Opportunities Lost — Could Ebola Have Been Better Contained?

This blog post, by IH Section member Mary Anne Mercer, originally appeared on Huffington Post. It was co-authored by Scott Barnhart and Amy Hagopian.


In a desperate attempt to contain the highly contagious Ebola virus in Liberia, 50,000 people were recently quarantined in a slum neighborhood of Monrovia, whether they were sick or not. Imagine being trapped in an open-air prison without any sense of when you would be released. And if you get sick inside that slum, there is no organized system to take care of you.

Quarantining 50,000 poor slum dwellers is far different from quarantining a household, a plane, a bus or a boat. Why would Liberia feel driven to take such a drastic move when only a few of the residents in the area had Ebola? Such is the desperation of a country with a health system so weak that it has no other way to cope with an epidemic of any serious threat, let alone one this virulent.

Francis Omaswa, who led Uganda’s successful effort to control an Ebola epidemic in 2000, said last week, “Controlling the epidemic is about early detection, isolation, treatment of new infections, contact tracing, and safe handling of body fluids and the remains of those who die.” These routine infection-control procedures are not hard to implement, but doing so requires basic public health infrastructure. When a country has no capacity to perform these functions, desperate measures such as quarantining a whole slum can seem reasonable.

How did Africa’s health systems come to be so weak? Didn’t the United States and other major donors just spend billions of dollars on global health in Africa? In the process of providing all that care for diagnosing and treating HIV, preventing malaria and distributing vaccines, didn’t we build clinics and laboratories and train health workers and create medical records systems? Well, not exactly.

Recent major global health initiatives have been aimed almost exclusively at specific diseases such as HIV, TB and malaria, while strengthening the health system is typically an afterthought. Funding generally favors the private sector, particularly faith-based non-governmental organizations, and views with skepticism the role of public institutions such as ministries of health. The private health organizations proliferating across Africa lure health workers away from their jobs in public clinics and hospitals, usually offering higher salaries than governments can pay. Yet the over-riding responsibility to care for an entire population, including the poorest, resides with governments, which remain under-resourced and struggle to keep up with the needs of their citizens.

When the choice was made to invest in single-disease programs that were walled off from government health systems, we missed an opportunity. We could have developed the capacity to address other emerging health problems by building infrastructure: facilities, information systems, the work force, logistics and supply chains. Some donors hoped their disease-specific initiatives would “spill over” in a way that would strengthen the health system. Unfortunately, recent research shows this did not occur.

When the funds stop flowing to private organizations that implement these single-disease programs, the work stops. Weak health systems limp along until the next emergency, when another cycle of global health programs sweeps through.

Meanwhile, the routine burden of illness from malaria, pneumonia, diarrhea, TB, malnutrition and, increasingly, diabetes and other chronic diseases, continues to shorten life expectancy in Africa. Weak systems can’t effectively keep up with those problems, let alone the sudden shocks imposed by emerging diseases like Ebola.

What will help? For one thing, we must stop focusing on disease-specific initiatives implemented primarily through the private sector. Donor funding should go through ministries of health whenever possible, and flow from there to health facilities and staff. Health workers funded by external donors must be paid at the same salary scale as the public sector.

Finally, as Ebola has shown, feeble ministry of health surveillance systems must be bolstered. Better surveillance is a large part of why wealthier countries are at much lower risk of major epidemics than are nations with scant public health resources. Ebola would not be the crisis it is today if it had been recognized earlier, with contacts traced, quarantined and cases treated. But for that to happen, the essential elements of functioning health systems in the affected countries would have to be in place. When we hear stories of nurses dying because they didn’t have the simple protective equipment needed to care for Ebola patients, the gaps in those health systems become clear.

The expanding Ebola epidemic underscores the urgency of making investments in the health systems of African governments. Global health initiatives of the last decade largely missed an opportunity to strengthen health care capacity in Africa. Will we have another chance with the next epidemic? Let’s make Ebola the last one to trample across the continent because there are no health systems to contain it.

Mary Anne Mercer began life in rural Montana and recently returned to her Montana roots, where she is rehabilitating a small ranch near Red Lodge. She holds a doctoral degree in public health and is on the faculty of the University of Washington in Seattle, where she teaches global health. She has worked or studied in 15 developing countries, lived in rural Nepal and Thailand, and currently supports maternal and newborn care projects in East Timor for a nonprofit organization, Health Alliance International. In addition to academic publications, Mary Anne co-edited a book on the health effects of globalization, “Sickness and Wealth: the Corporate Assault on Global Health.” She was a silver Solas Award winner for Travelers’ Tales in 2012. During the academic year she also sings and studies writing in Seattle.

