Ebola Virus Disease, Institutional Effectiveness, Professionalism and Human Behavior
Since the March 2014, relevant local, national and international health care and management systems have been playing catch up with the rapidly spreading Ebola Virus Disease (EVD) epidemic which started in Guinea and spread to Sierra Leone and Liberia. The local health care systems in these countries were already inadequate to begin with, laboring under endemic corruption, a culture of inefficiency and post war degradation of already threadbare healthcare systems.
The international response initially underestimated the scale of the outbreak, expecting a pattern of EVD which has been present in East Africa for decades. The pattern was often characterized by a rural outbreak with little mobility to heavily populated urban centers. In Liberia for example, there was no significant public health response until active cases were recorded in Monrovia. This outbreak is the worst since the first outbreak in Sudan and DRC in 1976. This is the 5th epidemic. None of the first four epidemics in DRC, Sudan and Uganda recorded more than 1,000 cases. The best case scenario for this epidemic is 11-27,000 through January 2015 if 70% of patients are treated. The worst case scenario for exponential growth is up to 1.4 million cases in the same time frame if that standard is not met.
Right from the outset, this epidemic with its brutally high mortality rate should have been recognized as a global security issue because of the ease of travel between continents these days. We know this from outbreaks of Marburg, SARS and MERS. The needs are immense. They include having enough well trained health care personnel at various levels, a culture of public health and prevention, the ability to accurately identify and trace contacts of identified patients and the capacity to isolate contacts effectively. In addition, a temporary but rapid increase in bed capacity to reduce the risk of overwhelming already underfunded healthcare systems is a necessity.
In Sierra Leone, many Cuban and Chinese doctors have arrived but the sick are being returned home as there are no field hospitals to absorb the sick for separate and safe treatment. The population in these three countries is of course traumatized by this modern day “Black Death” and in failing to understand the cause of this catastrophe has regressed to belief in witchcraft and are fighting any suggestion that there is a scientific explanation for this dark reality. In unaffected countries like Ghana, pastors are irresponsibly predicting the arrival of the disease or offering spiritual cures to muddy the public health education efforts, instead of using their pulpits to spread a message of calm based on current knowledge.
These beliefs have led to raids of Ebola treatment centers in Liberia and Sierra Leone and murders of health care workers in Guinea. The challenge of educating the public in the heat of this epidemic, speaks volumes about the human cost of years of neglecting investments in health and education by many governments in Africa.
Since April, Ghana has had a few “Ebola scares” in Kumasi, Komenda, Achimota, Nsawam etc. The infamous statement attributed to a leading physician suggesting that if Ebola cases were found, “doctors would run away” was unfortunate but rooted in reality. Africa's health care brain drain has more to do with the lack of resources to adequately care for the sick than remuneration. He should probably have said something like “If we do not receive the necessary protective equipment and supplies to treat Ebola patients, we will not be able to care for them, because we may die doing so.” That is the whole truth as we have seen in the 3 countries at the epicenter of the epidemic and in Spain and the US where the disease has been transported.
Medicine is indeed a calling, an art and a science and physicians give of themselves in many ways even in normal times but if the government fails to identify the health of its citizens as a priority, whole nations are endangered. The EVD epidemic is a security issue and the ability of the necessary health, defence, education and finance systems to co-ordinate effectively, anticipate and evaluate the risks ahead of active cases, will determine how we respond, should a case be diagnosed in Ghana.
There are many aspects of the culture of business in Ghana which do not lend themselves well to responding effectively to an epidemic of this nature. The proverbial “wait” when a problem arises, has no place in the Ebola response protocol. Immediate action on suspicion of a case is the first element of an effective response. A clear locus of authority is also necessary. Will district health units be able to isolate patients or will this happen only at regional hospitals? Will there be more than the 3 proposed isolation centers? Will the army be deployed to quickly erect temporary field hospitals? Do we have enough Personal Protective Equipment (PPEs) on hand at all response sites? Have healthcare workers at all levels participated in drills or simulations on both the proper use of PPEs and on what the path of communication should be in the event of an active case?
The importance of adhering strictly, without exceptions to an agreed upon protocol both for patient care and communication within the health care system is the bedrock of safety for everyone. Above all, truthful, ethical and professional conduct will guarantee public safety. The general public needs clear messages on the role that everyday hygiene such as proper hand washing, can contribute to public safety. In Ghana, the present cholera epidemic is a testament to our poor level of basic public sanitation. This promotes poor public behavior in the area of hygiene and increases the risk of poor outcomes for all. The need to be truthful during contact tracing needs to be emphasized in public health messages for the collective good. Both health care professionals and the public need to be altruistic, in going above and beyond the call of duty and demonstrating significant civic responsibility to keep the country safe. Public safety rests mostly on education and human behavior above all else.
Wherever failures have occurred in other countries, they have had to do with non-adherence to protocols, unethical professional conduct and poor communication between components of the multi-disciplinary response team. The success of any system designed for any purpose rests on decisions made by the people operating within that system. Nigeria is being widely praised for its response to late Mr. Sawyer's arrival with the disease in July. Early decisive action by late Dr. Adadevoh set the tone for the national response, saving many lives. Even though ethical failures led to another locus of the disease in Port Harcourt, adherence to basic public health principles have kept Nigeria safe. The world waits and watches as Dallas, TX and now possibly Boston, MA struggle to meet the gold standard set by Lagos and Port Harcourt for a public health response during the EVD global emergency. There are lessons for every country, big and small because EVD has no respect for man-made borders.
We must use the time we have had so far, to prepare effectively for the real possibility of EVD and educate the public with accurate information and the necessary behavioral steps to take if a case should present itself in any community within our borders.
Prof. T. P. Manus Ulzen is Professor of Psychiatry and Behavioral Medicine, CCHS, University of Alabama, Tuscaloosa, AL and author of “Java Hill: An African Journey” – A historiography of Ghana.
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