Co-authored by Scott Barnhart and Amy Hagopian
In a desperate attempt to contain the highly contagious Ebola virus in Liberia, 50,000 people were recently quarantined in a slum neighborhood of Monrovia, whether they were sick or not. Imagine being trapped in an open-air prison without any sense of when you would be released. And if you get sick inside that slum, there is no organized system to take care of you.
Quarantining 50,000 poor slum dwellers is far different from quarantining a household, a plane, a bus or a boat. Why would Liberia feel driven to take such a drastic move when only a few of the residents in the area had Ebola? Such is the desperation of a country with a health system so weak that it has no other way to cope with an epidemic of any serious threat, let alone one this virulent.
Francis Omaswa, who led Uganda's successful effort to control an Ebola epidemic in 2000, said last week, "Controlling the epidemic is about early detection, isolation, treatment of new infections, contact tracing, and safe handling of body fluids and the remains of those who die." These routine infection-control procedures are not hard to implement, but doing so requires basic public health infrastructure. When a country has no capacity to perform these functions, desperate measures such as quarantining a whole slum can seem reasonable. How did Africa's health systems come to be so weak? Didn't the United States and other major donors just spend billions of dollars on global health in Africa? In the process of providing all that care for diagnosing and treating HIV, preventing malaria and distributing vaccines, didn't we build clinics and laboratories and train health workers and create medical records systems? Well, not exactly.
Recent major global health initiatives have been aimed almost exclusively at specific diseases such as HIV, TB and malaria, while strengthening the health system is typically an afterthought. Funding generally favors the private sector, particularly faith-based non-governmental organizations, and views with skepticism the role of public institutions such as ministries of health. The private health organizations proliferating across Africa lure health workers away from their jobs in public clinics and hospitals, usually offering higher salaries than governments can pay. Yet the over-riding responsibility to care for an entire population, including the poorest, resides with governments, which remain under-resourced and struggle to keep up with the needs of their citizens.
When the choice was made to invest in single-disease programs that were walled off from government health systems, we missed an opportunity. We could have developed the capacity to address other emerging health problems by building infrastructure: facilities, information systems, the work force, logistics and supply chains. Some donors hoped their disease-specific initiatives would "spill over" in a way that would strengthen the health system. Unfortunately, recent research shows this did not occur.
When the funds stop flowing to private organizations that implement these single-disease programs, the work stops. Weak health systems limp along until the next emergency, when another cycle of global health programs sweeps through.
Meanwhile, the routine burden of illness from malaria, pneumonia, diarrhea, TB, malnutrition and, increasingly, diabetes and other chronic diseases, continues to shorten life expectancy in Africa. Weak systems can't effectively keep up with those problems, let alone the sudden shocks imposed by emerging diseases like Ebola.
What will help? For one thing, we must stop focusing on disease-specific initiatives implemented primarily through the private sector. Donor funding should go through ministries of health whenever possible, and flow from there to health facilities and staff. Health workers funded by external donors must be paid at the same salary scale as the public sector.
Finally, as Ebola has shown, feeble ministry of health surveillance systems must be bolstered. Better surveillance is a large part of why wealthier countries are at much lower risk of major epidemics than are nations with scant public health resources. Ebola would not be the crisis it is today if it had been recognized earlier, with contacts traced, quarantined and cases treated. But for that to happen, the essential elements of functioning health systems in the affected countries would have to be in place. When we hear stories of nurses dying because they didn't have the simple protective equipment needed to care for Ebola patients, the gaps in those health systems become clear.
The expanding Ebola epidemic underscores the urgency of making investments in the health systems of African governments. Global health initiatives of the last decade largely missed an opportunity to strengthen health care capacity in Africa. Will we have another chance with the next epidemic? Let's make Ebola the last one to trample across the continent because there are no health systems to contain it.
Scott Barnhart, MD, MPH, is Professor of Medicine and Global Health at the University of Washington. He has worked on health system strengthening in Haiti, Southeast Asia, and several countries in Africa.
Amy Hagopian, PhD, is Associate Professor of Public Health at the University of Washington. She has studied the migration of doctors and nurses from poor countries to rich ones, including Uganda, Nigeria, and the Philippines.