Re­spond­ing to Ebola

Financial Mirror (Cyprus) - - FRONT PAGE -

The hor­rific Ebola epi­demic in at least four West African coun­tries (Guinea, Liberia, Sierra Leone, and Nige­ria) de­mands not only an emer­gency re­sponse to halt the out­break; it also calls for re-think­ing some ba­sic as­sump­tions of global pub­lic health. We live in an age of emerg­ing and reemerg­ing in­fec­tious dis­eases that can spread quickly through global net­works. We there­fore need a global dis­ease-con­trol sys­tem com­men­su­rate with that re­al­ity. For­tu­nately, such a sys­tem is within reach if we in­vest ap­pro­pri­ately.

Ebola is the lat­est of many re­cent epi­demics, also in­clud­ing AIDS, SARS, H1N1 flu, H7N9 flu, and oth­ers. AIDS is the dead­li­est of these killers, claim­ing nearly 36 mln lives since 1981.

Of course, even larger and more sud­den epi­demics are pos­si­ble, such as the 1918 in­fluenza dur­ing World War I, which claimed 50-100 mln lives (far more than the war it­self). And, though the 2003 SARS out­break was con­tained, caus­ing fewer than 1,000 deaths, the dis­ease was on the verge of deeply dis­rupt­ing sev­eral East Asian economies in­clud­ing China’s.

There are four cru­cial facts to un­der­stand about Ebola and the other epi­demics. First, most emerg­ing in­fec­tious dis­eases are zoonoses, mean­ing that they start in an­i­mal pop­u­la­tions, some­times with a ge­netic mu­ta­tion that en­ables the jump to hu­mans. Ebola may have been trans­mit­ted from bats; HIV/AIDS emerged from chim­panzees; SARS most likely came from civets traded in an­i­mal mar­kets in south­ern China; and in­fluenza strains such as H1N1 and H7N9 arose from ge­netic re-com­bi­na­tions of viruses among wild and farm an­i­mals. New zoonotic dis­eases are in­evitable as hu­man­ity pushes into new ecosys­tems (such as for­merly re­mote for­est re­gions); the food in­dus­try cre­ates more con­di­tions for ge­netic re­com­bi­na­tion; and cli­mate change scram­bles nat­u­ral habi­tats and species in­ter­ac­tions.

Sec­ond, once a new in­fec­tious dis­ease ap­pears, its spread through air­lines, ships, megac­i­ties, and trade in an­i­mal prod­ucts is likely to be ex­tremely rapid. These epi­demic dis­eases are new mark­ers of glob­al­i­sa­tion, re­veal­ing through their chain of death how vul­ner­a­ble the world has be­come from the per­va­sive move­ment of peo­ple and goods.

Third, the poor are the first to suf­fer and the

worst af­fected. The ru­ral poor live clos­est to the in­fected an­i­mals that first trans­mit the dis­ease. They of­ten hunt and eat bush­meat, leav­ing them vul­ner­a­ble to in­fec­tion. Poor, of­ten il­lit­er­ate, in­di­vid­u­als are gen­er­ally un­aware of how in­fec­tious dis­eases – es­pe­cially un­fa­mil­iar dis­eases – are trans­mit­ted, mak­ing them much more likely to be­come in­fected and to in­fect oth­ers. More­over, given poor nu­tri­tion and lack of ac­cess to ba­sic health ser­vices, their weak­ened im­mune sys­tems are eas­ily over­come by in­fec­tions that bet­ter nour­ished and treated in­di­vid­u­als can sur­vive. And “de-med­i­calised” con­di­tions – with few if any pro­fes­sional health work­ers to en­sure an ap­pro­pri­ate pub­lic-health re­sponse to an epi­demic (such as iso­la­tion of in­fected in­di­vid­u­als, trac­ing of con­tacts, sur­veil­lance, and so forth) – make ini­tial out­breaks more se­vere.

