Ebola Highlights Problems With Global Health Security

The Ebola crisis in West Africa has quickly grown into the most difficult health security problem faced by the modern world, but it is also providing opportunities to better prepare nations for future health emergencies, said speakers at a recent conference on global health security in Washington, D.C.

"We need to capitalize on this moment. As deep and humanly unsettling as this moment is, shame on us if we can't build from it," said Laura Holgate, senior director for weapons of mass destruction terrorism and threat reduction for the White House National Security Council.

"The Ebola outbreak highlights where we are vulnerable and what remains to be done," said Keiji Fukuda, assistant director-general for health security at the World Health Organization (WHO).

Holgate and others gathered on 25 September for a conference addressing the role of non-governmental organizations in the Global Health Security Agenda (GHSA), which was held at the Milken Institute School of Public Health at George Washington University and co-sponsored by AAAS, the Nuclear Threat Initiative, CORDS: Connecting Organizations for Regional Disease Surveillance, the UPMC Center for Health Security, the Elizabeth R. Griffin Research Foundation and the CSIS Global Health Policy Center.

The conference marked the release — made official the following day at the White House — of 11 GHSA action packages intended to focus international discussion and efforts in certain areas, such as zoonotic diseases and antimicrobial resistance. By highlighting measurable approaches and providing mechanisms and five-year targets, the action packages should help nations to advance progress under the GHSA. Representatives of 44 nations and officials from the WHO, the Food and Agriculture Organization of the United Nations (FAO), and World Organization for Animal Health (OIE), the European Union, the African Union, the United Nations, the World Bank and Interpol met at the 26 September White House event, to discuss how to accelerate the implementation of the GHSA.

Globalization has allowed microbes and diseases to spread more easily and more quickly than they have in the past. Ebola is only the latest — if the most severe — global health threat that the world has faced in recent years. Severe Acute Respiratory Syndrome (SARS), for instance, first recognized in February 2003, infected fewer than 10,000 people but set off a global panic before disappearing in 2004. The H1N1 swine flu virus caused a pandemic in 2009, spreading to over 200 countries and killing more than 18,000 people. Other diseases, such as the Middle East Respiratory Syndrome (MERS) coronavirus, have since emerged. And there is concern about the rise of antibiotic resistance as well as bioterrorism.

To better prepare for such threats, the United States has partnered with dozens of countries and international entities, such as the WHO, to develop the GHSA. The intent is to accelerate progress towards preventing and reducing future outbreaks of disease, detecting threats early and providing rapid, effective, coordinated responses to emerging threats.

Where the Ebola Crisis Stands

The current Ebola epidemic began last December, mostly likely when a nearly-two-year-old child in Meliandou, Guinea, contracted the disease from an infected bat, killed for its meat. The disease killed the child and quickly spread to his family, then beyond, into the neighboring countries of Sierra Leone and Liberia.

While there have been several Ebola outbreaks previously in Africa, this is the first to strike West Africa. Because the three countries had no prior exposure to the disease, recognizing it proved difficult in the beginning. Many of Ebola's symptoms can easily be mistaken for other, more common diseases, such as cholera, and a quick diagnostic test for the disease has not yet been developed.

"If there had been rapid diagnostics at any of many points of intervention between December, when the first case occurred, and March, when it was finally diagnosed…it could have had an incredible impact," said Thomas Inglesby, director of the UPMC Center for Health Security. Around February, he noted, a doctor in Guinea who thought that the disease might be something other than cholera, the leading suspect, was misled by tests that came back with false positives for cholera.

Containing Ebola — a necessity to stop transmission — has proven exceptionally difficult. The first infections occurred at the nexus of the three nations, where people frequently move freely across the borders for economic and familial reasons, noted Joseph Fair, a virologist and senior advisor to Fondation Mérieux, which is dedicated to fighting infectious diseases. "More than a decade of civil conflict [in the three countries] has led to an almost complete lack of trust in government," he said. The eleven years that have passed since the end of the most recent conflict have not been long enough to develop a robust public health infrastructure, he noted. "The fragility cannot be overemphasized."

The legacy of conflict also contributed to a mentality that "run and flee" is the best response to a crisis, Fair said. Past Ebola outbreaks have been contained because it was possible to identify and segregate infected individuals, then trace and track anyone with whom they may have come in contact. That has not happened in Guinea, Sierra Leone, and Liberia.

The disease is now spreading quickly, noted Fukuda. As of 3 October, 7,470 people have been infected in the three nations and 3,431 have died, according to the WHO. "We have to stop transmission," he said.

The WHO has expressed fear that the disease could become endemic within the region. And the Centers for Disease Control and Prevention has projected that, unless more effective interventions are put in place, as many as 1.4 million people could be infected in Liberia and Sierra Leone by 20 January, 2015.

A Need for Health Facilities and Trained People

"The Ebola crisis right now is one of the clearest illustrations that [of] the link between the conditions on the ground — the lack of public health resources and infrastructure — and the importance of addressing that as a threat to global health security," said Scott Gordon, director of the Window of Opportunity Project at PATH, an international non-profit organization working on global health innovation.

Speakers agreed that the international response to the ongoing epidemic has been inadequate. "We just can't deny that the response was very late," said Ron Waldman, an epidemiologist at George Washington University. But he warned that any efforts implemented now should be tailored to the epidemic as it currently exists; measures that might have worked in June to contain the disease, such as building a few large hospitals, may be ineffective now.

Waldman is working with Save the Children to develop an Ebola-response strategy that the non-profit can implement in Liberia. Instead of investing in large Ebola treatment centers-which have been inadequate to respond to the current crisis-the organization is developing smaller, 20-bed facilities. Waldman described such facilities as "leaky," meaning that they may not completely prevent infected people from spreading the disease, but they could help to relieve some of the pressure on the larger hospitals.

