The Ebola crisis in West Africa might have preyed on weak health systems but just strengthening them – although necessary – is not the magic bullet to fixing the next epidemic.
“We have to be very careful when we say that a better health system is the answer,” said Prof. Dr. Peter Piot, the director of the London School of Hygiene & Tropical Medicine (LSHTM) at a recent symposium in Antwerp. “They are part of the answer but not the whole answer. They can also do a lot of harm.”
Ironically, in South Korea – which has a very sophisticated health system- , hospitals amplified the Middle East Respiratory Symptom (MERS) epidemic in 2015, Piot explained at the 8th International Symposium on Filoviruses hosted by the Antwerp Institute of Tropical Medicine (ITM).
The symposium reviewed the long journey and global progress against Ebola forty years after the first outbreak of the disease was reported in September 1976, in Yambuku, Zaire (now the Democratic Republic of the Congo (DRC)).
Prof. Piot explained that although countries clearly need good health systems and primary health care that is not enough to control epidemics. Emphasizing “the basics” and “public” health systems in particular, he mentioned there should be good laboratories, thorough surveillance, infection control, but also public preparedness and community engagement. “We talk health systems but it is also political and social systems as well as public trust that are a key element here,” said Prof. Piot.
He has a point. As the epidemic ravaged West Africa there was also an outbreak in DR Congo but the latter was controlled in the absence of a good or sophisticated health system.
However, you can argue that the environment was also very different. As Piot himself pointed out in his presentation, the Ebola crisis in West Africa is the story of a “perfect storm” creating a major epidemic. The crisis hit states that were unfamiliar with Ebola till then, were not well governed, just came out of civil war, lacked health staff, showed strong cross-border migration,…. Importantly, they were also countries in which (big parts of) the population lacked trust in government. The tragedy that unfolded was unprecedented, claiming 11,000 lives in 3 countries in just about two years.
DR Congo with seven Ebola outbreaks under its belt has experience, an equipped laboratory in Kinshasa and leadership headed by Prof. Dr. Jean-Jacques Muyembe, the director of the National Institute of Biomedical Research (INRB) who has been around since Yambuku. Prof. Muyembe concurs that indeed Africa needs to strengthen health systems but in addition to good surveillance systems, community engagement and trained health workers, above all epidemics like Ebola require leadership. “One of the things that went wrong in West Africa is that they did not have a national coordinating body,” Prof. Muyembe told me. At the peak of the Ebola epidemic in DRC (during the Kikwit epidemic that happened way back) he declared himself a coordinator and he has since lived up to the job.
So are we prepared for the next epidemic? “We are not prepared. The high risk of a major health crisis is widely underestimated and the world’s preparedness is still insufficient. That is not only the case for developing countries, although they are more vulnerable, but it is also the case here in Europe,” said Prof. Piot .
WHO reform, one of Piot’s recommendations for the world to get its act together in time for the next epidemic, is already ongoing. For example, the emergencies programme at WHO and the humanitarian and outbreak departments have been merged, said Dr. Rick Brennan, director of emergency risk management and humanitarian response, WHO, Geneva. In this sense, WHO will have one approach to a response: if it is an outbreak they’ll bring in a disease specialist, if they have to deal with a conflict they’ll fly in a humanitarian expert, and in the case of an emergency a manager.
Dr. Brennan said they are working to strengthen preparedness at the country level and not just for outbreaks. WHO has been working with some other actors on a ‘unified framework of preparedness.’ Regardless of the event, this will involve some basics like good medicine management, information and communication capacities, strong logistics.
He said WHO will borrow a leaf from the formal mechanism the international community uses to manage humanitarian emergencies and apply it to outbreaks. “The WHO is working to leverage these to create a system to support a more predictable mechanism with better leadership and coordination to manage large scale outbreaks.”
Prof Piot warned that although we need experts they are not necessarily the best managers. In emergencies we need perhaps more the experience of the humanitarian sector which is dominated by logistics, organization & coordination. “They may be more boring and bureaucratic but I believe we need more of that in the first place. The key to success is strong management. We should form a core of people who can do that and support them and value them.” And he concluded: “We need to strengthen the public health core capacities in such a way that not just Ebola outbreaks can be dealt with but that they benefit the entire health and social infrastructure.”