West Africa: Late, Slow and Wholly Inadequate – the Global Ebola Response

Ebola survivor Beatrice Yardola was one of Liberia's last Ebola patients. There could have been many fewer deaths with better national and global responses.
23 November 2015

Dr. Samuel Kargbo and his colleagues in Sierra Leone's health ministry were in despair.

West Africa's first Ebola epidemic was ravaging his country and its neighbors, Guinea and Liberia. Doctors and nurses experienced in treating hemorrhagic fevers were dead or dying. There were no laboratory tests to distinguish Ebola from illnesses with similar initial symptoms. Across the region, hospitals and clinics without the means to protect either patients or staff were forced to close.

Life-saving supplies were widely unavailable, as international airlines and shipping companies stopped services. MIT's Humanitarian Response Lab issued an appeal for immediate action, saying pallets of urgently needed caps, gowns, boots and masks contributed by Boston area institutions were left sitting at New York's JFK Airport. Similar blockages of critical supplies were happening around the world.

Video and discussion of the Independent Panel's report by global health experts: London | Washington DC

Two carriers, Royal Air Maroc and Brussels Airline, provided fragile lifelines. By July 2014, even before the epidemic's peak, Brussels officials said the airline had flown in thousands of passengers, including health workers, and 2000 tons of freight, mostly humanitarian supplies.

Masmina Sirleaf, a pediatric health administrator volunteering with Heartt, a capacity-building organization for the Liberian health sector, was one of those who relied on Brussels Airline. When she flew into the capital, Monrovia, she took tens of thousands of dollars' worth of donated gloves, IV fluids and other materials.

But the flights brought more than supplies and infectious disease experts.

"They helped us feel that we weren't completely alone," said Kargbo, who monitored the Sierra Leone Ministry of Health's Ebola response. In an interview this month in Washington, DC, where he traveled as an Aspen New Voices Fellow, Kargbo said he is determined to work towards national and international systems to prevent future Ebola-like catastrophes.

That goal may be advanced by a strong critique of the global Ebola response published today in the British medical journal The Lancet.

Among the recommendations of the report is that the World Health Organization (WHO)"must confront governments that implement trade and travel restrictions without scientific justification, while developing industry-wide cooperation frameworks to ensure private firms such as airlines and shipping companies continue to provide crucial services during emergencies."

The report – Will Ebola Change the Game? – is issued by the Independent Panel on the Global Response to Ebola, a joint initiative of the Harvard Global Health Institute and the London School of Hygiene and Tropical Medicine. It makes ten recommendations grouped into four themes: preventing major disease outbreaks; responding to major disease outbreaks; research that produces and shares data, knowledge and technology; and a global governance system for preventing and responding to outbreaks.

Recommendations in all three areas are specific – "concrete, actionable and measurable" in the words of the report. Examples are: establishing "a transparent central system for tracking and monitoring" resources, to ensure accountability from donors as well as from recipients of funds; a Global Health Committee as part of the United Nations Security Council; and "economic incentives for early reporting" of disease outbreaks by countries, through "committing to disburse emergency funds rapidly when outbreaks strike and compensating for economic losses that might result".

The 19-person panel includes its chair, the London School's Dr. Peter Piot, a Belgian microbiologist who identified the first known Ebola outbreak in 1976 in the Democratic Republic of Congo.

Three African members are panel co-chair Dr. Muhammad Ali Pate, an infectious diseases physician and health policy specialist who led Nigeria's successful effort to eliminate polio; Valnora Edwin, a civil society activist with advanced degrees in human rights, peacebuilding and transitional justice, who heads the Campaign for Good Governance in Sierra Leone; and Dr. Mosoka Fallah, an epidemiologist and immunologist who grew up in Liberia's civil wars before earning degrees from the re-opened University of Liberia, the University of Kentucky and Harvard.

Fallah played a central role in containing the disease for Liberia's health ministry but he has no time to mark the report's release this weekend. His team is swamped doing contact tracing on three new Ebola cases in one family – two and a half months after Liberia was declared Ebola free by international health authorities.

Harvard's Dr. Suerie Moon, who directs multiple global health research initiatives, is the panel's Study Director. She says the members' expertise and diversity led to vigorous debates and multiple drafts and revisions before panelists were satisfied.

By focusing detailed attention on a failed international response, the report differs from many previous evaluations of how Ebola spiraled out of control – and from the thrust of a large volume of media accounts – which often assigned the bulk of blame to weak health systems in the three most-affected countries. It was common, as well, to blame the victims, who were portrayed repeatedly as superstitious and ignorant, with strange cultural practices that spread the disease.

