BRIEF

Solidarity and Security in Global Heath What Can We Learn from the Ebola Crisis?

January 29, 2015



Keynote Speech delivered at the opening plenary of the

Prince Mahidol Award Conference

January 29, 2015

Tim Evans, Senior Director, Health Nutrition and Population,

World Bank Group

  • It’s been nearly 14 months since the Ebola virus first emerged in rural southwestern Guinea with the “index case” – a 2-year-old who died on December 6, 2013.  14 months.
  • What could have been an isolated and swiftly contained outbreak instead spiraled and spread out of control across Guinea and to neighboring countries to become the world’s worst Ebola epidemic ever.
  • We know all too well the human and economic toll this deadly epidemic has had, and continues to have, in Guinea, Liberia, and Sierra Leone.
  • And until we get to zero Ebola cases, the rest of Africa – indeed the rest of the world – continues to be at risk of contagion – both health  and economic-wise.
    • Last week, the World Bank Group released a new report showing that even as Ebola transmission rates in the three most-affected countries show significant signs of slowing, the epidemic continues to cripple the economies of these countries – with a projected $1.6 billion in lost GDP for 2015.
  • Of course, Ebola isn’t our first wake-up call that pandemics are costly.  From 1997-2009, six major outbreaks of animal-borne diseases that can be transmitted to humans, such as SARs, avian and swine flu, resulted in billions of dollars in economic losses.
  • And following the 2009 H1N1 epidemic, a Review Committee on the Functioning of the International  Health Regulations in relation to H1N1, aka “the Fineberg Report” identified serious shortfalls in the global pandemic response capacity noting:
    • "The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.”
  • Moreover, the succinct recommendations of the Fineberg Report proposed, for example, a global pandemic workforce and a pandemic fund, but failed to move beyond the paper on which they were issued.
  • But it is possible, indeed imperative, that we do better in managing global pandemic risk
  • Larry Brilliant – a key leader in the eradication of small pox along with DA Henderson - commented recently that “outbreaks are inevitable, epidemics are optional.”
  • The good news is that this Ebola epidemic is now being contained. We are seeing light at the end of the tunnel – although it’s still too early to declare victory.  We know this deadly disease has a history of resurgence, and we must remain vigilant.
  • But while the terrifying reality of the Ebola crisis is close at hand, let’s look now at what we can learn.

 

  • I would like to offer 10 lessons from the Ebola crisison which we must act NOW so we are prepared and can respond smartly and swiftly to the next pandemic.  

 

  • Lesson 1.  Public health and health care services go hand-in-hand.
    • In 1875, Theodor Billroth, a Professor of Surgery, noted, “The fanatical champions of public health are fighting for a goal that is too high for my myopic vision.  I can admire the struggle, but I cannot become interested in it.”
    • Professor Billroth may have thought differently if he had been working in the Kipe hospital in Guinea in April 2014 when a patient with stomach pain and fever presented in the emergency room.   The patient was admitted with a suspected bleeding ulcer, scoped by the gastroenterology service, admitted to an intensive care unit in shock and died.   A number of the hospital’s medical staff subsequently developed Ebola infection and succumbed to the disease!
    • Were Professor Billroth working in any of the Ebola-affected countries and presented with a mother with obstructed labor who also had a fever, he too might become “public health fanatical” in demanding a rapid diagnostic to rule out Ebola infection prior to proceeding to a Caesarian section.
    • Indeed the sinister nature of Ebola, whereby it infects the compassionate hands of health care providers that tend to sick patients, illustrates the inseparability of public health and clinical services.
    • Moving forward, we must build a seamless intersection in the planning and delivery of public health and clinical services that strengthens primary health care systems – the best defense against Ebola and other epidemic infectious diseases.

 

  • Lesson 2: Informed citizens and empowered communities are the most effective front line of preparedness and response.
    • The fatal attacks on Ebola workers in rural Guinea underscore the harsh reality that efforts to protect the public’s health are not necessarily welcomed by the community.
    • Instructions from public health authorities for “safe burials” to prevent further transmission of Ebola, which required abandoning traditional rituals of dealing with the deceased, were met with great suspicion and even outrage by aggrieved family members.  Attaining good levels of adherence required active engagement with communities such that they could better understand and accept these practices.  Community insights among Muslim populations, led to abandoning “black” body bags for “white” ones in order to match the white sheets in which the deceased are traditionally draped. 
    • Much of the success of the efforts to prevent spread of Ebola in Senegal, Mali and Nigeria was linked to the mobilization of religious and community leaders.   Dr. Awa Coll-Seck, the Minister of Health in Senegal --- and also the Senegalese “Man of the Year” for 2014 --- emphasizes the critical role women community leaders played across all of the villages of Senegal in spreading awareness of Ebola.
    • In Monrovia – it was volunteers from the community who assisted families to care for Ebola victims, and meet their daily food and water needs as they stayed at home for the 21-day quarantine period.  These same volunteers were instrumental in helping to integrate Ebola survivors back into the community.
    • These innovations in community engagement/empowerment should contribute to a rich legacy of know-how in the control of Ebola and other Epidemic Infectious Diseases.