Fi­nally, the re­quired med­i­cal re­sponses, in­clud­ing di­ag­nos­tic tools and ef­fec­tive med­i­ca­tions and vac­cines, in­evitably lag be­hind the emerg­ing dis­eases. In any event, such tools must be con­tin­u­ally re­plen­ished. This re­quires cut­ting-edge biotech­nol­ogy, im­munol­ogy, and ul­ti­mately bio­engi­neer­ing to cre­ate large-scale in­dus­trial re­sponses (such as mil­lions of doses of vac­cines or medicines in the case of large epi­demics).

The AIDS cri­sis, for ex­am­ple, called forth tens of bil­lions of dol­lars for re­search and devel­op­ment – and sim­i­larly sub­stan­tial com­mit­ments by the phar­ma­ceu­ti­cal in­dus­try – to pro­duce lifesaving an­tiretro­vi­ral drugs at global scale. Yet each break­through in­evitably leads to the pathogen’s mu­ta­tion, ren­der­ing pre­vi­ous treat­ments less ef­fec­tive. There is no ul­ti­mate vic­tory, only a con­stant arms race be­tween hu­man­ity and dis­ease-caus­ing agents.

So, is the world ready for Ebola, a newly lethal in­fluenza, a mu­ta­tion of HIV that could speed the trans­fer of the dis­ease, or the devel­op­ment of new multi-drug-re­sis­tant strains of malaria or other pathogens? The an­swer is no.

Though in­vest­ment in pub­lic health in­creased sig­nif­i­cantly af­ter 2000, lead­ing to no­table suc­cesses in the fights against AIDS, tu­ber­cu­lo­sis, and malaria, there has re­cently been a marked short­fall in global spend­ing on pub­lic health rel­a­tive to need. Donor coun­tries, fail­ing to an­tic­i­pate and re­spond ad­e­quately to new and on­go­ing chal­lenges, have sub­jected the World Health Or­gan­i­sa­tion to a de­bil­i­tat­ing bud­get squeeze, while fund­ing for the Global Fund to Fight AIDS, Tu­ber­cu­lo­sis, and Malaria has fallen far short of the sums needed to win the war against these dis­eases.

Here is a short­list of what ur­gently needs to be done. First, the United States, the Euro­pean Union, the Gulf coun­tries, and East Asian states should es­tab­lish a flex­i­ble fund un­der WHO lead­er­ship to com­bat the cur­rent Ebola epi­demic, prob­a­bly at an ini­tial level of $50-100 mln, pend­ing fur­ther de­vel­op­ments. This would al­low a rapid pub­lic-health re­sponse that is com­men­su­rate to the im­me­di­ate chal­lenge.

Sec­ond, donor coun­tries should quickly ex­pand both the Global Fund’s bud­get and man­date, so that it be­comes a global health fund for low-in­come coun­tries. The main goal would be to help the poor­est coun­tries es­tab­lish ba­sic health sys­tems in ev­ery slum and ru­ral com­mu­nity, a con­cept known as Uni­ver­sal Health Cov­er­age (UHC). The great­est ur­gency lies in Sub-Sa­ha­ran Africa and South Asia, where health con­di­tions and ex­treme poverty are worst, and pre­ventable and con­trol­lable in­fec­tious dis­eases con­tinue to rage.

In par­tic­u­lar, these re­gions should train and de­ploy a new cadre of com­mu­nity health work­ers, trained to recog­nise dis­ease symp­toms, pro­vide sur­veil­lance, and ad­min­is­ter di­ag­noses and ap­pro­pri­ate treat­ments. At a cost of just $5 bln per year, it would be pos­si­ble to en­sure that well-trained health work­ers are present in ev­ery African com­mu­nity to pro­vide lifesaving in­ter­ven­tions and re­spond ef­fec­tively to health emer­gen­cies like Ebola.

Fi­nally, high-in­come coun­tries must con­tinue to in­vest ad­e­quately in global dis­ease sur­veil­lance, the WHO’s outreach ca­pac­i­ties, and life-sav­ing bio­med­i­cal re­search, which has con­sis­tently de­liv­ered mas­sive ben­e­fits for hu­man­ity dur­ing the past cen­tury. De­spite tight na­tional bud­gets, it would be reck­less to put our very sur­vival on the fis­cal chop­ping block.

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