.
Even with the strengthening of the response, the reason that a few dozen cases continue to exist is because a few months ago people with signs and symptoms weren’t isolated, says Dr. Goosby, so now it’s just a matter of the virus which got out into the community running its course.
Now that most of the outbreak needs have waned, many leading global health policy experts feel donors need to ask and take input from the people who know their country and communities’ health needs best—how can the resources be used to put a system in place to strengthen lab quality control and other health infrastructure and procurement systems.
Once the number of cases is brought to zero “it is important to have the systems in place to detect a new case and respond quickly through community based surveillance systems,” says UNMEER’s former head Tony Banbury. A community based surveillance system and forms of prevention are part of UNMEER’s crisis management exit strategy. “It would be irresponsible to leave” West Africa without the capacity for a disease-based surveillance system in place on the community level says Banbury. But it is not for UNMEER as a crisis management organization to build that capacity, it is for UNMEER to say this is what is necessary to bring the number of cases to zero says the former head of UNMEER. Banbury adds that a community based surveillance system is necessary to bring the number of Ebola cases to zero because it is essential to knowing whether or not there are still isolated cases of Ebola in remote areas.
Pre-Ebola Liberia had a surveillance system through community clinics but the Ministry of Health realized that in areas strained by human resources it would be helpful to empower the local community to report on things that seem unusual within their village. “We can have simplified forms for people to report suspected cases in their community, for example if they have a lot of death within their immediate family within a short time.
These community members could be the link to the primary clinic,” says Gbanya. This is one way Liberia hopes to tackle the difficulties in access and surveillance in very rural areas because it helped when these forms of communication were developed during the Ebola outbreak, says Gbanya.
Dr. Goosby says another factor in building up health infrastructure and prevention is a matter of donors and their flexibility. “Donors needs to be flexible and consider the money that they allotted for one thing maybe being used for something else that would strengthen the response to not just an Ebola outbreak but any outbreak.” But most budget allocation systems don’t allow for the reallocation of donated funds. For example if money is donated to build isolation facilities and it is instead used to build hospital beds, most donor countries will view this as a transgression that is viewed as a misappropriation of funds and will call for a review.
The international community shouldn’t be focusing funds on building Ebola treatment sites at the moment, and the current system lacks the flexibility to change allocations of the remaining financial resources from the international community according to Dr. Goosby.
“Generally, the preference is for the money to be returned to the treasury and be reconsidered whether it will come out again, and they are not going to change that,” says Dr. Goosby. “Its important that we invest in those critical gaps in healthcare infrastructure,” says Miatta Gbanya. “Over the last few months we’ve been putting together a ten-year plan for what we want to see happen in the healthcare system because Ebola showed us all the gaps that we had. We have three main pillars for this plan: the first is investing in the workforce of healthcare workers and finishing old business. The second is surveillance and cross border coordination, making it more functional than before. We need to talk with Guinea and Sierra Leone. The third is healthcare infrastructure, but that is not something people invest in because it is expensive ” says Gbanya.
“Health is going to be even more expensive post Ebola. So donor governments and everyone should know it will not be business as usual because we need essential drugs, supplies, and isolation facilities, triages, prevention materials on standby—we need to invest in the hard things along with the soft,” says Miatta Gbanya.
“We have to advocate for funding to improve our health facilities,” says Gbanya. “We have been asking our investors: how can you realign some of that funding because if you set up for Ebola prevention you can put cholera patients in it, you can put hemorrhagic fever patients in it—which we have,” says Gbanya. “It’s an investment that will save lives in the future. Alongside of the curative part, a huge focus should be on prevention activities and investments in human capital.”
Dr. Goosby and other health experts say that it’s important to note Ebola is a blood borne disease with a deadly gene. If a disease that were as deadly as Ebola was airborne the results would have been catastrophic. Many health experts believe there is one question that is important to ask and it isn’t just how do we prepare for the next Ebola outbreak. Dr. Larry Brilliant says, “The question becomes how do we govern with low probability but high catastrophic result?”
