Philip A. Lederer
In this guest commentary, Philip A. Lederer, MD, assistant professor of medicine at Boston University School of Medicine and an infectious disease physician at Boston Medical Center, discusses lessons that the global health community must learn from Ebola virus outbreaks.
So far, we have lucked out. The latest Ebola virus outbreak in the Democratic Republic of the Congo, or DRC, although awful (at least 90 deaths), has not been as bad as some of us in the public health community had feared. It has not spread to neighboring Uganda, or to Kenya, then on to Europe or the United States, triggering panic and a global public health and economic crisis. Yet.
But the biggest issue is we have not learned important lessons from prior Ebola outbreaks.
Lesson 1: Preparation at the local level
Whether it is Ebola, pandemic influenza or a novel virus, the only way forward is strong, coordinated leadership by local health departments, ministries of health, elected officials, nongovernmental organizations like Doctors without Borders and WHO.
The preparation must start at the local level. Our qualitative research study demonstrated that involvement of community leaders, health care providers, traditional healers and patients is important to building trust. This is especially true in places with low literacy. Contact tracing, follow-up and vaccination are resource-intensive in areas of poverty, conflict and insecurity.
Lesson 2: Country leadership
The DRC is responsible for investing in infection control in local health care facilities. It is important to understand that we cannot prevent human-animal interaction and, therefore, cannot necessarily prevent introductions of Ebola or novel viruses. But we can prevent outbreaks. Every introduction that has evolved into an outbreak has been because of poor infection control in health care facilities. Once Ebola spreads in a health care facility, it becomes a community problem. But the key intervention that could easily be made is to make health care delivery safe. That should be both an ethical and a security obligation of governments. It is not cheap, but it is essential.
The DRC is impoverished and is often viewed by Westerners as dependent, but the country actually has wealth that has been misaligned or misappropriated. We also need to study the colonial history and atrocities that occurred in countries like the DRC to understand the current situation. We need to start thinking about how to influence countries to train public health nurses and epidemiologists rather than soldiers.
Lesson 3: Global leadership
At the global level, WHO has learned its lesson and done a great job under the direction of Tedros Adhanom Ghebreyesus, PhD, MSc. This year may be the first time that a WHO director-general visited an outbreak zone early in the response. The broader question is when the world will invest not just in people and supplies, but logistics. Getting into and out of rural areas to deliver essential supplies and medications should be simpler. Global health agencies should have the same logistics infrastructure as militaries do. The advent of drones and advanced communication technology should help with supply chain.
Lesson 4: Coordination, communications and relationships
The resources expended on the outbreak response by the CDC and U.S. government should be better coordinated. Decisions for who is deployed to the DRC, to WHO headquarters and to neighboring countries like Uganda and Rwanda are challenging and require long-standing relationships and excellent communication.
The CDC’s Field Epidemiology Training Program and the newly established Africa CDC also need to be funded and staffed appropriately. Experts are needed to work on cross-border health, communication, security, laboratory strengthening and cultural awareness. Training and cultural awareness are very important.
Lesson 5: Global health security
More broadly, cuts are expected in the U.S. Global Health Security Agenda, a plan to prevent and combat infectious threats. We need to build capacity for a country-level response. Cuts limit the CDC's and the U.S. government’s ability to do that. The funding needs to be increased.
The U.S. also should re-establish a body for global health security in the biosecurity arm of the National Security Council. Since its inception under President Harry S. Truman, the NSC’s function has been to assist the president on national security and foreign policies. Pandemic preparedness is an essential component of national security.
The NSC should coordinate with CDC’s Epidemic Intelligence Service, the U.S. Army Medical Research Institute of Infectious Diseases and Navy Medicine, as well as academic medical centers and public health departments.
Lesson 6: Advocacy
Organizations such as the Infectious Diseases Society for America need to lobby more vociferously for funding and coordination. And infectious diseases clinicians, an integral part of the first-line response to infections of public health importance such as Ebola, need to act. Knowledge of outbreaks is important, but advocacy is crucial. We each need to speak out before it is too late. Real collaboration is what it takes for global health to succeed.
Schwitters A, et al. Glob Health Sci Pract. 2015;doi:10.9745/GHSP-D-14-00145.
Disclosure: Lederer reports no relevant financial disclosures.