David Heymann and a number of Chatham House authors also contributed to a special issue of The Lancet that explores different perspectives on the wider lessons that can be drawn from the Ebola outbreak.
By 2 April 2015, the Ebola outbreak that started in Guinea and affected nine countries, including G7 countries, had killed more than 10,000 people. There are signs of improvement: in Sierra Leone, Guinea and Liberia, weekly cases decreased to 132 on average in February 2015, from almost 1,000 in October 2014. On 20 March, however, Liberia notified its first confirmed case in 20 days, reminding all that the outbreak will not be over until the last chain of transmission is broken. Beyond the outbreak, this tragic crisis is an opportunity to strengthen health systems globally and reduce the probability of the next global epidemic.
Between 1976 and 2013, 24 Ebola outbreaks were controlled using the same strategy: first, rapid identification and isolation of Ebola cases in health facilities with rigorous infection control; second, tracing and 21-day temperature-monitoring of all contacts, isolating those who developed symptoms; and third, social mobilization in affected communities to reduce person-to-person spread, including hygiene measures, social distancing and safe burial practices. The current outbreak will be controlled if the same approach is applied systematically and rigorously down to the last case.
The ‘endgame’ – breaking the last chains of transmission – presents additional challenges: first, identifying these last cases requires continued efforts for an exhausted healthcare workforce that may feel less supported as international attention wanes. Second, other health priorities compete for healthcare workers’ time as the Ebola burden decreases. Third, the remaining Ebola clusters may present particular challenges, such as population density and movement in urban areas, or secret societies resisting intervention in rural locations.
The Ebola outbreak in West Africa is a consequence of weak healthcare and public health systems. In the early phases of the outbreak, inadequate surveillance allowed transmission chains to accumulate and spread over a wide geographic region. Weak laboratory capacity enabled the virus to spread from Guinea to Liberia and Sierra Leone before it could be confirmed. Preventing future outbreaks entails building health systems with more robust primary care and disease surveillance, within the framework of the International Health Regulations, which require countries to strengthen their public health infrastructure and build core capacities.
This outbreak also highlighted the risks of concentrating clinical expertise in one organization: by June 2014, Médecins Sans Frontières (MSF), which concentrated on Ebola-management expertise, reached capacity and could no longer deploy teams to new outbreak areas. MSF had to train other medical non-governmental organizations before they could operate, delaying the response by several weeks. This lesson needs to be taken on board when preparing for future health crises. Although vaccines, which have been trialled during the current outbreak, may come too late to control this outbreak, they may play a role in future ones by protecting entire populations in areas at risk or individuals at highest risk as crises emerge.
The UN response
While the United Nations, and the World Health Organization (WHO) in particular, acknowledged shortcomings in its response, it continues to work towards ending the outbreak. On 8 August 2014, the WHO declared the outbreak a public health emergency of international concern. The Global Outbreak Alert and Response Network (GOARN), a WHO-coordinated emergency response network, deployed more than 530 experts between March 2014 and February 2015.
In addition, following the UN Security Council’s first emergency meeting on a public health crisis, the UN Mission for Ebola Emergency Response (UNMEER) – the first-ever UN emergency health mission – was set up on 19 September 2014, bringing the full range of UN actors and expertise under the leadership of a special representative of the secretary general. Furthermore, in September 2014, the WHO called for accelerated clinical trials of experimental therapeutics during the outbreak. The WHO also proposed the creation of a contingency fund and an emergency workforce. Beyond the crisis, it advocated the need for individual countries to build their healthcare systems, with a focus on surveillance, laboratory and response capacity, within the framework of the International Health Regulations.
The UN is not the only actor with a responsibility to avert future health crises. The role of the private sector needs to be better understood, particularly in contexts where one sector employs a large proportion of the population, such as the extractive industry in Sierra Leone or Guinea. Armed forces are another emerging actor in public health crises. They have contributed to the West Africa Ebola response with capacity-building, training, and the establishment of treatment centres and laboratories. After an unexpected call by MSF for military intervention as part of the outbreak response, there appeared to be a high level of cooperation between health actors and the military. Their adaptability, discipline, ability to operate in challenging environments, and logistical capabilities are particularly valuable during large-scale public health crises.
The momentum generated by the Ebola outbreak provides an opportunity for G7 leaders to strengthen national public health capacity in developing countries by providing development assistance through the framework of the International Health Regulations. Currently, only 20 per cent of countries fulfil their core surveillance capacity requirement. The G7 can also support the global health emergency workforce being conceptualized by the WHO and its international partners, and the development of safe and effective vaccines for neglected diseases such as Ebola.
Finally, G7 members could consider the opportunity to build on the momentum and solidify relationships between defence and health, and integrate the response to civilian health crises into the core function of their armed forces.
The West Africa Ebola outbreak, which started in rural Guinea and evolved into a global health crisis, demonstrated the risk that a weak healthcare system in one country can pose to global health security. While this crisis started in West Africa, no one knows where tomorrow’s outbreak will occur. G7 members have the opportunity to decrease the occurrence of such events by supporting global health-systems strengthening via the International Health Regulations, fostering medical innovation and vaccines in particular, and providing technical, clinical and logistical support during public health crises via their public health, healthcare and military workforces.
This article was originally published by G7/G20 Publications.
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