Scott Barnhart, MD, MPH, is Professor of Medicine and Global Health at the University of Washington. He has worked on health system strengthening in Haiti, Southeast Asia, and several countries in Africa.

Amy Hagopian, PhD, is Associate Professor of Public Health at the University of Washington. She has studied the migration of doctors and nurses from poor countries to rich ones, including Uganda, Nigeria, and the Philippines.


Announcing APHA International Health Section Election Results

The following announcement is from Amy Hagopian, the IH Section’s Nominations Committee Chair.


Dear International Health Section members of APHA,

As your nominating committee chair, it is my pleasure to announce APHA has finally, at last, announced the winners of the APHA’s International Health Section election!

I am very very grateful to everyone who agreed to run for these offices. It’s not a democracy unless there is more than one candidate for a position.

As I told the candidates, everyone who ran this time but did not succeed will be an excellent candidate for a position in the next election. Please welcome all our candidates at the next business meetings in New Orleans, as we all work together to strengthen the section.

Paul Freeman will chair the proceedings at our upcoming meeting in November in New Orleans. He will be succeeded by Omar Khan at the end of the meeting. At that time, Laura becomes the chair-elect and Paul becomes the past chair.

For the coming meeting, the following individuals are our section councilors: Jessica Keralis and Michelle Odlum (whose terms end November 2016), Jaya Prakash and Lenee Simon (whose terms end November 2015), and Sosena Kebede and David Fitch (whose terms end November 2014). David Fitch and Sosena Kebede will be replaced by Mark Strand and Christopher Ibanga at the end of the 2014 meeting.

For the coming meeting, the following individuals are our section governing councilors: Laura Altobelli, Gopal Sankaran, Carol Dabbs, Malcolm Bryant, Peter Freeman (all of whose terms end at the end of the meeting this year) and Ramin Asgary (whose term ends November 2015). Laura and Peter will be replaced by Oscar Cordon and Caroline Kingori. Only 3 consecutive terms are allowed, so my records show this is Gopal’s last term until he has a 2-year retirement.

All members are encouraged to get involved in these committees and working groups. Contact the chairs today to find out about meetings scheduled in New Orleans.

Working groups:
Community-based primary care (Elvira Beracochea & Laura Parajon, Elvira@midego.com)
Pharmaceuticals (Maggie Huff-Rousselle, mhuffrousselle@ssds.net)
Trade and Health (Mary Anne Mercer, mamercer@uw.edu)
Global Health Connections (Jaya Prakash, Jayadoc21@gmail.com, and Theresa Majeski, theresa.majeski@gmail.com)
Maternal and Child Health (Laura Altobelli, laura@future.org)
Systems science for Health systems strengthening (Robert Swanson, swancitos@gmail.com; Kaja Abbas, kaja.abbas@gmail.com)
Climate Change (Hala Azzam, hala_azzam@yahoo.com, and Christine Benner, Christine-Benner@ouhsc.edu, and Rose Schneider, RoseSDC@aol.com)
US Border Initiative/PAHO (Josefa Ippolit-Shepherd, ippolitoshepherdj@yahoo.com)

Organizational committees:
Program committee (Mini Murthy, Minimurthy@aol.com)
Communications committee (Jessica Keralis, jmkeralis@gmail.com)
Membership and students (Rose Schneider, rschneider@jhu.edu)
Policy and Advocacy (Peter Freeman, pffreeman@gmail.com)
Awards (Gopal Sankaran, gsankaran@wcupa.edu)
Nominating committee (Amy Hagopian, hagopian@uw.edu)

There are also members of the section who assume organization-wide responsibilities. These include Len Rubenstein (Action Board), Mary Anne Mercer (Trade & Health), Elvira Beracochea and Len Rubenstein (International Human Rights committee), Amy Hagopian (Publications board), and Omar Khan (Science board).

Thanks again to all our candidates for running.

Students, You Should Go Abroad Too!

Leaving your comfort zone is one of the hardest, yet most rewarding experiences you can have. It was for me. During my undergraduate years, I spent three consecutive semesters studying abroad in Spain and Chile fulfilling my Spanish & Latin American Literature and Culture major. I realized the importance of expanding my horizons, gaining a multicultural perspective of the world and becoming more culturally competent. As a public health graduate student, my travels to Latin America took a global health perspective. My mind was once again exposed to another side of the world that we often miss while secluded in our comfort zones. In Central and South America, I volunteered on heath initiatives and sustainable development projects, and conducted research. I witnessed numerous global health disparities including lack of sanitation, children living in homes made with plastic walls and dirt floors, and physicians striving to provide quality reproductive care to low-income, immigrant women at a family planning clinic with scarce resources.

