In global public health, 2016 was a year defined by the end of two important emergencies: Ebola and Zika.
But that doesn’t mean the risk either of these viruses pose has gone away. Zika transmission continues despite the World Health Organization declaring it is no longer a public health emergency in November. And some have characterized Ebola’s resurgence in 2017 as “a certainty.” We have to be prepared for these viruses to return, causing future epidemics.
With Zika and Ebola, much of the attention has focused on the need for more effective vaccines, faster deployment of staff and resources in response and better diagnostics. And all of these are vitally important.
But relatively little attention is paid to rebuilding the underresourced and underperforming primary health care systems in the places most vulnerable to epidemic disease.
I am a primary care physician, public health practitioner and researcher, and have designed, worked within and studied global health and primary care systems for the last 15 years. We need to take a close look at how these systems function in places at great risk of epidemic disease, and what we can do to make these systems more resilient. All too often, however, primary care is simply an afterthought.
Primary care is a first line of defense
Why is primary care important in epidemics like Ebola or Zika? First, we know that primary care providers play an important role in initial outbreak response and surveillance. This has been studied in the context of the H1N1 flu pandemic which infected approximately 60 million people and killed over 12,000 worldwide in 2009.
In Canada, for instance, interdisciplinary teams of primary care practitioners (called family health teams) played a critical role in epidemic response and control. These teams identified and isolated suspected H1N1 cases to reduce the spread of the disease. They also helped to treat and stabilize these patients, and took pressure off the hospital system by managing uncomplicated cases of the virus.
Others have argued that a “primary care safety net” is critical to stem the tide of future flu epidemics. They are often the first health care providers a person with the flu or other illness will come into contact with. This means they are vital to surveillance, patient triage, and initial prevention and treatment, including distributing medications and vaccines and providing important health information.
But during the Ebola outbreak, fewer people accessed health care services and more people died from malaria, HIV and TB. People stayed away from front-line health facilities – the backbone of the primary care system – in part for fear that they could acquire Ebola there. This suggests a basic lack of confidence and trust between affected communities and the health care system.
Focusing on local primary care builds trust
A lack of trust between communities and government health care systems can fuel epidemics, in part because people may not follow advice from public health authorities that could reduce their risk of getting or spreading infection. One survey from Liberia showed that respondents who expressed low trust in government were much less likely to follow Ebola-related public advisories or precautions, thus increasing the chance of the virus’ spread.
But even in settings like West Africa, where there was a lack of trust in basic health services, there are ways to bridge this gap. Community health workers, for example, are a major pillar of the primary care system in many rural areas and in developing countries. These workers often share common heritage and historical background with the people they are trying to help. And they typically live in or near the communities they support.
During the Ebola epidemic in West Africa, hot spots were often in communities isolated because of distance or poor transportation and roads, bad weather, or mistrust and fear of aid workers, government or international health officials.
So community health workers carried out important epidemic response functions and were able to overcome geographic and trust barriers by virtue of their cultural and physical proximity to patients. They tracked whom infected patients came into contact with and identified suspected cases. They also taught people how to recognize Ebola, how to safely bury victims and tend to the ill. In performing these functions, they improved trust between communities and the government.
Community health workers were able to fulfill these roles because they operated outside of the facilities many people perceived as unsafe, and thus avoided. They took on larger roles, in part, to fill the gap created by decreased clinic attendance due to mistrust.
Better primary care means better health
Countries with stronger primary health care have better health overall.
As the late Barbara Starfield, a pediatrician and professor of health policy at Johns Hopkins Bloomberg School of Public Health, showed, countries, and regions within countries, with more primary health care practitioners had lower rates of death overall and less inequality in deaths. This means that these areas are healthier, and have fewer disparities in health based on race, socioeconomic status or ethnicity.
Primary care systems also help prevent and treat chronic illness and diagnose common diseases sooner. This is largely because primary care providers develop long-term relationships with their patients, which in turn increases willingness of patients to seek care, and to seek it earlier.
This foundation makes it easier to respond in times of stress, like during infectious disease outbreaks.
Primary care on the global agenda
There are some early signs that primary health care is becoming a priority on the global development agenda.
The U.N. High Level Panel on Health Crises specifically called for strengthening of primary health care systems as an essential component of pandemic disease prevention in developing world.
The World Bank, WHO and Gates Foundation in late 2015 launched the Primary Health Care Performance Initiative to make it easier for government decision-makers and public health leaders in developing countries to understand how well primary care works in their countries and where improvement is needed. This is an important and encouraging start. However, it should not deter us from taking real action to improve primary health care systems in the poorest countries, which face the greatest epidemic risk.
This means more front-line staff and better training and support for them. Shifting to team-based care that includes community health workers, social workers and others is another key. Health information technology would improve the quality of front-line patient care, strengthen disease surveillance and reporting, and make it easier for primary care providers to communicate with each other and with the rest of the health care system. These are among the investments into primary care that cannot wait.
The United Nations Special Envoy for Ebola reported that a total of US$8.9 billion was pledged for Ebola response by the end of 2015, with $5.9 billion disbursed. This includes $5.4 billion pledged by the United States, which is the U.S.‘ largest ever commitment to an epidemic. Almost 80 percent of the $5.9 billion disbursed has been specified for immediate epidemic response functions. Just 18 percent of these funds support “recovery” efforts which include rebuilding primary health care systems. This is inadequate at best, abject at worst.
The National Academy of Medicine, by contrast, has recommended $5.4 billion in additional annual investment to strengthen essential health services in high-risk settings with weak public health infrastructure. The National Academy of Medicine also recommended that 87 percent ($3.4 billion) of this annual investment be directed to core functions of the primary care system like treatment and primary prevention as a first line of defense against epidemic disease.
This level of support for front-line health care is the first step in establishing a foundation of health services that is resilient to unexpected shocks like Ebola and Zika, and provides consistent, high-quality primary care to all.
The epidemic emergencies that ended in 2016 have awakened us to the threat that weak health systems and poor primary health care pose. We must repair these systems and improve primary care now, or risk being similarly unprepared for the next wave.