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. 

Empowerment is Key to Improving Health Infrastructure in Developing Countries

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

Providing greater health access and more efficient health care delivery, especially for vulnerable populations, are priorities for anyone involved in public health. Poor health systems in developing countries mean a shortage of trained health care workers, inconsistent inventory of medical supplies, and inadequate surveillance systems. This list is not exhaustive, but we can start here. Building a better health infrastructure, like many public health priorities, requires multi-level coordination. Empowerment has to spread out from the government to the community and to the individual.

We can address the problem first by tackling the shortage of health care workers. Doctors in developing countries are in critically short supply. In 2006, the World Health Organization compiled data on the impact of HIV/AIDS on the health workforce in developing countries. Results showed that while European and North American countries have doctors at a ratio of 160 to 560 per 100,000 people, African countries only have two to sixty doctors for every 100,000. In Malawi, for example, there is one doctor for every 50,000 people. The global shortage of trained hospital and health care staff currently exceeds four million. Training more staff and volunteers is one solution for improving health systems in developing countries. Training other previously unqualified individuals could ameliorate these shortages. Providing incentives for already trained workers to stay in a vulnerable state or country could help build a struggling health system. Having a foundation of trained workers and preventing them from migrating to wealthier countries is an important first step. Empowerment and opportunities to grow and help are at the heart of this strategy.

The second hurdle is maintaining a constant inventory of equipment, medicines, and other health supplies. War, along with political and social unrest, in certain regions further dampens the efforts to provide a steady supply chain. There has to be cooperation between donors and the government to work with the private sector to ensure receipt of necessary health supplies. Partnering with emerging pharmacy chains increases the availability of medicines and drives down the cost for the patients. In the Philippines, Generics Pharmacy has thousands of small storefronts that are widely used by both the rich and poor. Convenience and ease of access are often of paramount interest to every person, regardless of income. The issue of payment is another facet of the supply and demand problem. Corruption that trickles to the local governments, and even the health care workers themselves, leads to some patients having to pay for medicine or services that should have been free. Reforming payment systems to ensure that patients have the medicines delivered before payment is processed directly to the provider will empower the patients and promote compliance. 

Compounding the shortage problems, both of trained workers and supplies, are the inadequate surveillance systems in place. This is the third issue that needs to be addressed, and it is arguably the most crucial. Surveillance is necessary to monitor not only the needs within health facilities, but also within the community and surrounding areas. Without real-time tracking of disease and medical supplies, logisticians, doctors and community health workers are unable to properly estimate need and completely evaluate the effectiveness of their clinic’s efforts. This is where data comes into play. The Novartis Malaria Initiative, under the Roll Back Malaria Partnership, has led SMS for Life, which harnesses mobile phones, internet, and electronic mapping technology to track stock levels for health facilities. Sending SMS messages between health facilities and the district medical officers ensures treatment availability. Stock-outs have been reduced in Tanzania during a six-month pilot program from 79% to 26% in three districts. Not only are these stock-outs reduced, but when they occur, they are also resolved much quicker due to the ease of communication. In areas where internet is unavailable or running inconsistently, Relief Watch has offered a similar solution. It also uses mobile technology, but the application allows workers to not only track supplies but also disease (http://www.reliefwatch.com/). The easy and free setup is invaluable to developing countries that have previously relied on paper spreadsheets and forms. Giving workers data at their fingertips gives them more control over their health facility and their patients. These technological innovations are not only crucial for immediate supply tracking and disease surveillance, but they provide research institutions and governing bodies more accurate data. After all, it is data that public health professionals and policy-makers rely on to make decisions and plan strategies. 

The aforementioned plan to improve health systems is by no means novel. Public health practitioners have stressed the importance of training more workers, creating a steady supply chain of treatments, and addressing surveillance shortcomings for decades. Adhering to these solutions requires cooperation and active coordination that extend from the public to the private sector. This is something that cannot be over-emphasized. Empowerment—of individuals, community health workers, and governing bodies of fragile states—is an important foundation from which a better health infrastructure can grow.


Resources:

The impact of HIV/AIDS on the health workforce in developing countries http://www.who.int/hrh/documents/Impact_of_HIV.pdf
Healthcare logistics: delivering medicines to where they're needed most
http://www.theguardian.com/global-development-professionals-network/2013/jul/29/healthcare-logistics-best-practice
SMS for Life http://www.malaria.novartis.com/innovation/sms-for-life/
Relief Watch http://www.reliefwatch.com/
Avert: Universal access to HIV treatment http://www.avert.org/universal-access-hiv-treatment.htm