My ultimate goal is to become a primary care physician to help reduce health disparities globally. Going abroad was one step towards that goal.

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Media Wars: #Ferguson, American Hypocrisy and a Hint of Spring

This was originally posted on my professional blog.

America has experienced an ugly spotlight reversal with the eruption of popular discontent into violence in its own backyard. Just a few weeks ago, international media was buzzing with reports of ISIS steamrolling the Iraqi military and Russian-supported separatists in Ukraine shooting down passenger airlines. Now, the US squirms uncomfortably under international scrutiny of Ferguson, Missouri, where the shooting of a young black man by a white police officer has once again raised the specter of racism and police brutality.

Obviously, the incident itself is complicated. Eyewitnesses – who have given conflicting testimonies – are the only window into what happened, since there was no dashboard camera. The initial description of Michael Brown, the victim of the shooting, as a “gentle giant” about to start college clashed with video footage of him stealing a box of cigarillos from a convenience store. Commentators have drawn parallels with the case of Trayvon Martin, whose mother has now reached out to Brown’s mother. Peaceful protests have given way to violence and looting, reporters have been arrested, and witnesses have complained of excessive use of force by the police.

Social media, which played a major role in bringing media attention to Ferguson in the first place, has played host to the battleground of ideological responses to the incident. The primary complaint from conservatives is that the uprising in Ferguson, and the underlying racial tensions it has exposed, don’t deserve our consideration because some of the protesters have been looting and vandalizing stores…

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…including a few gems that actually blame the community for the excessive force used against it.

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Meanwhile, people used the Twitter hastag #IfTheyGunnedMeDown to spar over which photos of Brown were used by traditional media (wearing a cap and gown vs. striking a “thug” pose) and post their own side-by-side pictures. Still others are expressing frustration at the fact that the vandalism and looting has been used as a straw man to distract from ongoing widespread racial profiling and policy brutality against blacks, including one refreshingly blunt protester at a rally in DC:

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What has been the most interesting to me is the global shock and horror at the incident and resulting fallout. The international community sees what many Americans are apparently missing: that the protests and unrest in Ferguson are the manifestation of a minority group sick of being oppressed and ignored. The UN High Commissioner for Human Rights drew parallels to South African apartheid, while several countries have been using the situation to take shots at America’s own human rights record when we so often criticize other countries. One might expect Iran and Russia troll the US over civil unrest, but as one friend of mine pointed out on Facebook, “When Egypt calls you out for human rights abuses, YOU’RE DOING IT WRONG.”

American police brutality, and the unwillingness of many police departments to be held accountable for their actions, have also been focal points. What happened to Michael Brown will unfortunately always be shrouded in mystery, since the Ferguson police department apparently prioritizes riot gear and tear gas over cameras for officers or police cruisers. They also seemed to have forgotten the meaning of “free press,” as they arrested and harassed several reporters who were trying to cover the protests. Interestingly, Obama was quick to condemn the bullying of journalists “here in the United States of America,” despite his own administration’s secrecy and aggression toward the press, including prosecuting a journalist who refused to identify the source of an intelligence leak.

Indeed, many observers have been quick to point out America’s hypocrisy at fingering human rights abuses outside our own borders when we have threads of discontent, similar to those found in the Arab Spring and other global protest movements, woven throughout our own society. A lovely little piece of satire from Vox portrays how American media might describe the events in Ferguson if they happened in another country.

When everything is said and done, America doesn’t look so much like a shining beacon of democracy and human rights – we just kinda look like everybody else.

Screwing Global Health for the Sake of Spying

Two weeks ago, my husband and I visited a couple that we knew from university that I hadn’t seen since before we left for Korea in 2012. The wife actually got her Master’s in international development and worked in DC for a few years after graduating, but returned to Texas with a general distaste for the development industry. “I always wanted to work for USAID,” she told me, “until I figured out that they were just a tool of US foreign policy. I felt kind of betrayed – I thought they just helped people!”

usaid branded aid

Photo credit: USAID.

My friend’s complaint is common among development professionals. Many in the industry believe that US foreign assistance should come without political strings attached to it, and they object to practices such as obvious branding of foreign aid supplies and using aid as a tool to strong-arm other countries into going along with American foreign policy moves. Personally, I get that foreign aid is one of many tools in a country’s foreign policy toolkit – it may not be ideal, but it’s at least logical.

