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    UncategorizedGlobalization, epidemics and weak health systems

    Globalization, epidemics and weak health systems

    Date:

    Chronic, non-communicable diseases are increasing in unprecedented rate elsewhere. A critical challenge for the candidates would be overlooking the need for proper articulation of the balance. Some of the candidates are champions of communicable disease prevention, while others are global leaders and advocates for non-communicable disease programs and funding, writes Dawit Seyum.

    Over the past decades we have heard and faced so much about social, economic and political uncertainties in the future. Building on the uncertainty models, in the summer of 2015, I wrote a semi-academic article about the implications and lessons from the Ebola epidemic and the need for a robust new global health systems governance structure. The article was not a manifesto calling for a revolution, but it was a contribution that shaded light based on existing evidences. With an increasing uncertainty of the global health, heavyweight candidates emerged to hold the top leadership at the World Health Organization (WHO). Although a number of countries and candidates have yet to announce their bid, by the end of May 2016, Tedros Adhanom (PhD), Ethiopia’s former Minister of Health and current Minister of Foreign Affairs; Philippe Douste-Blazy, (MD) France’s former Minister of Health and Foreign Minister; and Sania Nishtar (MD), Pakistan’s  Former Minister of Education and Training, Science and Technology, Information Technology and Health, have formally announced their candidacy. 

    The succession and election process would be much complicated than ever before for four reasons. First, the new election process that offers one vote for one-member country (irrespective of population size, funding contribution, or United Nations Security Council membership) means that candidates have to gain as much numerical support as possible to win. Second, majority of the institutions, governments and individuals agree that the reputation, credibility, financial and technical capacity of the WHO to address complex global health issues has been eroded. Thus the voters expect the upcoming leader to be capable and energetic enough to take the responsibility of overhauling and reinvigorating the image of the institution. Third, although all countries will have equal votes at the end, countries and donors with larger financial contribution for the WHO will have disproportionately larger say during the vetting process. The three top candidates to be tabled for voting in the World Health General Assembly will be rigorously vetted and selected by this group. Accordingly, candidates have to position themselves in Washington DC, London, Beijing and so many capitals and headquarters to garner support; that requires for massive lobby and advocacy. We will see money playing a greater role in the election process. The fourth reason would be the epidemic pattern and health priorities. The West and most developed countries have a chronic-non-communicable disease oriented prioritization while most of the developing countries have prevention oriented approaches. These challenges would be easily negotiated given the latest epidemic transition reported from developing countries. Chronic, non-communicable diseases are increasing in unprecedented rate elsewhere. A critical challenge for the candidates would be overlooking the need for proper articulation of the balance. Some of the candidates are champions of communicable disease prevention, while others are global leaders and advocates for non-communicable disease programs and funding.    

    Upon successful completion of the hurdle race, the WHO welcomes its new leader with lucrative compensations, reputable position, and complex problems on the table. The leader will have a responsibility to clean the house, face chronic age old problems and emerging challenges. In this article based on the Ebola context, I will present the intricacies of globalization, epidemics and weak health systems, the most likely competency the candidates should prove to win the post.  

    The world after the Ebola epidemics

    Intensified globalization as well as the epidemic named ‘Ebola Virus Disease (EVD)’ emerged during the late 1970s and early 1980s. In the consequent decades, whereas globalization has been embraced at the global scale; EVD has remained disguised, neglected and deadly within its endemic countries. By mid-2014, however, EVD blasted into a global threat and concern of the 21st century, affecting three continents. The latest EVD epidemic is the most catastrophic, with ten times higher cases compared to the sum of cases in the entire EVD history since 1976. According to World Health Organization (WHO), by July 2015 a total of 27,514 confirmed, probable and suspected cases were reported, among which 11,220 died in ten countries. Thus, it is the right time to inquire how the institutions and actors of globalization promoting the movement of people, goods and services responded to this epidemic and why the global community failed to contain EVD.

    The central argument of this article is that globalization has ‘globalized’ epidemics. It accelerated speed and extended the scope for the spread of epidemics. Yet, the hegemonic powers of economic and financial globalization overlooked this fact just as they have disregarded the other negative globalizing forces, such as climate change, poverty, and human trafficking. The very institution, WHO, entrusted to deal with epidemics, has admitted failure and lost its credibility. Local and international health systems failed to pass the test of the epidemics; and the 2015 EVD catastrophe exposed that the epidemics management system is fragile and characterized by ‘vacuums’ at local, regional and global level.

    The nomenclature ‘Ebola Virus’ was derived from the Ebola River, where the first case was detected. Ebola is the virus, while EVD is the disease. Since 1976, the Center for Disease Control (CDC) recorded 36 separate incidences in humans and animals in 19 countries globally. By 2014, the total recorded EVD cases approached 30,000 of which approximately 90 percent are in 2014/15 upsurge. Although the latest average global fatality rate is 57 percent, the trend was extremely variable.

