Offline: The mistakes we made over Ebola

Abstract

Where did global health go wrong? The failures the global health community made collectively over Ebola, argued Caroline Voûte (Médecins Sans Frontières) at last week's Global Health Lab, held at the London School of Hygiene & Tropical Medicine (LSHTM), were not simply abstract errors in outbreak responses. They were errors that failed people. The actions in west Africa in 2014–16 and more recently in the Democratic Republic of the Congo (DRC) certainly evolved in their complexity and understanding. But the fundamental mistakes were the same. Systems were designed around the disease, not those affected. There was a surprising lack of urgency to deploy vaccines and treatments. Money was invested in global surveillance and response systems, but little attention was given to standards of care and the effects of the outbreak on families, communities, and health workers. The Ebola outbreak response was securitised and politicised. A security-based approach emphasised deterrence, compliance, and punishment, principles contrary to public health. Security concerns diverted attention from human-rights-based protections and violations. There were pervasive failures to apply best public health practices. Decision making was often slow. There was no continuity of care. Ebola responses were not integrated into existing health systems. Interventions, such as new vaccines, can never be substitutes for building trust and cooperation with local populations. Wider health and humanitarian needs were neglected. There was little transparency and almost no accountability regarding the massive financial resources mobilised to address Ebola. Together with colleagues in Africa, Melissa Parker (LSHTM) established the Ebola Response Anthropology Platform in 2014. Technical solutions were insufficient in the face of communities afflicted by precipitous losses of trust. Community engagement often meant little more than issuing instructions. Existing inequities were elided. And those affected saw that their lives were valued differently from the lives of those living in western nations. What went right? Gillian McKay (LSHTM) offered a different assessment based on her work during west Africa's and DRC's Ebola outbreaks. Lessons were learned. First, the importance of national and regional leadership was acknowledged and given. Second, evidence-based decision making was successfully implemented. Third, the value of high-quality medical treatment, especially supportive care, became outstandingly clear. Fourth, vaccination reached over 200 000 people. And finally, despite challenges, the critical value of humanising the response to Ebola was recognised. These “successes” surely do deserve appreciation. As Mo Koker, an NHS emergency medicine specialist deployed to Sierra Leone in 2014, observed, many people didn't believe that Ebola was Ebola. The response to this tragedy was therefore a remarkable story of international cooperation. Francesco Checchi (LSHTM), who oversaw Save the Children's response to Ebola in west Africa, underscored how the Ebola outbreak response revealed extraordinary levels of collaboration, courage, and empathy. But these unprecedented events also showed the astonishing bargain that was being negotiated between affected countries and the international community. Manage Ebola well, those counties were told, and the gates of heaven will open for you. Fail, and you will go to hell. The threat was palpable—and unconscionable. I sat in international conferences, convened after the west Africa outbreaks, where country leaders pleaded for the equivalent of a Marshall Plan, a west African recovery programme, to counter the de-development that Ebola had wreaked on their economies. Big promises were made. But the fact is that once Ebola withered away, the international community lost interest in Africa. The US and Europe were concerned about Ebola only in so far as it represented a threat to their own borders. Once that threat had dissipated, Africa was once again left to clear up the debris of a humanitarian catastrophe. Watching this betrayal unfold was not surprising. It was simply one more deception western nations have perpetrated on African peoples. Yes, a vast amount of money was invested in controlling Ebola. Yes, important lessons were learned. Yes, the global health community did sharpen its understanding of public health emergencies. But Ebola showed how western countries bequeathed one more chapter of duplicity and treachery on the history of Africa.