Ebola has overwhelmed the public health systems in West Africa and left those with non-Ebola diseases without any place to go. "We have no idea-I don't know if we ever will-how many people have died of non-Ebola-related causes," Fair said. "We've seen a complete breakdown in an already vulnerable public health infrastructure."

In addition, people with Lassa fever, a type of hemorrhagic fever similar to Ebola and endemic in the region, are being mixed together with Ebola patients in some hospitals, noted Fair. No one knows what the result would be of being co-infected with both Lassa fever and Ebola, "but obviously it wouldn't be good," he said.

The Ebola crisis has highlighted the deficiencies in the infrastructure for healthcare in the region, noted Patty Olinger, director of global programs at the Elizabeth R. Griffin Research Foundation and director of the environmental, health and safety office at Emory University in Atlanta. Water may have to be collected from a river. Lighting may come from kerosene lanterns. Sanitation may be lacking. At one hospital Olinger visited, laundry from infectious patients was mixed with everyone else's.

West Africa was already lacking in trained healthcare workers, but the Ebola crisis has devastated their small number. Three-hundred-and-sixty-six healthcare workers had been infected with the disease as of September 28 (and another 11 in Nigeria, where Ebola's spread has been contained); 216 have died, according to the WHO .

Dr. Melvin Korkor, an attending physician at a hospital in remote Bong County in Liberia was one of the survivors. Ten of his colleagues, including five nurses, became infected and died early in the outbreak. "I was so compassionate in my profession to the extent that I had to touch one of the nurses," he said. A few days after she died, Korkor fell sick. "I isolated myself from my family," he said.

By the time he recovered, his hospital was closed but still had a lot of patients needing care. "We're going to re-open our hospital," he pledged, "but we're going to need to stop the transmission of Ebola." That will require training people in infection control and providing necessary supplies.

But there are no dedicated academic institutions or programs that are able to research and train the multi-disciplinary specialists needed to respond to disasters such as Ebola, noted Laud Boateng, a public health physician from Ghana who is currently a Mandela Washington Fellow working on an Ebola education campaign for African youth. And the region is lacking in trained medical workers in general. Boateng said that when he tried to volunteer to help in the current crisis, he realized that he lacked the special skills necessary to do so.

But there is hope that the Ebola crisis may prompt the development of a more robust public health infrastructure in the region. "We failed Liberia when we accepted that a country of 4 million people" can be adequately served by only 50 doctors, he said.

Lessons Learned

Scientists aren't yet certain which animal is the natural host to the Ebola virus or how the virus moves from animals to humans, but fruit bats are prime suspects, noted David Hayman, a senior lecturer in veterinary public health at Massey University in New Zealand. As the human population in West Africa has grown, people have increasing contact with wildlife, which has aided the spread of zoonotic diseases. But conservation could help. "We might be able to put in place systems that both preserve the healthy ecosystems but also prevent people from being exposed to too many novel pathogens," he said.

Educating local people about disease and sanitation is crucial. Because Ebola is new to West Africa, "people have a poor understanding about what it is," said Waldman. There have been such educational efforts since the crisis was identified. And the three-day lockdown that Sierra Leone held in September, which many misinterpreted as an attempt at quarantining infected individuals, was actually a huge, door-to-door educational initiative, he noted.

More is needed, however, and any messaging needs to be tailored to the people who are to receive it, noted several speakers. Stern directives to avoid eating bushmeat or to send the ill to clinics, now often viewed as simply places to die, are ineffective, said Nigel Lightfoot, executive director of CORDS. "You can't just tell them 'don't do it' because that doesn't work." Effective communication will require nuance and working with locals to better understand what is needed and what will work.

Preventing a future crisis like Ebola requires better diagnostic tools and disease surveillance networks so that outbreaks can be identified and stopped before they get out of hand. "It's pretty hard to know when you have an outbreak of an unknown disease if you don't even have diagnostics to rule out the known diseases," said Mark Smolinski, director of global health threats at the Skoll Global Threats Fund. "Simple diagnostics have a critical role to play."

More complex tests being developed can be useful but only if the people using them have the necessary knowledge and support. "How do you take a technology like that and move it into a clinic in Zimbabwe that's never used a diagnostic ever?" he noted. And, any new tests will have to be able to work in environments where resources such as electricity and refrigeration may be in short supply.

Past efforts to provide help in developing countries have not always taken into consideration those limitations, said Olinger. As an example, she showed a picture of a medical-waste incinerator that went unused because it couldn't be repaired.

The key to making any of these efforts effective is in not doing things to local people but in first asking what they need, said Lightfoot. "It will surely become sustainable."

One example of that is the Epihacks sponsored by the Skoll Global Threats Fund. These events bring together technology developers and animal and human health experts in local hack-a-thons to create digital disease surveillance tools. At an August event in Cambodia, participants devised several systems, including one that would monitor symptoms of respiratory diseases, such as influenza, by taking reports from people via SMS.

Such efforts could have additional benefits in helping to prevent bioterrorism, noted Andrew Weber, assistant secretary of defense for nuclear, chemical and biological defense programs at the U.S. Department of Defense.

But, even with all the ideas and a great willingness among people in the international community to help, there was concern that maintaining these efforts over the long term may be difficult. "One of, if not the, greatest challenges in terms of developing the health security agenda," noted Fukuda, "is that we go through an emergency, there's a great deal of attention, there's a lot of words said about how important it is, then it tends to evaporate."

[Photo credit for teaser image associated with this story: Flickr/European Commission DG ECHO]