 

 

  • Lesson 3. Secure “staff, stuff and systems” to deliver services.
    • My dear colleague, Paul Farmer is “famous”… and well-known for repeatedly calling attention to the “staff, stuff and systems,” the basic resources required to protect populations and to provide services of quality to those with the greatest needs.
    • Shortfalls in these basics, as we have seen in the Ebola-affected countries, prevent the provision of life-saving services and contribute to the spread of the disease.
    • It is not only availability of the staff, stuff and systems. but the way in which these ingredients come together in a timely way…or not… that also explains performance.
      • For example, while the standard diagnostic test for Ebola only takes 3-4 hours to yield a result, in many places patients were waiting 3-4 days before finding out whether they had infection.
      • Similarly, even when staff are successfully recruited and trained to work in Ebola Treatment Units, running out of protective equipment such as gloves or goggles can bring a halt to care.
    • In overcoming such bottlenecks, the resources and know-how of the private sector should be tapped more systematically. This could include rapid setting up of communications networks in areas that are off the grid, such as with Vodaphone's Instant Network, or drawing on the supply chain expertise of companies like FedEx or DHL, which can guarantee regular and timely delivery of key commodities.
    • Excellent managerial and logistic competencies – often the human resource that is the most scarce – are critical to making sure the staff, stuff and systems from various sources can come together to deliver quality services in a timely way.

 

  • Lesson 4: “Command and control pluralism”- 21st Century leadership for epidemic infectious disease.
    • The powerful concept of “One Health” – the theme of PMAC in 2013 – recognizes that health interdependence is a growing reality of the 21st century, not only between animal and human health, but also across sectors like agriculture and education; across public, private, civil society institutions; and across geographies – local through global.
    • The paradox, however, is that operationalizing the “One Health” concept is dependent on coordinating One Hundred partners!
    • In each of the affected countries, the various national coordinating mechanisms have attracted a large number and wide array of institutional actors and constituencies that must be, or want to be, involved in the Ebola response, thereby creating a major leadership and coordination challenge. 
    • National leaders from Liberia, Sierra Leone and Guinea have identified an important agenda of issues where international partners could improve their support in terms of speed and common sense (e.g. limiting the use of UN equipment to UN staff!)
    • Encouragingly, over the months of the Ebola crisis, we have witnessed growing strength in the national coordinating mechanisms, with some veterans of emergencies claiming they have never witnessed such a high level of discipline and alignment amongst so many.  
    • This leadership ability of bringing discipline and efficiency to a wide array of partners is what I call “command and control pluralism,” and should be harnessed to deal with other complex health emergencies.

 

  • Lesson 5:  There is a need to make more room for analysis and accountability in the midst of a crisis response.
    • While the basic descriptive epidemiology of the Ebola crisis has emerged…albeit slowly…there has been a virtual absence of more analytic assessments of the crisis.   This epidemic has clustered in poor urban areas – does this reflect a change in Ebola virus disease transmission dynamics?  How many transmission chains are there?  Is there evidence of herd immunity?  Why do case fatality rates differ widely across treatment facilities?   As my colleague Ariel Pablos-Mendez, the Assistant Administrator of USAID, recommended recently, we need more “analytic epi on the go.”
    • At the same time, we can use new information technologies to bring greater accountability to the response.  In providing “hazard pay” to health workers, for example, the World Bank Group has advocated a shift from cash payments and paper records to e-payments made directly to bank accounts of health workers.  This has shaved large numbers of “ghost workers” off the payroll and improved overall accountability. 

