The Ebola Outbreak Shows Why the Global Health System Is BrokenBy
At the end of last week, the World Health Organization declared the West African Ebola outbreak an international health emergency. The move was largely symbolic, however; the organization did not suggest trade and travel restrictions, a reflection of the slim chances of a global epidemic. Even in the West African countries where the disease has spread, it’s still far down the list of killers. Over the past few months infections such as malaria and tuberculosis have caused far more deaths in the region than Ebola.
At the same time, the Ebola outbreak is a wake-up call to governments everywhere: The international health system is broken. Preventing a recurrence of this tragedy will require more money and attention on global progress against infectious disease and epidemics.
As of Aug. 6, 1,779 cases of Ebola had been reported to the WHO, including 961 deaths. Of the four countries affected, Sierra Leone (with 717 cases) has suffered the worst. The country’s first reported Ebola deaths were in April this year. In approximately four months, Sierra Leone suffered a total of 298 deaths. More are surely to come.
It’s worth putting those numbers in perspective. According to global burden of disease estimates, every four months in Sierra Leone sees around 650 deaths from meningitis, 670 from tuberculosis, 790 from HIV/AIDS, 845 from diarrheal diseases, and more than 3,000 from malaria. This is the worst outbreak of Ebola yet; since it began, the disease has been responsible for just 2 percent of all deaths in Sierra Leone. It killed no one in the country in the months and years before that, and assuming this outbreak is controlled soon, years will pass before it kills anyone again.
One reason for hope that the Ebola outbreak will eventually be controlled, as it has been after the 20 previous deadly outbreaks of the disease, is that it is hard to contract. It takes the bodily fluids of an infected person showing symptoms coming into direct contact with an open wound or the mucous membranes (eyes, nose, mouth, or genital area) of an uninfected person. That is why nearly all those infected have been caring for victims, and it makes the disease comparatively easy to halt. Masks, gloves, and gowns for caregivers, preferably working in isolation units, give considerable protection.
Why hasn’t Ebola been stamped out already? The problems start with national health systems. Only a little more than a decade ago, Sierra Leone was embroiled in a civil war, which has left scars of distrust and weak governance. According to the World Bank, health expenditures per person in the country are about 26¢ a day at market exchange rates. That won’t buy many gloves and gowns. And while the country reports vaccination rates against measles and tetanus as high as 80 percent for 1-year-olds, the most recent estimates suggest only about a quarter of children sleep under a bed net—which reduces the chance of catching malaria from an infected mosquito.
Worldwide, the WHO’s legally binding International Health Regulations lay out steps countries must follow to identify disease outbreaks and stop them from spreading. But out of 193 member countries in 2013, only 80 were meeting and sustaining core capacities required by the regulations for hazard alert and response, according to the WHO. And just 100 had surveillance reporting based on international standards for epidemic disease.
Extremely poor countries with crumbling health systems simply don’t have the ability to monitor outbreaks and isolate and care for victims of an epidemic or to provide cheap and effective tools to protect people from major killers. That’s why greater international support is essential. To be sure, backing for health programs in developing countries has increased considerably. Aid going to health amounted to around $4 billion in 2000, but by 2012 that had climbed to $11 billion (compared with $37 billion going to infrastructure).
Yet major funding gaps still exist—after all, $11 billion adds up to only about $2 per person per year in the developing world. The WHO is the global body best able to coordinate and provide assistance to countries facing a disease outbreak. Its budget, which comes from member countries, has been declining since 2011. The annual level is now a little less than $2 billion. Of that, supporting communicable disease control in member countries gets $420 million; country preparedness, surveillance, and response gets $143 million. The WHO’s global budget for its own outbreak and crisis response efforts is just $109 million—half the level it was two years ago. The portion of the WHO budget that goes to support African countries in preparedness, surveillance, and response against epidemic and pandemic diseases alongside outbreak and crisis response totaled $22 million—or a little less than $500,000 per country.
More broadly, diseases of the poor don’t get research attention from medical companies, because those organizations want to develop treatments for people who can pay a lot for them. Luckily for two U.S. victims of the Ebola outbreak, the Department of Defense had taken interest in the disease as a bioterror threat and was financing development of the drug ZMapp as a potential response. The Americans were given the experimental medicine last week. But Ebola is the exception: Only a little more than 1 percent of new drugs approved between 1975 and 2004 were designed to address tropical diseases that account for more than 10 percent of the years lost to premature death and disability worldwide. Research and trials for tropical diseases focusing on cheap prophylactics, such as vaccines, and easily administered treatments for sufferers should be a priority for global support.
Funding is only part of the problem. A lot of resources at the country level are wasted on doctors who don’t bother to diagnose, health-care workers who don’t turn up, and expensive hospitals catering only to the elite. While the WHO has some significant accomplishments in global health—not least negotiating the International Health Regulations themselves and leading the fight to eradicate smallpox and polio—it is far from a paragon of effectiveness. The WHO has undertaken some reforms since then, but a 2011 U.K. government review of the organization suggested it was “weak” in some areas, from financial resource management through transparency to its focus on poor countries.
Still, money can make a difference, if combined with an effort to strengthen the global health architecture. And that should start here at home: the U.S. Centers for Disease Control had a 2013 budget of $45 million for global disease detection and response—3 percent of what the country spends on baldness treatments each year. If we want to save lives abroad and protect ourselves from future threats posed by diseases that really could spread in the U.S., it’s time to replace periodic panicked calls for quarantine in response to a new outbreak with sustained support for global health systems.