Ebola emerges in fragile states: another ‘wake-up’ call for action on health systems in conflict affected states?

If the global community has been sleeping on the job of supporting fragile and post-conflict settings, then the Ebola outbreak is certainly something to wake us up.

Ebola emerges in fragile states: another ‘wake-up’ call for action on health systems in conflict affected states?

By Suzanne Fustukian and Karen Cavanaugh

In 2013 World Bank President Jim Kim stated that the lack of progress for many fragile states: “should be a wake-up call to the global community not to dismiss these countries as lost causes,” and that “timely and critical support [is needed]to improve the lives of people living in these fragile countries.”

If the global community has been sleeping on the job of supporting fragile and post-conflict settings, then the Ebola outbreak is certainly something to wake us up. 

Ebola emerges

Why did this Ebola Virus strain surface in three fragile West African countries only recently emerging from major conflicts (Guinea, Sierra Leone, and Liberia)? Bausch and Schwarz highlight that Ebola, rather than mysteriously appearing at random, previously appeared in regions with compromised local economies and weak public health systems, such as Northern Uganda, the Democratic Republic of Congo and South Sudan.  In these regions – often devastated by conflict:

poverty drives people to expand their range of activities to stay alive, plunging deeper into the forest to expand the geographic as well as species range of hunted game and to find wood to make charcoal and deeper into mines to extract minerals, enhancing their risk of exposure to Ebola virus and other zoonotic pathogens in these remote corners.

Ebola spreads

Why was the Ebola virus able to spread so rapidly this time throughout border regions and from these more remote areas to capital cities of three neighbouring nations? In other words, why was the virus not contained in the locality of the outbreak, as in earlier Ebola outbreaks? In part, the lack of prior experience with this disease delayed recognition by health officials. We also know that within fragile states are even more fragile sub-national regions – remote not only geographically from national capitals but, effectively, remote from the notice of those in power. These particular border areas are notoriously neglected in general, but in this case, inadequate numbers of health personnel, surveillance systems, diagnostic facilities, isolation wards and protective equipment meant that all three health systems were slow to recognise and respond to the crisis before becoming overwhelmed.

The Ebola outbreak only aggravates underlying health systems challenges of health worker shortages, insufficient financing, fragmented information systems, and limited leadership to deliver quality health services. The ability of Liberia, Guinea and Sierra Leone’s health systems to provide essential services for maternal and child health, malaria, HIV/AIDS and other diseases, is being compromised, resulting in increased deaths from those diseases in addition to the lives that Ebola is claiming.

The recent cases in Spain and Texas, however, show that even well prepared public health systems can make grievous errors in recognising the Ebola Virus Disease and that these errors can have far-reaching health, economic and social consequences. One Texas Ebola patient’s commercial jet flight led to tracking of 1,000 air passengers, the closure of six schools whose students were fellow passengers, and at least 6 airline crew off work for 21 days.

Health system response to Ebola

Health facilities in Sierra Leone, for example, are chronically understaffed by poorly trained, overworked healthcare personnel. Only a fraction of Sierra Leone’s 136 doctors are trained in infectious disease control.  Colleagues from the College of Medicine and Health Sciences (COMAHS) in Freetown, and research partners in the ReBuild Research Consortium, have noted that “health workers have no or little infection control training. They are working in conditions that are not supported by adequate logistics. The basics of sanitation, electricity and personal protective equipment [PPE] to ensure the safety of health workers from infection are not always available when required.”  Furthermore, training has been done during the outbreak instead of before – in preparation of a potential outbreak, at a time when the pressure of demand for treatment was outstripping supply. Local diagnostic capacity is also low.

The health systems of these Ebola-affected countries can be rebuilt; lessons from previous crises can guide the process of revitalizing the post-Ebola health system. For example, Afghanistan experienced some of the highest maternal and child mortality rates in the world after the fall of the Taliban, but with the aid of international partners, the new government was able to restart a viable health care system to rapidly deliver essential health services and sustain high coverage rates by contracting through NGOs. Other fragile and conflict-affected states such as Cambodia, Haiti, DRC, Rwanda and South Sudan, have demonstrated that deploying community health workers ensures remote areas have access to health services; creating platforms for external partners and host governments facilitates strategic coordination, and developing databases on key health resources ensures that decision-makers are well informed.

Community-health system interaction

As Farrar and Piot have pointed out, the encounter between affected and frightened communities and a functional health system is equally important in controlling such outbreaks. However, the time to build trust and communications between the health system and the community is not during an epidemic when fear and panic are high. Trust and effective communications need to be in place before these events. Fostering these is part of building a responsive and resilient health system.

In Uganda, since the Ebola outbreak in 2000, the Ministry of Health has taken steps to educate both health workers and the general public on Ebola symptoms. For this reason, each subsequent outbreak in Uganda is smaller than the one before. In Sierra Leone today, high levels of distrust have led communities to avoid health facilities, associating them with the virus, relying instead on traditional healers or self-medication. Lacking both sufficient training and PPE, Ebola has taken a heavy toll among health workers in Guinea, Liberia, and Sierra Leone. Nosocomial transmission, where the health system itself has become a “reservoir of infections,” has meant that “patients and health-workers alike carry the infection to the general population”. Without a cure, supportive care for patients while their immune systems fight off the virus is all that health services are able to provide, yet health facilities are in disarray and the number of beds available in Liberia and Sierra Leone is drastically short of required capacity, (only 21 and 26 per cent of beds available, respectively).

What next?

The attention to the current crisis in West Africa has meant the world’s gaze is on this part of the world again.  The UN Secretary General, Ban Ki-moon, has recently described this as the “biggest global health threat since AIDS” and the international response as “inadequate”. The World Bank and other major donors have pledged to support the Guinea, Liberia and Sierra Leone; with the Bank committing $400 million, the U.S. Government obligating more than $300 million to date, and the IMF giving $130 million in emergency financing. More than a cheque, the region needs people – to fight this epidemic and assist the people and the health system to recover and rebuild more resilient health systems. With USAID’s recent launch of the “Fighting Ebola: A Grand Challenge for Development,” there is hope that innovators around the world will pioneer solutions targeted at improving the tools used by frontline health workers.

The development partner community is moving forward quickly as representatives from WHO, WAHO, UKAID, JICA, the World Bank Group, the Wellcome Trust, USAID, UNICEF, the Rockefeller Foundation, and the Bill and Melinda Gates Foundation will coordinate plans for partnering with Liberia, Sierra Leone and Guinea and vulnerable countries throughout the region to rebuild health systems. This includes a focus on restoring equitable access to essential services, building a sufficient workforce, and ensuring preparedness and response capacity throughout West Africa.

The call to action is urgent – and needs to be heard.

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