    EVD signaled a new landscape. The North/South dichotomy lost all the empirical and practical importance. Except the magnitude of transmission, little differences were observed in management capacity of both resource rich and resource poor countries.  In both ends, the same panic, trial and error dominated the landscape. Even the US was not ready to effectively respond and trapped in a crisis of misdiagnosis and further infections.

    The situation of the health system in EVD stricken countries was already in crisis before the epidemic. As CBC News, the health systems of the countries were barely functional even before the outbreak. The number of health workforce is extremely low to deliver health services, leave alone to respond to unprecedented crisis. The countries are characterized by neglect to the health sector. According to a report from Save the Children, in 2012 the Liberian government spent USD 20 per person per year on health compared to USD 7,704 in Norway.

    The 2014 case load of EVD was ten times higher than the historical aggregate. Salam-Blyther, reported between 1976 through 2012, there were 2,387 cases and 1,590 deaths. The rapid expansion of EVD was conditioned by the transnational, globalizing movements of people and goods.

    In terms of movements of goods and transnational epidemics, the ‘Asian Tiger mosquito’ has spread globally due to used tire trades. Others also found that emergence of global capitalism and associated growth of transportation further accelerated globalization of smallpox. Moreover, according to the Center for Disease Control (CDC), Ebola was diagnosed over four times in imported monkey quarantine facilities in the US and Italy. Two incidences of imported Ebola infections were recorded in Russia due to laboratory contamination.

    It seems that globalization, ‘globalized’ epidemics too. All the index EVD cases were associated with transnational movements. Initially, most of the EVD cases in West Africa were imported from a cross-border funeral event in Guinea. International employment and subsequent relocation after infection contributed to ‘globalize’ the epidemics. Patient relocation saved lives, but in the meantime spread the virus (1996 from Liberia to South Africa; in 2014 from West Africa to US and Spain). As a result, other health workers were infected; hospitals and schools were closed. Consequently, ethnocentric views emerged; and some governments were questioned for their actions.

    Local and global responses and the lessons learnt  

    While globalization has worked to “globalize” epidemics, there were simply no proper matching systems to contain these epidemics. Actors and institutions of globalization have been promoting increasing movement of people and commodities yet they have ignored the consequences of the expansion of transnational interactions when it came to the spread of epidemics. That is why the EVD response all over the world was full of panic and ill-informed; the response ranging from “euthanizing a suspected dog” to the use of “space and military technology”.  Clinical responses ranged from ‘tent based isolation’ in a village to intensive care in Emory Hospital.

    WHO as a UN body was entrusted since 1948, as a specialized agency to direct and coordinate global health. However, EVD outbreak exposed that WHO was too weak, late, far and stringent to respond. As WHO indicated, WHO learned the importance of capacity. WHO can mount a highly effective response to small and medium-sized outbreaks, but when faced with an emergency of this scale, WHO’s current systems – national and international – simply have not coped.

    In the absence of WHO, NGOs such as MSF stepped up to fill the vacuum, and warned about the unprecedented crisis. On April 1, 2014 after four months of the first death, Medecins Sans Frontieres warns EVD’s spread is “unprecedented.” Unfortunately, the same day, a WHO spokesman calls the epidemic is relatively small and sporadic. Although, by July 2014 MSF urged WHO to declare global health emergency, it took eight months for WHO to declare the same. This was a massive embarrassment to our only institution, we entrusted to take care of our health.  

    The internationalization of the epidemic unified the world leaders globally and within Africa; however, it was too late. On 18 September 2014, the Security Council called the EVD outbreak a “threat to international peace and security”. EVD was an ‘olive branch’ between the critical US Congress and Barack Obama. Congressional actions to address the outbreak have been accelerated, legislations enacted, and various financial resource allocations were approved. On the other side, the African Union mobilized and deployed 86 volunteer health workers, from 12 African countries. As the response protracted, Nigeria, Ethiopia, Kenya and Cuba contributed over 864 health workers. In terms of financing the response, the World Bank, European Union and USAID, mobilized over USD 5.5 Billion by July 10, 2015.  Thus, there are tendencies that there have been seeds of globalization of responses, though uncoordinated and less synchronized.

    Despite the flow of billions of dollars and commitments, the issue of governance remained an unabated gap. The global leadership was in limbo: Liberia, Sierra Leone and Guinea] have put in place Ebola Recovery Plans, which laid out the cost, the strategies needed to respond, the price tags and several grassroots initiatives.  Unfortunately, how much donor financing has been received so far, from whom, and for what exactly is a million-dollar question. The answer is that no one quite knows. 