Dr. Goosby and many other health experts say the inequity between urban and rural healthcare is an issue in Sub-Saharan Africa as it is in many other areas including the United States. While past Ebola “outbreaks didn’t spread like this one did because the incubation period wasn’t long enough and the infections mostly stayed in the rural areas, even if the outbreak had taken place in the capitals of Sierra Leone, Guinea and Liberia, it still would have been poorly responded to,” says Dr. Goosby. These three countries lacked the capacity to isolate those that health workers may have been suspicious of having symptoms; many hospitals were sending the infected home where they were infecting other members of the same household, and most families were carrying on with the traditional burial practice of thoroughly bathing the dead—tragically further spreading the disease according to Dr. Goosby.
Prior to Ebola, data collection and surveillance carried out by the Ministry of Health had been improving in Liberia says Miatta Gbanya. Within the nation’s 15 counties data collection was taking place on the community-base level from the local clinics to the district level via health workers. And then the information was being passed along to the county level where it was logged into a database that was centralized within the Ministry of Health. The software Liberia was using to keep track of its health data is one being used in South Africa and many other countries throughout Africa says Gbanya. “The thing we were working towards was to see how the district and county levels could use the information they collect to influence their decision making within their own communities even before it reaches the central government level,” says Gbanya.
Prior to Ebola, Liberia was also training teams to go into the field to conduct data verification. “It seems easy, but as a developing country Liberia struggles with certain issues such as connectivity, roads, and phone service. Sometimes these communication problems interfere with the timing with which the information is shared,” says Gbanya. Communication issues interfered with Liberia’s Ebola response according to the Ministry of Health’s Deputy Incident Manager. “These communication issues caused a lot of problems if it was information that required quick action and there was a delay with that information being shared,” said Gbanya.
Another issue that many developing countries struggle with is capacity. “We didn’t have enough hospital beds,” says Gbanya. “One of our hospitals had to use a chapel where they put six beds for patients.” That is why Gbanya and international health policy experts say global health infrastructure is so essential to preventing pandemics. “People would not have died had they gotten to a bed and had access to treatment on time,” says Gbanya.
But then there’s also the human element of how Ebola spreads: “people got infected because they couldn’t just watch their loved ones suffering,” says Miatta Gbanya. Health officials were telling Liberians not to touch those who may be infected. But at the end of the day how can you tell a child not to hold their mother who is ill? Or a brother not to comfort or take care of his ill sister? Or a father not to care for his dying son? “Whole families were wiped out because they were caring for one another,” says Miatta. “It seems easy but it is hard, when someone who you know calls you and is sick and you say you need to go to the hospital. Ebola really tears everything apart,” says Miatta Gbanya.
Another less talked about factor was the controversy within the NGO community surrounding the risk to health workers in the field who were providing IVs for patients infected with Ebola. “People in West Africa were largely treated without IVs,” says Dr. Goosby. At the height of the Ebola outbreak there was a debate on whether or not to use IVs to treat Ebola patients considering the risk to the healthcare worker versus the benefit to the patient. It was felt, for the early part of the Ebola response, an IV was not necessary. The benefit was viewed as high to both the healthcare worker and patient if an IV was not used so long as the patient could drink water and fluids from a cup, says Dr. Goosby.
“As a physician I know that the reason the people who came to the United States did better was because we were able to control their fluids and electrolytes. There is no magic anti-ebola drug yet but there is better coordination of supportive care and you can keep someone hydrated well, profusing all their organs, and lowering the mortality rate,” says Dr. Goosby.
“We don’t know the reservoir so we don’t know when the next outbreak could be. It could be months, days, or years. We still don’t know the exact mode of transmission to humans,” says Dr. Goosby. But if it Ebola is proven without any doubt to be carried by fruit bats, experts will be able to map out high risk and low risk areas and we will have the opportunity to become more knowledgeable on how Ebola is transferred to humans. “Once we know the reservoir, we can eliminate the reservoir and the outbreaks will stop,” says Dr. Eric Goosby.
Read Part One
The views presented in this article are the author’s own and do not necessarily represent the views of any other organization.
