Ebola: A watershed for health systems and development? Hossinatu Mary Kanu, Senesie Margao and Jill Iliffe At the end of December 2013 a two-year-old child living in the remote village of Meliandou, Guinea, died from a ‘mysterious disease’. In March 2014 the Ministry of Health in Guinea reported concerns about the spread of this ‘mysterious illness’, which was eventually diagnosed and reported on the website of the World Health Organization (WHO) Regional Office for Africa on 23 March as Ebola Virus Disease (EVD). By that time, the end of week 11 of the epidemic, there were 86 reported cases in Guinea and 60 deaths (WHO, 2015a). Médecins Sans Frontières (MSF) was the first international agency to respond, establishing a base in Guinea in March 2014 within four days of the declaration of the epidemic in that country. By week 25, on 23 June 2014, MSF warned the world that the epidemic was ‘out of control’, with 528 cases and 337 deaths being reported across 60 sites in Guinea, Liberia and Sierra Leone. However, it was not until the end of week 31, on 9 August 2014, that the WHO declared the Ebola epidemic a ‘public health emergency of international concern’. By this time there were 1,171 cases and 932 deaths. The WHO noted that the three countries most affected had fragile health systems with significant deficits in human, financial and material resources, resulting in a compromised ability to mount an adequate Ebola outbreak control response. They were inexperienced in dealing with Ebola outbreaks; there were misperceptions about the disease and how it was transmitted; there was high population mobility across borders; and a high number of infections had been reported among health care Ebola Virus Disease 60 Commonwealth Health Partnerships 2015 workers, highlighting inadequate infection control practices. The international community was already aware that the affected countries faced these challenges long before the outbreak of Ebola. It was not until week 37 that, on 18 September, the United Nations Security Council unanimously passed Resolution 2177 (2014), stating that the ‘unprecedented extent’ of the epidemic ‘constituted a threat to international peace and security’. Twelve months after the first epidemic was declared in Guinea in March 2014, there had been 24,282 cases and 9,976 deaths, 491 of them health workers (WHO, 2015b), and the EVD epidemic in West Africa – Guinea, Liberia and Sierra Leone – is still not over. Many questions are now being asked the world over as to how and why this situation developed, and what we can do to make sure it does not happen again. The international response In 2010 a WHO review committee was convened to evaluate the response to the 2009 H1N1 influenza pandemic and assess the level of global preparedness for similar events in the future. The committee concluded: ‘The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global and threatening public health emergency.’ However, in November 2014, four years later, only 64 of the 194 WHO member states were assessed as having the essential surveillance, laboratory, data management and other health system capacities to respond to a public health emergency. Having faced the threat of H1N1 in 2009 and knowing in 2014 that at least 130 countries were unprepared for a public health emergency, why was nothing done? Wilkinson and Leach (2014) offer a set of explanations and contend that ‘structural violence’ contributed to the epidemic. They define structural violence as ‘the way institutions and practices inflict avoidable harm … damage is done unequally and often in a manner which comes to be taken for granted’ (p. 1). They argue their case within three domains: the failure of outbreak response and global health governance; compromised health systems and development policy; and misleading assumptions and myths. Failure of outbreak response and global health governance Wilkinson and Leach maintain that from the outset, and despite warnings, the international response to Ebola was ‘disastrously ineffective’, lacked leadership, funds, equipment and human resources, and that it was an avoidable disaster. While the WHO comes in for criticism, they point out that essential restructuring following significant budget and staff cuts in 2011 led to a re-focus of WHO priorities on non-communicable diseases (NCDs) and a shift to providing technical advice rather than taking responsibility Ebola Virus Disease is a severe, often fatal, illness. The origin of the virus is unknown, however, the WHO reports that, based on available evidence, fruit bats (Pteropodidae) are considered the likely host. In areas of Africa, infection has been documented through the handling (blood, secretions, organs and other body fluids) of infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines, either alive or dead. In the current outbreak in West Africa, however, the majority of cases have occurred as a result of human-to-human transmission. Infection occurs through direct contact of broken skin or mucous membranes with the blood or other body fluids (faeces, urine, saliva, semen, sweat) of infected people. Infection can also occur if broken skin or mucous membrane comes into contact with clothing, bed linen, needles or surfaces that have been contaminated with an Ebola patient’s infectious secretions or body fluids. There are five different strains of the Ebola virus. The Zaire strain of the Ebola virus was responsible for the outbreak in West Africa (MSF, 2015).
Commonwealth Health Partnerships 2015
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