    Before the latest Ebola epidemics, markets were not interested in developing neither drugs nor vaccines for EVD, mainly due to its confined impact on poor and remote communities. However, the 2014 epidemics signaled number of drugs and vaccine trials by American and British firms, supported by the EU and the World Bank. The Economist (01 November, 2014) called this as “drug-makers bet’ to resolve the crisis.

    In conclusion, the 2014-15 EVD crises exposed the vacuum in global governance pertinent to large scale epidemics. This is a yawning hole calling for a leader to make bold actions to close; a recurrent culture of failure in containing epidemics elsewhere needs an urgent action. The new WHO leadership will inherit either the whole vacuum or a large doughnut hole!

    Envisioning a new global governance

    As I have said it earlier this article is not a manifesto. History, time and again, educated us that epidemics are inevitable. Thus, epidemics management is a concern for four reasons: population, movement, ‘biological weapon’ as well as moral imperatives. The increase in global population has increased the threshold population in danger. Second, sustaining increased population demands for an equally increased movement of goods and services – and epidemics will easily move as well or sometimes limit the movement of goods and services. Third, EVD and other biological pathogens could be easily capitalized by extremist groups as a “biological weapon/suicide bomb”. Fourth, previous global efforts indicated that controlling deadly diseases was possible even decades ago. Thus, – a moral question – why have we failed now in the high-tech era? As discussed below, new challenges require new systems that can cope with the global and local realities.

    Interestingly, there are excellent examples of global collaboration. The global community is successful in eliminating Smallpox and averting HIVAIDS. Why? Smallpox was eradicated due to the concerted global action led by the United Nations, starting from 1959, with the goal to eliminate. Anti-HIV efforts started to bear fruits. As WHO estimated, among 13 million PLHIV receiving HIV treatment globally, significant proportions are from low- and middle-income countries. Global leadership by US government and the Global Fund facilitated a rapid scale-up of treatment and an elimination of mother-to-child transmission and number of countries are transitioning towards AIDS free generation.

    EVD outbreak was a practical test on health systems globally. The main test was not treating the cases (or not), but stopping the transmission of the disease. Health systems were found to be weak enough to play significant roles in cutting the transmission chains as they were generally patient-oriented and facility-based. This has been the same in the developed and developing economies. Resilient health systems are prerequisite for a response. Kruk and colleagues defined health system resilience as the “capacity of health actors, institutions, and populations; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis.”  However, the post EVD epidemics scenario left us skeptical about the existence of such systems.

    Old approaches are not able to cope with new challenges. The capabilities of epidemics to be carried by people and goods undetected, means that quarantine and border closure are no longer effective responses. Restricting population movement is ineffective way of containing diseases. EVD could not be effectively stopped at international borders because travelers could cross boarders while asymptomatic.

    Thus, I envision two alternative approaches – I hope will be in the agenda of the upcoming WHO leadership – at least they will be interviewed to prove how they are capable of. The alternatives are either calibrating WHO or nurturing a new global institution. Calibrating WHO requires structural reforms, mandate redefinition, and adequate resources including setting up rapid response team. New brains and new ideas should be given an opportunity to prevail, including transferring the leadership role to the developing countries.  The second option is a radical approach – nurturing a new, robust and up-to-date institution for early warning, detection, and rapid epidemics response, equipped with the people and resources – including military and cyber technology.

    The realization of both options depends on three preconditions: strengthening health systems, investing in technology, and global consensus/protocol on harmonized epidemics prevention. Building local capacities avoids patient relocation and limits disease spread. Investing in new technologies increases forecasting, surveillance, treatment and control capacity; and avoids forced use of experimental drugs on humans, as it has been the case during the 2014/15 Ebola epidemic response. The global consensus may allow for standardization, equity and efficient resource distribution.

    Finally, an unabated gap in global governance was the major factor behind the unprecedented upsurge of EVD. EVD exposed the vacuum in global governance and fragility of health systems. Increased population and increasing global movement of goods and services have increased both the tendency and threshold population in danger. Accordingly, effective global response could be achieved either through calibrating WHO or nurturing a new institution to lead globally while simultaneously being embedded at local levels. Both options would be feasible in a resilient health system, backed up by technology, and harmonized by a global prevention strategy/protocol. That is why the upcoming election of the right candidate, capable of leading a complex institution facing complicated challenges is crucial.

    Ed.’s Note: Dawit Seyum (BA, MA, LDP, and MPH) is based at Washington University in Saint Louis. All the materials cited in this article are formally acknowledged in the original academic version, which can be accessed from the author. The views expressed in this article are solely attributable to the author and does not reflect the views of The Reporter and the institutions he is affiliated with. He can be reached at [email protected].

     

    Contributed by Dawit Seyum

     

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