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Part Two: The Future of Health Security
May 27, 2015
Even with the strengthening of the response, the reason that a few dozen cases continue to exist is because a few months ago people with signs and symptoms weren’t isolated, says Dr. Goosby, so now it’s just a matter of the virus which got out into the community running its course.
Now that most of the outbreak needs have waned, many leading global health policy experts feel donors need to ask and take input from the people who know their country and communities’ health needs best—how can the resources be used to put a system in place to strengthen lab quality control and other health infrastructure and procurement systems.
Once the number of cases is brought to zero “it is important to have the systems in place to detect a new case and respond quickly through community based surveillance systems,” says UNMEER’s former head Tony Banbury. A community based surveillance system and forms of prevention are part of UNMEER’s crisis management exit strategy. “It would be irresponsible to leave” West Africa without the capacity for a disease-based surveillance system in place on the community level says Banbury. But it is not for UNMEER as a crisis management organization to build that capacity, it is for UNMEER to say this is what is necessary to bring the number of cases to zero says the former head of UNMEER. Banbury adds that a community based surveillance system is necessary to bring the number of Ebola cases to zero because it is essential to knowing whether or not there are still isolated cases of Ebola in remote areas.
Pre-Ebola Liberia had a surveillance system through community clinics but the Ministry of Health realized that in areas strained by human resources it would be helpful to empower the local community to report on things that seem unusual within their village. “We can have simplified forms for people to report suspected cases in their community, for example if they have a lot of death within their immediate family within a short time.
These community members could be the link to the primary clinic,” says Gbanya. This is one way Liberia hopes to tackle the difficulties in access and surveillance in very rural areas because it helped when these forms of communication were developed during the Ebola outbreak, says Gbanya.
Dr. Goosby says another factor in building up health infrastructure and prevention is a matter of donors and their flexibility. “Donors needs to be flexible and consider the money that they allotted for one thing maybe being used for something else that would strengthen the response to not just an Ebola outbreak but any outbreak.” But most budget allocation systems don’t allow for the reallocation of donated funds. For example if money is donated to build isolation facilities and it is instead used to build hospital beds, most donor countries will view this as a transgression that is viewed as a misappropriation of funds and will call for a review.
The international community shouldn’t be focusing funds on building Ebola treatment sites at the moment, and the current system lacks the flexibility to change allocations of the remaining financial resources from the international community according to Dr. Goosby.
“Generally, the preference is for the money to be returned to the treasury and be reconsidered whether it will come out again, and they are not going to change that,” says Dr. Goosby. “Its important that we invest in those critical gaps in healthcare infrastructure,” says Miatta Gbanya. “Over the last few months we’ve been putting together a ten-year plan for what we want to see happen in the healthcare system because Ebola showed us all the gaps that we had. We have three main pillars for this plan: the first is investing in the workforce of healthcare workers and finishing old business. The second is surveillance and cross border coordination, making it more functional than before. We need to talk with Guinea and Sierra Leone. The third is healthcare infrastructure, but that is not something people invest in because it is expensive ” says Gbanya.
“Health is going to be even more expensive post Ebola. So donor governments and everyone should know it will not be business as usual because we need essential drugs, supplies, and isolation facilities, triages, prevention materials on standby—we need to invest in the hard things along with the soft,” says Miatta Gbanya.
“We have to advocate for funding to improve our health facilities,” says Gbanya. “We have been asking our investors: how can you realign some of that funding because if you set up for Ebola prevention you can put cholera patients in it, you can put hemorrhagic fever patients in it—which we have,” says Gbanya. “It’s an investment that will save lives in the future. Alongside of the curative part, a huge focus should be on prevention activities and investments in human capital.”
Dr. Goosby and other health experts say that it’s important to note Ebola is a blood borne disease with a deadly gene. If a disease that were as deadly as Ebola was airborne the results would have been catastrophic. Many health experts believe there is one question that is important to ask and it isn’t just how do we prepare for the next Ebola outbreak. Dr. Larry Brilliant says, “The question becomes how do we govern with low probability but high catastrophic result?”