What’s not logical to me, however, is the use of aid – specifically, of global health interventions – as a cover for intelligence operations.

Development types will remember the uproar over the CIA’s use of a vaccination drive as a cover for collecting DNA in a (failed) effort to locate Osama bin Laden in Pakistan. (Widely reported as a polio vaccination drive, the CIA scheme actually used hepatitis B vaccine.) Pundits predicted – correctly – that it would set polio eradication efforts back and put aid workers in danger. Luckily for us, the CIA has now promised not to do it again – which is lovely, but a shame that it took three years for them to get around to doing.

Now it would seem that USAID is trying its hand at endangering global health efforts through half-baked intelligence schemes. Last week, the AP released its major investigative journalism report on a USAID operation that used young and inexperienced Latin American activists to try to stir up dissent in Cuban civil society. Aside from major issues such as the fact that the Latin American youths were poorly trained (and paid!) and not prepared for the risks they faced (particularly when USAID’s management of the scheme was utterly amateur), or the fact that this really is not USAID’s job, development professionals have been irate that yet another government covert operation has jeopardized global health – in this case, HIV/AIDS prevention efforts, in response to the revelation that one of the operatives used an HIV workshop to “recruit promising individuals”:

The choice of a U.S.-sponsored HIV workshop in Cuba is an interesting one, since Cuba’s HIV infection rate is one of the lowest in the world, and one-sixth that of the U.S. But it appears the disease was not necessarily the focus of the workshop, which was attended by 60 people. Fernando Murillo, after returning from Cuba, put together a report detailing his activities for Creative Associates, the USAID contractor hired to work against Cuba’s government. His only mention of HIV says it was “the perfect excuse for the treatment of the underlying theme,” meaning anti-government organizing.

In a press release, Congresswoman Barbara Lee (D-CA) blasted the program. “As co-chair of the Congressional HIV/AIDS Caucus, I am particularly concerned by the revelation that HIV-prevention programs were used as a cover,” she said. “This blatant deception undermines U.S. credibility abroad and endangers U.S. government supported public health programs which have saved millions of lives in recent years around the world.”

Frankly, I am scratching my head at why USAID thought that this kind of operation, or the “Cuban Twitter” called Zunzuneo that was uncovered earlier this year, was a good idea. Perhaps they are fighting to stay relevant in an era of US global health policy when the State Department and the White House are also jockying for position, but it’s no excuse. Jeopardizing global health programs, particularly programs that target HIV/AIDS – which is universally acknowledged as at the top of the global health agenda – is just a way to shoot yourself in the foot. In the end, they only lose credibility – and USAID, as a development agency, should understand what that can cost. They should know better.

Let’s Get Ethical: Giving Untested Experimental Drugs to Ebola Patients

West Africa is in the throes of the worst Ebola outbreak to date. Ebola virus disease, the hemorrhagic fever caused by the Ebola virus, has been seen in small but often deadly outbreaks in tropical sub-saharan Africa since its discovery in 1976. Though researchers are fairly certainly that it is transmitted through bush meat, and fruit bats are suspected, no animal species has been confirmed as a reservoir. Combined with the fact that the virus is highly contagious and so often deadly (usually because there is little to no medical infrastructure in areas where outbreaks occur), it is the source of international fascination and fear. It is the perfect plot device for outbreak movies and sensational media reports – a mysterious ailment from the heart of darkness that could rear its ugly head in our packed population centers at any moment.

Although it’s not quite as scary as movies like “Outbreak” would have you believe, the havoc that it is currently wreaking in West Africa is most definitely real. The most recent update from WHO puts the death count at 932 and the number of cases (both suspected and confirmed) at over 1,700. Guinea, Liberia, and Sierra Leone have been battling the virus since the spring, and last week it made its way to Nigeria and there was even a suspected death in Saudi Arabia. We all know that international air travel means that these types of illnesses are only a plane ride, which raises the question of why we haven’t made more progress in developing a vaccine or treatment for such a devastating disease.

Frankly, most global health and development professionals know the answer – if the only market for potential drugs is among the poor in central Africa, commercial drug companies won’t exactly be lining up to put money into the research:

The factor preventing such trials in humans, though, has been cost, said Dr. Daniel Bausch, an associate professor of tropical medicine at the Tulane University School of Public Health who is currently stationed at the U.S. Naval Medical Research Unit 6 in Lima, Peru.

