Emergencies preparedness, response

What this – the largest Ebola outbreak in history – tells the world

Deadly pathogens exploit weak health systems

Ebola at 6 months

What does this outbreak, that has been making media headlines for months, tell us about the state of the world at large? What does it tell world leaders, and the citizens who elect them, about the state and status of public health?

WHO Director-General, Dr Margaret Chan, sees 6 specific things.

First, the outbreak spotlights the dangers of the world’s growing social and economic inequalities. The rich get the best care. The poor are left to die.

Second, rumours and panic are spreading faster than the virus. And this costs money. Ebola sparks nearly universal fear. Fear vastly amplifies social disruption and economic losses well beyond the outbreak zones.

The World Bank estimates that the vast majority of economic losses during any outbreak arise from the uncoordinated and irrational efforts of the public to avoid infection.

Third, when a deadly and dreaded virus hits the destitute and spirals out of control, the whole world is put at risk. Our 21st century societies are interconnected, interdependent and electronically wired together as never before.

This became clear when the virus entered Nigeria’s oil and natural gas hub, the city of Port Harcourt. Nigeria is the world’s fourth largest oil producer and second largest supplier of natural gas. If that outbreak flares up again, it could dampen the economic outlook worldwide.

Fourth, decades of neglect of fundamental health systems and services mean that a shock, like an extreme weather event or a disease run wild, can bring a fragile country to its knees.

These systems cannot be built up during a crisis. Instead, they collapse. A dysfunctional health system also means zero population resilience to the range of shocks that our world is delivering, with ever greater frequency and force – whether from a changing climate, armed violence and civil unrest, or a deadly and dreaded virus.

Deadly pathogens exploit weak health systems

WHO is aware that, in the three hardest-hit countries, high numbers of deaths from other causes are occurring, whether from malaria and other infectious diseases, or zero capacity for safe childbirth.

The size of this “emergency within the emergency” is not precisely known, as systems for monitoring health statistics – not good to begin with – have now broken down completely.

It is, however, important to understand one point: these deaths are not “collateral damage”. They are all part of the central problem: no fundamental public health infrastructures were in place, and this is what allowed the virus to spiral out of control.

In the simplest terms, this outbreak shows how one of the deadliest pathogens on earth can exploit any weakness in the health infrastructure, be it inadequate numbers of health care staff or the virtual absence of isolation wards and intensive care facilities throughout much of sub-Saharan Africa.

WHO has been making these arguments for at least two decades. Some signs are beginning to suggest that they are now falling on more receptive ears.

When presidents and prime ministers in non-affected countries make statements about Ebola, they rightly attribute the outbreak’s unprecedented spread and severity to the “failure to put basic public health infrastructures in place”.

No incentive for Ebola research

A fifth especially striking issue is this: Ebola emerged nearly 40 years ago. Why are clinicians still empty-handed, with no vaccines and no cure? Answer: because Ebola has been, historically, geographically confined to poor African nations.

The R&D incentive is virtually non-existent. A profit-driven industry does not invest in products for markets that cannot pay.

Again, WHO has been trying to make this issue visible for more than a decade, most recently through the deliberations of the Consultative Expert Working Group on Research and Development: Financing and Coordination.

Now people see the reality of this R&D failure, this market failure, on TV screens and in the headline news: the world’s empty-handed clinicians in their hazmat suits, trying to help Africa’s desperate poor, putting their own lives at risk, and losing them.

Fast action on new Ebola therapies and vaccines

On the issue of experimental therapies and vaccines, WHO has moved fast in securing ethical approval and coordinating worldwide collaborative efforts to move the most promising products forward.

Three weeks ago, the Organization brought together more than 100 of the world’s leading experts on the many complex issues surrounding the use of these experimental medical products. As a result, this could be the first Ebola outbreak in history that can be tackled with vaccines and medicines.

For vaccines, testing on human volunteers has already begun. If all continues to go well, 2 vaccines could be ready for progressive introduction near the end of this year. Some 5 to 10 drugs are also being developed as quickly and safely as possible.

For vaccines, the projected year-end quantities are considered large enough to have at least some impact on the future of the outbreak’s evolution.

Blood from survivors holds hope

The experts also debated the pros and cons of treating Ebola patients with transfusions of whole blood taken from patients who survived their infection. This form of treatment has been used empirically in the past, in a small group of patients, with promising results.

Convalescent plasma was also considered as an alternative treatment option. Of the two options, use of convalescent plasma is technically more complex and more demanding in terms of facilities and skills. The eventual use of this experimental therapy in Guinea, Sierra Leone and the Democratic Republic of Congo will depend on the availability of skilled technical expertise.

The experts decided that both treatment options should be prioritized for further investigation. WHO is already in discussions with health experts in the Democratic Republic of Congo, Guinea, Liberia, Nigeria and Sierra Leone. These joint discussions are currently looking at the practicalities of using whole blood transfusions and convalescent plasma from survivors.

Finally, the world is ill-prepared to respond to any severe, sustained and threatening public health emergency. That statement was one of the main conclusions of the Review Committee convened, under the provisions of the International Health Regulations, to assess the response to the 2009 influenza pandemic.

The Ebola outbreak proves, beyond any shadow of a doubt, that this conclusion was spot on.