Though there have been regular reports in the American press covering the expanding Ebola outbreak in Guinea, Liberia, Mali, and Sierra Leone it has not caused the public panic of Swine Flu or SARS of recent past. There is good reason for this. Anyone sitting next to a sneezing person on a plane likely knows anecdotally that the risk of infectivity is high with certain respiratory viruses. The risk of death from influenza among healthy hosts, however, is relatively low. Other viruses can be quickly lethal but are inefficient at transmission from person to person. Ebola falls into this category. Thus far, over 100 deaths have been attributed to Ebola, with no containment in sight. The World Health Organization characterizes this outbreak as “the most challenging since the virus emerged in 1976.”
Ebola sheds light on a besieged health system, an acute calamity on top of a chronic tragedy. Eleven years after the end of two successive civil wars, Liberia struggles to rebuild itself. Plagued by poverty, corruption, and infrastructure in rubble, the Liberian Ministry of Health is ill equipped to stop this epidemic without outside assistance.
Since July I have worked at a government hospital in rural Liberia. As a Global Health Fellow at the University of California, San Francisco I spend 7 months a year in rural Liberia working closely with the Ministry of Health and the local Non-Governmental Organization (NGO), Last Mile Health. I am tasked with strengthening Liberian human resource capacity and slowly improving the quality of care in our 100-bed district hospital. As the panic of Ebola came to Liberia, I shifted my focus to handling the logistics of diagnosing Ebola and addressing the large safety risk the outbreak poses for our health workers.
Due to supply shortages, our hospital does not have the basic equipment for adequate infection control and outbreak response. Even before the epidemic, materials as basic as soap and gloves were often out of stock; disinfectant and laundry detergent are scarce. The hospital is rife with the potential for transmission of infections to hospital and clinic staff.
The Ebola outbreak is a marker of vulnerability in a system that struggles with health care delivery even in the best of circumstances. From half a world away, the fact that the emerging disease primarily affects the impoverished may offer those living in industrialized nations a sense of reassurance; this is emphatically false. With incubation periods of up to three weeks, such diseases can reach any nation’s doorstep in our increasingly globalized world. If viruses like Ebola give way to viruses that are both highly infective and highly lethal, health systems in the poorest countries must be rigorous and robust to deal with containment, not only for the moral imperative of caring for our neighbors across the oceans, but also for the safety of us all.
The spread of Ebola is an acute symptom of a chronically ill healthcare system. In our district of 150,000 people, charities are trying to provide infection control supplies to the healthcare facilities, making it the most prepared district in the country of 4 million. Unfortunately, this is just a Band-Aid. We need to strengthen the healthcare system, which means developing a steady supply chain, a strong health workforce, and functioning facilities. The work is long and slow, and very often does not attract the strong donor interest of more technologically sexy solutions for difficult health problems. But it is this work that will build a health system strong enough to deal with a lethal outbreak amongst its population as well as enable the delivery of quality healthcare for HIV, TB, Malaria, heart disease and high blood pressure. The 1918 influenza epidemic killed an estimated 20-40 million people in Western Europe. We in the western world must increase our role to support health systems in places like Liberia for a similar scenario not to unfold in the near future. The latest Ebola epidemic is the canary in the health system strengthening coal mine we can no longer ignore. Too many health systems are too weak to handle the basics of care, must less epidemics. The reasons to shore up health systems between epidemics are both moral and those of vital self-interest. Ebola is signaling a new call to action. We ignore this canary at our own peril.
Alexandra Stanculescu, MD.
UCSF Global Health Hospital Medicine Fellow