 

 

  • Lesson 6:  We need to establish and/or strengthen regional disease surveillance networks.
    • The current crisis is defined by the fact that it took root in three countries that share borders, and that it poses a persistent threat to the health security of the entire West African region.   This reflects not only inadequate national capacities to manage epidemic infectious diseases; it also reveals a deficit in regional collaborative arrangements.
    • There is growing recognition of the value of regional networks – in East Africa, Southern Africa, Southeastern Europe, and in the Mekong Basin – in fostering cooperation among neighboring countries to control cross-border disease outbreaks at their source and improve health outcomes.
    • Regional organization of laboratories, surveillance, and training capacity is more cost-effective than each country trying to manage its own.  It also encourages more truthful reporting and sharing of sensitive information, and helps to reinforce common standards.
    • Encouragingly, many partners, including the World Bank Group, are supporting the development of this type of regional disease surveillance capability in West Africa

 

  • Lesson 7: We need a global health workforce ready to respond.
    • For Ebola, fear of infection, uncertain working conditions and the lack of treatment and medical evacuation options have limited the in-flows of foreign health workers at rates needed to scale up the response quickly.
    • Securing a stronger supply of workers required to respond to a wide range of epidemic infectious diseases – what Michele Barry and Larry Gostin refer to as a “global health reserve force” – is a good idea that needs to be operationalized.
    • We can build on the Global Outbreak and Alert Response Network model and extend it to assure the full range of skills required.
    • Managing it requires a professional, end-to-end deployment capability, from recruitment and proper training (that is refreshed regularly and properly accredited); to housing, pay, insurance, and health care in case workers get sick; to repatriation support. 
    • To be successful and sustainable, the workforce must draw from as many national contexts as possible to ensure sufficient multicultural and multilingual depth.

 

 

  • Lesson 8:  We need to sustain “fast-tracking” in the development and distribution of new vaccines, drugs and diagnostics. 
    • The efforts to fast-track clinical trials/testing of candidate vaccines have led to important breakthroughs in collaborative arrangements between institutions, as well as trial designs for evaluating the safety, efficacy and effectiveness of new vaccines.
    • Unfortunately, with the rapid decline in the number of cases of Ebola, the window for testing the promising candidate vaccines is closing quickly.  
    • It is critical to sustain interest and investment in Ebola vaccine development so that further testing can be done wherever and whenever conditions are appropriate.
    • A point-of-care diagnostic that can determine Ebola infection status within minutes is also an important research and development priority, given its importance in the triaging of patients that present with fever to health facilities.
    • Preparing manufacturing capacity and distribution logistics, including stockpiles, will ensure that an adequate volume of products is produced and accessible when needed.

 

 

  • Lesson 9: We need new financing tools to ensure that money can flow quickly in the event of a pandemic. World Bank Group President Jim Yong Kim has laid out a vision for creation of a Pandemic Emergency Facility.
    • The idea for the Pandemic Emergency Facility (PEF) is being developed in consultation with a number of multilateral, bilateral, private sector and civil society partners. Most recently, this was the topic of several discussions last week in Davos. There is growing interest in this idea across stakeholders.
    • The basic idea for the facility is create a pool of resources that will encourage development of preparedness plans and ensure that money can flow quickly to enable a robust pandemic response.
    • The facility would build on existing financing mechanisms (such as the Crisis Response Window of IDA -- the World Bank Group’s fund for the poorest countries) and create new ones, such as a pandemic insurance market and a contingency fund.
    • Funds would be released based on a pre-agreed trigger, which would signal a reliable assessment of pandemic threat. 
    • We envision a pre-negotiated, global coordination platform that identifies distinct, but integrated, roles for public institutions, including international organizations, national governments, bilateral and multilateral donors.
    • Funds raised could enable support for a range of actors in the pandemic response.
    • The facility could also provide a platform to direct private sector and philanthropic initiatives toward the areas of greatest need.

 

 

  • Lesson 10. Underinvestment in public health kills people and derails economies!
    • As Larry Summers and Gavin Yamey wrote in the Financial Times in November 2014, “We play with fire if we skimp on public health.”  
    • Investments in public health are a notorious blind spot in health systems financing: Interventions are often invisible to consumers of health care and, as such, fall to the bottom of the priority list. 
    • Following the Avian Flu Pandemic in 2007, Integrated National Action Plans for public health preparedness and response were drawn up across Africa.   The cost of these plans across Guinea, Sierra Leone and Liberia amounted to $26 million dollars in 2007 and failed to find any investors. In hindsight, this was a miniscule amount compared to the multi-billion dollar price tag of the Ebola crisis!

Closing

In closing, your Royal Highness, and colleagues, the World Bank Group is so concerned about the Ebola crisis, not only because of its devastating impact on health, but because it is quickly eroding hard-won gains in development.   The World Bank Group recognizes that investing in health is one of our best investments for economic growth and shared prosperity.

Looking forward, we are excited by the prospect that the post-2015 global health agenda can accelerate equity in health and development.   The Ebola crisis reminds us of a shared threat and shared responsibility that unites us in this most important mission. As Winston Churchill said, “Never let a good crisis go to waste.”

Thank you for your attention.