Ebola: How Emergency Relief Can Harm Public Health

The now subsiding Ebola outbreak was first recognised in December 2013 in southern Guinea from where it spread to eight other countries in West Africa. it was declared a ‘public health emergency’ by the WHO in August 2014. It now has a current estimated death toll of 11 297 and almost 28 500 people have been infected.

However the health impact of Ebola must be inspected more broadly than the direct health implications of the virus; we must look to the disruption to public health.

 

So what is the public health cost of the Ebola outbreak and to what extent is emergency humanitarian assistance responsible?

The extent of disruption to the health services is difficult to quantify but a modelling analysis of malaria in all Ebola-affected countries estimated there was around 10 900 more deaths due to malaria during this time (for more detail see link here); the same as those killed by the Ebola outbreak itself.

The limited knowledge of the extent of malaria service disruption prevents accurate extrapolation from this model but overall it clearly indicates that the reduced health-care capacity resulted in many deaths from untreated malaria.

However, it is not only malaria that has capitalised on this outbreak.

By the end of 2014, 62% of health facilities in Liberia were closed, vaccinations, outpatient deliveries and institutional deliveries had dropped significantly and outpatient attendance was as low as 10% in some areas. This breakdown in core health services was also seen across Guinea and Sierra Leone.

 

So what caused this breakdown in the core health services?

With any humanitarian response to a health emergency, resources and personnel must be drawn from the existing health system. Unfortunately in the case of Ebola, the existing health systems were already fragile and unable to cope with the diversion of resources resulting in the neglect of public health services in favour of tackling Ebola.

This is illustrated by the 2000 malaria community health workers in Sierra Leone who were retrained to fight Ebola prioritising the immediate threat of Ebola over the future threat of malaria. This transfer of health care professionals not only disrupts current programmes but has long term impacts as many of them became infected with Ebola themselves and died, depleting the national health workforce. In total, around 850 healthcare workers became infected, of which over half died.

Other causes, such as a fear of public health facilities, also contributed to the reduced use of core health systems but were not the primary cause of their breakdown.

 

Medical Humanitarian Assistance vs Public Health Priorities

The balance between immediate medical humanitarian assistance and public health priorities is a difficult issue. The humanitarian model primarily seeks to provide direct medical treatment of immediate needs regardless of long term consequences. On the other hand, the public health model emphasises cost-benefit analysis to achieve the best long-term health outcomes.

There is no easy solution as, although building up of core public health systems may have the best long term outcomes, it raises a strong ethical debate as humanitarians choose to withhold immediate treatment for people who are sick now in favour of stopping a larger number of people becoming sick later.

By doing this they become representatives of society in deciding ‘who should live and who should die’ (Rony Brauman, ex-director of MSF), a very questionable position. Conversely, are humanitarians good stewards of the tools and finances they have if they use them ineffectively to treat only a few people when they could be treating many?

In the case of Ebola, its rapid transmission throughout West Africa meant an immediate humanitarian response was required. However, as we have seen, this single minded approach undoubtedly had a significant negative impact on the immediate and long-term public health of the countries affected.

 

Can we provide an effective medical humanitarian response without damaging or neglecting public health?

Most likely, as in the case of Ebola, the answer is no.

The direct response, although essential, will almost always need to neglect some public health services as the existing system is overwhelmed, which is the nature of a health crisis. However this does not mean public health should be neglected completely during a crisis, nor does it mean that the core health system should be left in a worse state than before.

Although the humanitarian response to Ebola did neglect and disrupt many public health services, there were some efforts to tackle other public health issues arising during the crisis. One such example was the mass administration of anti-malarials to large sections of the population and distribution of long-lasting insecticidal nets as recommended by the WHO.

Although appearing to follow the public health model this initiative was put in place to limit the burden malaria patients were having on the Ebola response programmes. This was due to the fact that reduced malaria control redirected malaria patients, who present with similar symptoms to those with Ebola, into Ebola care pathways causing cross infection of previously Ebola-free patients and an increase in the number of patients to run diagnostic testing on (MSF, 2014). In this way, a public health issue was addressed but primarily because of the effect it was having on the Ebola programmes.

 

Looking Broader than Immediate Health Concerns

Of course, there is no easy solution here as Ebola was a quickly escalating emergency that required immediate action. Alternatively, was the cost of the response to public health too high or higher than it should have been?

When providing emergency humanitarian medical assistance it is essential that humanitarians look broader than the immediate health concerns to avoid leaving a broken public health system behind, especially if it is fragile to start with. The values of humanitarianism and public health will never truly be able to align and therefore it may simply be a case of minimising collateral damage to public health when providing emergency humanitarian assistance.

However it is clear that an emergency humanitarian response must simultaneously address ongoing public health threats in order to be considered truly successful. It is the integration of resources and personnel from a humanitarian response back into strengthening the public health system that will truly determine the final state of the affected health system and its resilience to cope with future emergencies. Hopefully the world will have the opportunity to observe this successful transition in West Africa as the Ebola outbreak comes to a close.

Joe Watson


Joe Watson

Joe Watson is a fourth year intercalating medical student studying Humanitarianism and Conflict Response (MA) at the University of Manchester. He is also one of the editors of the Manchester Global Health Society Website.

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