That’s because, while the National Institutes of Health and the U.S. government often fund the early animal safety and efficacy testing of a vaccine, pharmaceutical companies typically fund the human clinical trials to take a drug or vaccine to market.

“When you have a population or situation with Ebola where it only sporadically occurs, and it occurs really in the world’s poorest populations, it’s not exactly an attractive candidate for the pharmaceutical industry on the economic side,” Bausch said.

That all changed, however, when two American aid workers who were treating Ebola patients in Liberia fell ill with the virus themselves. Dr. Kent Brantly, a doctor working with Samaritan’s Purse, and Nancy Writebol, a nurse employed by Service in Mission, are now all over U.S. and global headlines as the first Westerners to contract the virus – and, because of their privileged status, as the first people to receive an experimental treatment in the early stages of development before being flown back to Emory for medical care (despite objections from Donald Trump and Ann Coulter).

Though several people have raised objections to bringing Americans back stateside for treatment (particularly at what it probably cost), Emory is probably the safest and best-equipped facility to treat and contain the patients. Samaritan’s Purse is footing the bill for transporting them, so no government funds are being used. Bringing them back to the states for treatment is not so much of an issue, in my opinion – but using an experimental drug which is untested in humans is another matter.

At first glance, an outbreak of a disease with a high fatality rate (usually 40-70%) and no cure seems like the perfect situation to bypass the standard drug testing and approval process, which can take several years. However, it is the recklessness generated by precisely this type of desperate situation that raises ethical dilemmas. Does informed consent really count when patients are panicked at the prospect of imminent death? What if the drug is administered to the afflicted on a large scale and turns out to be toxic, or causes long-term disability? Who determines which patients to prioritize and how to protect those most vulnerable – such as children or pregnant women – who may react very differently to the drug?

Additionally, the fact that the drug has only been given to the two Westerners raises a very different, but equally important, problem. The international community has struggled for years to bring critical medicines to populations with the greatest need, who are simultaneously the least able to afford them. The fact that this experimental treatment was given to two aid workers – who, unlike their patients, have the support of large and wealthy organizations and will be more able to access the needed high-quality supportive care than their own patients – raises some disturbing questions.

The WHO has announced that it will convene a panel of medical ethicists to discuss and provide guidance on the issue. The pharmaceutical companies that develop and manufacture the drug are, naturally, chomping at the bit to get a large production run funded in order to provide ZMapp, the experimental serum, to a large number of Ebola patients. It is unclear how the global health community will move forward. But perhaps it can serve as a lesson to the pharmaceutical industry to take a more active interest in developing therapies for diseases that may not seem lucrative at first glance. Perhaps then we’ll be prepared for an unexpected multi-country outbreak – instead of having to scale up an untested drug developed by a tiny biopharmaceutical.

Spotlight on Brazil: The World Cup and More Doctors

The World Cup ended on Sunday and with all the controversy surrounding host country Brazil, I found myself wondering about their health care system. I knew access to basic health services was one of the main points of protest against the Brazilian government’s spending for the World Cup, but I didn’t know all the details.

A few quick searches online provided me with the information I wanted and led me to this video from the Pan American Health Organization (PAHO) documenting the impact of the arrival of doctors in two Brazilian towns that previously had no doctors. According to the World Health Organization, there is a serious shortage of doctors in Brazil with 1.8 physicians for every 1,000 people. Although the Constitution calls for free health care for all citizens, the reality is that there are major inequalities in access to health services with 700 neglected municipalities and a lack of local primary health care.

The PAHO video focuses on Mais Medicos (More Doctors) – a program between the Brazilian and Cuban governments that allows Cuban doctors to work in under-served Brazilian communities for three years. I did some more searching online and learned that the program is part of an initiative by President Dilma Rousseff to import 13,000 foreign doctors in order to address the shortage of medical professionals. The program has been criticized and although I agree with some of the points of opposition (How are their foreign credentials vetted for local standards? How does this translate to a long-term plan to address the larger issues with health care in Brazil?) I think the reception of Cuban doctors by local Brazilian doctors was too harsh.

Despite the controversy surrounding the program, the PAHO video illustrates its positive outcomes through patient testimonials about improved access to health care, fewer journeys to far away hospitals, and increased treatment and service quality. Residents in the two remote communities featured in the video are quite happy with the program and appreciative to have basic health care.

What do you think? Does the program provide enough value to balance costs and outweigh the risks? Watch the video and share your thoughts in the comments below.