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EBOLA: are ‘weak’ health systems to blame?

DECEMBER 15, 2014  ByAbu Bash-Taqi

Dr. Abu bakar Fofanah - Minister of Health and Sanitation
Dr. Abu bakar Fofanah – Minister of Health and Sanitation

As the number of infected cases reaches the 10,000 mark, and the forecasted cost to West African economies approaches US$33 billion, the question of how the outbreak in a small district in Guinea became a global health crisis continues to reverberate with growing public anxiety. Many have jumped, predictably, to argue that ‘weak’ health systems in the countries concerned were to blame for the rapid spread of this disease. A more informed approach, however, suggests otherwise.

Similar to cholera and malaria, Ebola outbreaks are known in the wider economics and development literature as ‘health shocks’. Many researchers and practitioners have extensively investigated the nature of these, and of other types of shocks, including hurricanes and recessions. The literature shows that the ability to cope with and manage shocks of this nature is not only dependent on the available mechanisms or strategies, whether ex-ante or ex-post, but more importantly, on the level of the shock that has occurred.

In general, shocks are classified as either idiosyncratic or covariate. Idiosyncratic shocks affect only a unit or fraction of the reference group, while a covariate shock affects every member of the cohort. Clearly, the dichotomy is best understood when such a classification is made with respect to a reference group, which may be a set of individuals, households, villages, towns, districts, countries and so on, under investigation.

Using Sierra Leone, one of the countries at the centre of the Ebola outbreak, it is evident that at the earlier stages of it, Ebola was an idiosyncratic shock. As at 27 May 2014, confirmed cases of the disease were only reported in one of 14 districts. Kailahun, the affected district then, had only seven confirmed cases and four community deaths. At that time, Sierra Leone’s health system would certainly not have been incapable of containing the disease.

However, by September 22, 2014, a day after the unprecedented nationwide lockdown in Sierra Leone, 13 of the 14 districts including the capital city Freetown had reported confirmed cases of the disease and a total of 501 persons had lost their lives to it. Approximately four months after the first confirmed cases, this health crisis can now be rightly referred to as a covariate shock.

Once a shock, whether it is environmental, health or otherwise, becomes covariate, it is rarely possible to mitigate and cope with its impact using only local resources. As demand on resources is stretched, systems become inefficient, and pushed to the point of near collapse. Unless there is external intervention, the ensuing consequences of a covariate shock will always be severe.

So, how does an idiosyncratic shock become covariate? A brief history of the epidemic will help. The first suspected outbreak of Ebola was reported in Guinea on December 2, 2013. The suspected case was in Gueckedou District in the Forest Region of Southeastern Guinea. By February 2014, three more districts in the same region- Macenta, Kissidougou, Nzerekore- had reported cases. After six of the seven blood samples turned positive upon tests carried out at Institut Pasteur in Lyon, France, the World Health Organisation (WHO) declared officially on March 23, 2014 that an outbreak of Ebola had occurred in Guinea.

At the time of this declaration, further incidents of Ebola had already been reported in Conakry, the capital city of Guinea, about 800km from the index district. This development clearly highlights the fact that the disease can spread, and has been spreading. After the official declaration, the Guinean government promptly instituted a number of containment measures such as the creation of isolation wards in hospitals, prohibition of traditional burial practices and prohibition of the transportation of Ebola infected corpses. Although these measures were not implemented robustly or nationwide, they were nevertheless a step in the right direction.

As news of the outbreak became public, a contrasting pattern emerged in the behaviour of foreign nationals and Guineans. An exodus of foreign nationals, mainly those originating from Western nations, was the immediate reaction to the outbreak. On the other hand, the citizens of Guinea, where such a disease had never been reported or experienced, were in total disbelief and certainly in denial about the existence of the malaise. Consequently, the attitude was ‘business as usual’.

Despite international media coverage and the unprecedented exodus of foreign nationals from Guinea, life and business in that country carried on as normal. With the exception of Senegal, Guinea’s official borders with her neighbours- Guinea-Bissau, Mali, Sierra Leone, Cote d’Ivoire, Liberia- remained open and the cross border movement of people continued unabated. Efforts to raise public awareness in this country were either absent, or lacklustre to say the least.

To many observers and health professionals, it came as no surprise when on March 31, 2014, Liberia officially informed WHO about an outbreak of Ebola. Within two months of the Liberian outbreak, Sierra Leone formally notified WHO on May 26, 2014 about a confirmed incidence of Ebola in the country. Since the first reported case, six months previously, Ebola has crossed five national borders in West Africa including Nigeria, the most populous country in Africa with a population of over 177 million.

The three countries at the centre of the Ebola crisis in West Africa share common borders. Sierra Leone and Liberia have land boundaries with Guinea spanning a distance of 652 km and 563 km respectively. The epicentre districts of the outbreak in Guinea are bordered to Sierra Leone’s Kailahun District, and to Liberia’s Lofa County, where the outbreaks in those two countries were first reported.

As the death toll approached four thousand, it became apparent that something needed to be done quickly in order to contain the virus. The scramble for a response probably started on August 8, 2014 when WHO informed the world that Ebola was now a “public health emergency of international concern”. Following WHO’s declaration, President Obama announced that he will be sending 3,000 troops to West Africa, and his government will spend more than US$750 million to contain the epidemic.

Amid the flurry of pledges, the government of the United Kingdom launched a £100 million mission to contain and control Ebola in Sierra Leone, and as part of that effort hosted the international conference “Defeating Ebola in Sierra Leone” on October 2, 2014. In that conference, a leading charity warned that there were five new Ebola cases every hour in that country. Speaking to the BBC on that day, Philip Hammond, the UK Foreign Secretary cited a worst-case scenario, “issued by experts”, which claimed that one and a half million people could be infected by January 2015.

The emerging picture from the UK conference was that a mass human tragedy is unfolding, and in the absence of a response that is robust, the Ebola outbreak will become a cataclysmic event with unimaginable consequences. The United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) estimates that US$1 billion is needed to contain this outbreak. WHO has requested US$145 million of this amount; compared to the amount of US$20 million requested (half was received) by the same organisation in March this year, there has now been a sevenfold increase in the cost of containing the disease.

A question that will haunt many, and will be asked repeatedly, is why the virus was not contained in Gueckedou in the first place, and why was it allowed to spread to other districts in Guinea, Sierra Leone and Liberia?”

Obviously, the response to the outbreak taken currently by national governments and the wider international community could have been made at the first appearance of the virus. A swift response at that stage would have saved lives, and the financial cost for that exercise would have been a fraction of what it is today. The rudimentary and inadequate response allowed the virus to quickly gain ground and escalate what should have been a local battle to a global health crisis.

As the situation becomes increasingly desperate, disparaging claims about the ‘hopeless’ state of these countries are heard with increasing frequency. But while the appeal for finance to combat Ebola goes on, it appears that the official line, even in the affected countries, continues to attribute it largely to the ‘weakness’ in the structure and organisation of their health systems.

Yes, the health systems in these countries are weak, certainly compared with those in Middle or High-Income countries, but it would be naïve to suggest that it is these systems that bear primary responsibility for the current scale of the crisis.

The global Ebola health crisis is the result of the failure of national governments and of the wider international community to respond robustly to the crisis.

Indeed weak health systems alone do not explain the rapid spread of the virus from the interior regions of Guinea, Sierra Leone and Liberia to the capital cities of these countries. If the initial response to the Ebola outbreak was robust, as was the case in Senegal and Nigeria, the high costs in human lives and financial resources could have been avoided. These two countries that have robustly contained Ebola should represent the model for others.

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