* Any views expressed in this article are those of the author and not of Thomson Reuters Foundation.
Acute crises like the West African Ebola epidemic can illuminate public health issues that lie dormant under normal circumstances. The following are some insights arising from the epidemic.
1. One disease does not break a system
While coverage and health outcomes were improving in Liberia and Sierra Leone, according to Liberia’s chief medical officer these systems were still “barely functional” prior to the start of the Ebola outbreak. Care was concentrated in urban areas and public-sector rural infrastructure was nearly non-existent.
When Last Mile Health conducted a household survey in 2012 in a rural district in southern Liberia, they found the average age of death was 28.6 (equivalent tomedieval Europe at the time of the Plague). Ebola was a stress test and the health systems of Liberia, Guinea, and Sierra Leone couldn’t bear the load.
2. Bad care may be worse than no care at all
Liberian confidence in the health system was low in 2014: people felt that they would not get the treatment they needed if they sought care. This lack of trust has continued through the epidemic: hospitals are not viewed as a safe haven, but a place of risk.
For example, when intake procedures are not streamlined within an Ebola Treatment Unit, all at-risk patients may be required to wait together. As such, people may be exposed to Ebola by simply showing up to get tested. When quality of care is poor, it can be rational to avoid health care facilities. Improving access to care is critical, but improving access to bad care can be lethal.
3. Good care is centered on people
In the absence of high quality clinical care, people often care for seriously ill relatives at home. Over and over, we’ve heard that Ebola is a caregivers’ disease. According to the CDC, exposure to infected blood or bodily fluids puts caregivers at the highest risk of getting sick.
As such, the picture of Ebola, as drawn by local and global communities, has been dominated by fear. Survivor narratives, however, are beginning to put faces to the people who have been successfully treated and the people who have bravely supported them. Survivors are joining their caregivers to play an active role in the fight against Ebola: identifying new cases, educating communities, working with clinical teams, building facilities, and supporting comprehensive treatment.
This parallels efforts by other disease-impacted groups – such as the work ofmothers2mothers to combat mother-to-child transmission of HIV. Experience with disease can be a powerful tool to not only combat that same disease, but also to address issues of stigma.
4. A death sentence can become a treatable disease
Prior to this outbreak, researchers understood Ebola to be a probable death sentence. The case fatality rate at the start of the outbreak was predicted to be upwards of 80 percent. However, evidence has shown that with timely and appropriate care, this can be significantly reduced, closer to the 31 percent case fatality rate in Freetown.
Still, too often, the people who are cured are the people who are already likely to be healthy (e.g., patients under 21 vs. those over the age of 45) and wealthy – the case fatality rate of American citizens has been zero.
5. Disease is predictable
The course of the Ebola epidemic recalls the spread of other diseases among poor people. Disease thrives on poverty: recall cholera outbreaks in Zimbabwe, Vietnam and Haiti, polio’s persistence in Afghanistan, Nigeria and Pakistan and even the spread of HIV in poor U.S. neighborhoods (in 2010 44% of new HIV cases in the U.S. were African Americans despite representing only 14 percent of the U.S. population).
Not only does disease disproportionately impact the poor, poor people often receive worse care, care that can be actively harmful. Harm caused by adverse medical events was more than twice as high in low- and middle-income countries as in high income countries.
This trend persists within high-income countries: in 2001, the gap in life expectancy between urban black males and Asian females in America was 20.7 years. If we know this, we can craft strong systems that protect groups at risk and guard against future pandemics.
6. Resource-poor systems don’t have to be weak systems
Good health care can be provided even with limited resources. Rwanda, for example, has been able to move the needle on critical health outcomes despite spending only ${esc.dollar}55 a year per person on health. In every country the health system reflects a particular history, culture, and socioeconomic circumstances, but the challenges facing weak health systems are, beneath the surface, surprisingly similar.
Paralleling primary care innovation in Rwanda, BRAC in Bangladesh has instituted a multi-tiered Community Health Worker program employing non-medical professionals to identify at-risk mothers, addressing health issues before they become acute. To support amazing work like this we need to get better at sharing what we learn – and that means both successes and failures.
There’s more work to do
The response to the Ebola epidemic has laid bare how we choose to value human life as a global community. And it doesn’t look good. But regardless of your expertise, there are myriad opportunities to help strengthen global health systems: direct care, delivery innovation, actionable research, policy and institutional reform, and health education – to name a few. We can learn from one another, across countries and disciplines, assessing how we address illness to craft robust systems that can deal with health crises, both unexpected and predictable.
Liana Rosenkrantz Woskie is Program Manager with the Harvard Global Health Institute.
The 2015 Skoll World Forum takes place April 15-17 in Oxford, England.
