After Ebola: Are We Ready for the Next Epidemic?

May 5, 2015
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The West African countries that saw the first cases of the Ebola outbreak are among the poorest in the world.

They lacked the manpower and the resources to check its initial spread. At the same time, the international agency tasked with coordinating global responses to such outbreaks had moved, according to critics, at a glacial pace.

“We are not the first responder,” Dr. Margaret Chan, director-general of the World Health Organization, the United Nations’ dedicated agency for health, told The New York Times in September, about six months after the outbreak was first detected. “You know, the government has first priority to take care of their people and provide health care. WHO is a technical agency.”

Today, the outbreak has largely subsided. But it has left more than 10,000 people dead, and devastated the countries that have been hardest hit. It also raised a terrifying question: Is the world ready for the next epidemic?

The WHO leadership released a statement in April acknowledging flaws in its response to the crisis. It also admitted that it wouldn’t necessarily be prepared for what comes next. The outbreak, it said, “served as a reminder that the world, including WHO, is ill-prepared for a large and sustained disease outbreak.”

“Nobody Was Prepared for This Last Outbreak”

There were many reasons this outbreak was so dangerous. Unlike central Africa, where more than two dozen Ebola outbreaks have occurred since 1976, countries in West Africa had never dealt with the disease before. It first surfaced in a small village in Guinea in December 2013, but it was not until March 2014 that the national health ministry learned about some troubling deaths and sent out samples for testing. By the time officials realized what they were dealing with, the virus had already begun to spread.

Previous Ebola outbreaks had begun in remote villages, making them easier to manage. This time, the disease hit bustling capital cities — Conakry, Guinea and Monrovia, Liberia — where it was difficult both to contain and trace those who had been exposed.

And the outbreak hit some of the most vulnerable countries in the world. The public health systems in Guinea, Liberia and Sierra Leone were understaffed, poorly equipped and insufficiently trained to deal with such an onslaught. It costs an estimated $86 per person annually to ensure a minimum level of health care, according to a recent report on global health systems by Save the Children.

In 2012, the Liberian government spent $20 per person per year on health, and Sierra Leone spent $16. In Guinea, where the outbreak began, the government spent only $9.

Even NGOs that have experience responding rapidly to outbreaks, like Doctors Without Borders — known by its French acronym MSF — were overwhelmed.

“Nobody was prepared for this last outbreak,” said Henry Gray, who leads MSF’s Ebola emergency task force. The group has an impressive history of responding quickly to curtail outbreaks on the ground. But Gray said this one moved so rapidly across national borders that it made it harder to coordinate efforts, and stretched staff and supply lines to their limits.

“This outbreak has eclipsed all of MSF’s previous operations in terms of human resources and money spent,” he said. “It’s an enormous effort for 15 months. It’s been a gargantuan task.”

The affected countries’ vulnerability, and the complexity of the outbreak, underscored the importance of the role of the agency tasked with leading the global response — the WHO.

“There Was Kind of a Pandemic Fatigue”

The WHO has known that it was unprepared to deal with a major outbreak for years.

In 2009, a pandemic of the H1N1 virus swept across the globe, killing roughly 300,000 people worldwide. Once the outbreak was contained, the WHO conducted a review of its response, and issued a report in 2011 concluding that while it hadn’t made any significant errors, “the world is ill-prepared for a severe pandemic or for any similarly global, sustained and threatening public-health emergency.”

It also detailed several recommendations for how the WHO, and member states, could prepare for the next outbreak. That included establishing a global response team that could be dispatched to the epicenter of the outbreak, a contingency fund of $100 million, and more support for developing vaccines and treatment. It also noted that poorer countries needed help to shore up their infrastructure.

Ultimately, the most significant changes weren’t put in place. That’s in part because the WHO was hamstrung by member states’ reluctance, or inability, to give it what it needed, said Sylvie Briand, the WHO’s director of pandemic and epidemic diseases. Some member states questioned whether the WHO had overreacted in dealing with the pandemic. At the same time, the economic crisis was still hitting hard, and many states had slashed their budgets for international donations.

“There was kind of a pandemic fatigue,” she said. A few years later, in December 2013, the Ebola outbreak began.

What Happens Now

Last month, the WHO said that it would adopt some of the recommendations it wasn’t able to put in place after the 2009 pandemic: a global response team, the contingency fund, and a better framework for how member states should respond to outbreaks. It also said it would offer more support to impoverished countries to ensure they can meet those guidelines.

In the wake of the crisis, these limited health systems have been devastated in the affected countries, according to the Save the Children report. An estimated 500 health care workers have died, and funds and supplies are depleted. Treatment for other diseases, like malaria, HIV/AIDS and even malnutrition, has fallen off.

Rebuilding that infrastructure is a major priority, Briand said, because countries offer the first level of defense.

These countries will have more support from NGOs, such as Alliance for International Medical Action, a French NGO known as Alima; the Red Cross societies, and the International Medical Corps, among others. These groups have have significantly increased the number of staff members who know how to respond to an Ebola outbreak.

For example, MSF used to keep 50 people trained to respond to emergency outbreaks. Now, there are about 1,300 worldwide, and thousands more national staff in the affected countries. Gray said the organization was examining its own process to be able to train staff and funnel resources more quickly in response to a new outbreak.

The risk of global outbreaks in an increasingly connected world — whether Ebola or something else — won’t go away. But as MSF’s Gray noted, that fact has also spurred wealthier nations to take the risk of an outbreak more seriously.

“I don’t think it will be a disaster the next time, because there’s so much more capacity in the world to respond,” he said, then added: “If you’re not an optimist in my job, you wouldn’t last very long.”

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