulate that Medicine is micro managed organised human behaviour, at times right down to the molecular level. If we examine the Ebola outbreak/s (globally) and how it is being managed on a macro (politics) and micro scale (medicine) we can begin to see the cracks in the system, and hopefully then move to addressing these cracks, before they begin yawning chasms that are not repairable.

The region (Liberia, Sierra Leone and Guinea) has had success (we could add Nigeria and Senegal to the successes) and failures in both areas. Neither is Spain and the USA exempt from this analysis as can be noted from the various press releases (government and medical) over the past few months.

Since the first outbreaks in 1976 (Sudan and The DRC) till the current one in West Africa; care has generally been palliative and symptomatic, questions have often been asked during this period; What of a vaccine and/or other means of treating the infected patients? There was a report in the British Sunday Times (12/10/14), cited a Cambridge University zoologist as saying that “it is quite possible to design a vaccine against this disease” but reported that applications to conduct further research on Ebola were rebuffed because “nobody has been willing to spend the twenty million pounds or so needed to get vaccines through trial and production”. Globally this has been one of the failures of the pharmaceutical companies, and most probably even the WHO, for not pushing harder over the years to get this in motion.

In her 1994 book /The Coming Plague: Newly Emerging Diseases in a World Out of Balance http://lauriegarrett.com/#item=the-coming-plague, //Laurie Garrett warned that there are more than 21 million people on earth “living under conditions ideal for microbial emergence.” http://www.independent.co.uk/arts-entertainment/science-mutating-microbes-1601604.html Garrett when on to win the Pulitzer Prize in 1996 for reporting on Ebola. In 1995 Joshua Lederberg, the American molecular biologist said: "The world is just one village. Our tolerance of disease in any place is at our own peril. Are we better off today than we were a century ago? In most respects, we're worse off. We have been neglectful of the microbes, and that is a recurring theme that is coming back to haunt us."

Jump forward to the 23^rd of September 2014, US President Obama issued an unprecedented ‘Presidential Memorandum on civil society http://www.whitehouse.gov/the-press-office/2014/09/23/presidential-memorandum-civil-society’ recognising that: Through civil society, citizens come together to hold their leaders accountable and address challenges that governments cannot tackle alone. Civil society organisations…often drive innovations and develop new ideas and approaches to solve social, economic, and political problems that governments can apply on a larger scale./

If we look at the current crises in West Africa civic leaders are what is missing, hence the inability to track and trace potential infected persons, motivate communities to change risky behaviours (handing of the deceased), agitate with government to create better health care systems, this all adds fuel to the fire of the current epidemic.

Have we listened and learnt as governments, NGO's and Multinational Pharmacare companies since then?

Despite Medical Advances, Millions Are Dying, this is a banner from 1996, not 2014! from the WHO, which was "declaring a global crisis and warning that no country is safe from infectious diseases, the World Health Organization says in a new report that diseases such as AIDS, Ebola, Hanta, Mad Cow, tuberculosis, etc., killed more than 17 MILLION people worldwide last year”.

As Laurie Garrett wrote in her the closing section of her book, The Coming Plague, /“In the end, it seems that American journalist I.F. Stone was right when he said, ‘Either we learn to live together or we die together.’ While the human race battles itself, fighting over ever more crowded turf and scarcer resources, the advantage moves to the microbes’ court. They are our predators, and they will be victorious if we, Homo sapiens, do not learn how to live in a rational global village that affords the microbes few opportunities. It’s either that or we brace ourselves for the coming plague.” Time is short.

The Ebola outbreak in West Africa is “unquestionably the most severe acute public health emergency in modern times,” Dr. Margaret Chan, the director general of the World Health Organization, said Monday 20/10/2014). We do seem to be going in circles... circa 1995.. have we learnt nothing from history.

Sooner or later we learn to throw the past away History will teach us nothing ~Sting – Musician, singer-songwriter

Where have all the people gone, long time passing? Where have all the people gone, long time ago? Where have all the people gone? Gone to graveyards, everyone. Oh, when will they ever learn? Oh, when will they ever learn? ~Pete Seeger - American folk singer and activist