Moon is quick to say that the panel is "not alone in recognizing that Ebola revealed a global system for managing outbreaks that was extremely fragile and full of gaping holes."

The report recognizes, she says, that "what happened with Ebola was an extremely delayed response. It should have happened much, much sooner."

At the same time, she says, the goal of "an independent panel that drew its participants from academia and civil society and think tanks was to offer a perspective that had a bit of an arms-length distance from the policy makers who were responsible for launching the global response."

The panel finds fault nearly everywhere. Some national authorities, the report says, initially downplayed the problem. It mentions that Guinea did so, out of fear of creating panic and disrupting the economy, despite "warnings about the unprecedented scope of the outbreak".

International action, according to the report, was slow to develop; was inadequate at the critical period for containing the epidemic; and was inflexible in responding to changing realities.

Examples on the ground are everywhere. When AllAfrica's Boakai Fofana toured the first Ebola Treatment Center built by the U.S. military, he reported that by the time it opened, there were few Ebola cases left. The center sat empty of patients in a country whose health system, just beginning to recover from decades of conflict, had been shattered by Ebola. The U.S.-built facility was not designed to meet any other critical needs – such as treating malaria or intervening in a difficult childbirth.

Medicine Sans Frontiere (MSF), the international medical crisis group whose work played a central role in bringing Ebola under control, supplied expertise and facilities but relied primarily on thousands of courageous local staff. Its poignant appeals for greater international assistance elicited little response when help was needed most. The group's July 2014 report – Where is everyone? – which discusses failures of the global emergency response in three health crises, sounds similar alarms as the Ebola panel.

Without the early intervention of international charities, private companies, and the massive deployment by MSF, the toll would have been far higher than over 28,000 people infected and more than 11,000 deaths. But none of those entities could compensate for the lack of a massive response that only large international organizations and governments could have provided.

"An excessive burden," the panel's report says, "fell on national and international non-governmental organizations and local communities to do the highest-risk work, such as patient care and burials."

Nigerian epidemiologist Chikwe Ihekweazu, managing partner of health consultancy EpiAFRIC, has been conducting an evaluation of the Ebola response by the African Union (AU), an organization of 54 African member states. He says AU assistance was important in several ways. It mobilized African medical and research experts from previous epidemics, who were in many cases able to reassure frightened populations and gain their cooperation in seeking treatment for themselves and others. It was able to field as many as 700 or 800 doctors, nurses and other health professionals at a given time, and they stayed an average of five months – longer than most international volunteers.

Of particular usefulness, Ihekweazu says, was "the AU's contribution to restoring vital health services. It could send 10 doctors and 30 nurses to a clinic to restart clinical care."

When asked about the magnitude of the Ebola effect on non-Ebola illnesses, Ihekweazu says there is no means of compiling quantitative evidence for the claim that more people died as a result of health-system disruptions than from Ebola itself. But there is no doubt, he says, that "the AU's contribution to restoring services at existing health facilities saved a significant number of lives".

In the Independent Panel's report, the World Health Organization receives particular attention for inaction. The report says: "WHO did not mobilise global assistance in countering the epidemic despite ample evidence the outbreak had overwhelmed national and non-governmental capacities – failures in both technical judgment and political leadership".

The report urges sweeping overhaul of WHO, which it says remains ill-prepared to deal with future global health emergencies. But while the panel criticizes the organization's leadership and structures, it says that WHO's international funders also bear blame for imposing controls that have eroded WHO's flexibility. The report makes recommendations for establishing transparent WHO governance and expenditures, while conferring the capacity for quick response.

"Our primary goal," says the report, "is to convince high-level political leaders worldwide to make necessary and enduring changes to better prepare for future outbreaks while memories of the human costs of inaction remain vivid and fresh."

Ihekweazu agrees that it is necessary for the global community to plan both preventive and responsive strategies for future health threats. But he insists that the tragedy of Ebola is that it should never have spread as it did. "The big public health failure," he says, "was letting that happen."

Have governments and multi-national organizations learned that lesson? Moon says the panel recognized that there was, in the end, a large global response to Ebola, as well as an outpouring of support from around the world.

"There were many, many acts of heroism and courage and generosity, and we applaud all of those," she says. "But thinking about when the next outbreak hits, are we confident that the world is ready? I would say, 'Absolutely not'.

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