Dr. Goosby and many other health experts say the inequity between urban and rural healthcare is an issue in Sub-Saharan Africa as it is in many other areas including the United States. While past Ebola “outbreaks didn’t spread like this one did because the incubation period wasn’t long enough and the infections mostly stayed in the rural areas, even if the outbreak had taken place in the capitals of Sierra Leone, Guinea and Liberia, it still would have been poorly responded to,” says Dr. Goosby. These three countries lacked the capacity to isolate those that health workers may have been suspicious of having symptoms; many hospitals were sending the infected home where they were infecting other members of the same household, and most families were carrying on with the traditional burial practice of thoroughly bathing the dead—tragically further spreading the disease according to Dr. Goosby.
Prior to Ebola, data collection and surveillance carried out by the Ministry of Health had been improving in Liberia says Miatta Gbanya. Within the nation’s 15 counties data collection was taking place on the community-base level from the local clinics to the district level via health workers. And then the information was being passed along to the county level where it was logged into a database that was centralized within the Ministry of Health. The software Liberia was using to keep track of its health data is one being used in South Africa and many other countries throughout Africa says Gbanya. “The thing we were working towards was to see how the district and county levels could use the information they collect to influence their decision making within their own communities even before it reaches the central government level,” says Gbanya.
Prior to Ebola, Liberia was also training teams to go into the field to conduct data verification. “It seems easy, but as a developing country Liberia struggles with certain issues such as connectivity, roads, and phone service. Sometimes these communication problems interfere with the timing with which the information is shared,” says Gbanya. Communication issues interfered with Liberia’s Ebola response according to the Ministry of Health’s Deputy Incident Manager. “These communication issues caused a lot of problems if it was information that required quick action and there was a delay with that information being shared,” said Gbanya.
Another issue that many developing countries struggle with is capacity. “We didn’t have enough hospital beds,” says Gbanya. “One of our hospitals had to use a chapel where they put six beds for patients.” That is why Gbanya and international health policy experts say global health infrastructure is so essential to preventing pandemics. “People would not have died had they gotten to a bed and had access to treatment on time,” says Gbanya.
But then there’s also the human element of how Ebola spreads: “people got infected because they couldn’t just watch their loved ones suffering,” says Miatta Gbanya. Health officials were telling Liberians not to touch those who may be infected. But at the end of the day how can you tell a child not to hold their mother who is ill? Or a brother not to comfort or take care of his ill sister? Or a father not to care for his dying son? “Whole families were wiped out because they were caring for one another,” says Miatta. “It seems easy but it is hard, when someone who you know calls you and is sick and you say you need to go to the hospital. Ebola really tears everything apart,” says Miatta Gbanya.
Another less talked about factor was the controversy within the NGO community surrounding the risk to health workers in the field who were providing IVs for patients infected with Ebola. “People in West Africa were largely treated without IVs,” says Dr. Goosby. At the height of the Ebola outbreak there was a debate on whether or not to use IVs to treat Ebola patients considering the risk to the healthcare worker versus the benefit to the patient. It was felt, for the early part of the Ebola response, an IV was not necessary. The benefit was viewed as high to both the healthcare worker and patient if an IV was not used so long as the patient could drink water and fluids from a cup, says Dr. Goosby.
“As a physician I know that the reason the people who came to the United States did better was because we were able to control their fluids and electrolytes. There is no magic anti-ebola drug yet but there is better coordination of supportive care and you can keep someone hydrated well, profusing all their organs, and lowering the mortality rate,” says Dr. Goosby.
“We don’t know the reservoir so we don’t know when the next outbreak could be. It could be months, days, or years. We still don’t know the exact mode of transmission to humans,” says Dr. Goosby. But if it Ebola is proven without any doubt to be carried by fruit bats, experts will be able to map out high risk and low risk areas and we will have the opportunity to become more knowledgeable on how Ebola is transferred to humans. “Once we know the reservoir, we can eliminate the reservoir and the outbreaks will stop,” says Dr. Eric Goosby.
Read Part One
The views presented in this article are the author’s own and do not necessarily represent the views of any other organization.
