You could ask Barbara anything…How did she respond?

By Kate Hawkins

A couple of weeks ago the Nossal Institute for Global Health set up a Reddit IAmA. Our Director Barbara was available to answer any questions that you had on health systems in post-conflict settings. So, what were you interested in? I’ve put together a selection of questions from the Internet and answers from Barbara to shine a light on some of the issues that were highlighted:

Q. How much should the USA worry about the Ebola virus? Does it have the potential to spread like in other parts of the world? (Asks: ScumBucket84, yes really)

A. I think the general American public has little to worry about. Undoubtedly there will be more cases arriving from West Africa, but I think the Dallas events have alerted other American hospitals to the pitfalls. Although the American health system has its problems – I believe the gentleman who died was sent from one hospital to another because he didn’t have health insurance – I’m sure as more cases emerge, protocols will be followed. Some health workers will be infected but they will receive excellent care and I doubt there will be deaths.

It will spread to other parts of the world equally easily, and it is those countries with weak health systems that have the most to worry about. In this context, it’s helpful that transport systems around Africa are not good. It’s easier to fly to Europe or the US from West Africa than to North, East or South Africa for example. This might protect the health systems in the immediate region to some extent.

Q. Considering the state of infrastructure in much of rural India and China is abysmal at best do you believe that introducing Ebola to either of those two regions will be as catastrophic as people say? (Asks: King_of_Carcosa, according to Wikipedia Carcosa is a fictional city. It was recently referenced in the popular American drama True Detectives. He is unlikely to be a genuine member of any royal family, although this is the Internet so you never know.)

A. It’s true that there are huge problems in India and China with their health systems, though both have been improving greatly recently and some states in India now have much more functional public systems. It’s useful to remember what happened with SARS in China. At first, the government was in denial, and this allowed the virus to take hold. But when the problem was recognised, the Minister of Health was sacked, the system geared up to tackle prevention and treatment and the virus was eliminated. In the end, the government in China is very strong and can do things when it wants to.

The situation in India is a bit different, State governments are more powerful than the national one in relation to health matters which would make things more complicated. But there are huge resources in India – health professionals, disease control experts, capacities to develop isolation facilities and to protect health workers which would enable a response once the situation is taken seriously. The problem would be identifying cases in remote areas and getting them to where help can be found.

Overall, I think the two countries would be able to control things before they got catastrophic.

Q. In a perfect world – assuming everything was to run perfectly! – how should emergency responses to health crises function? And how does Australia/US/global response to the current ebola crisis measure up to that? (Asks scalesthefish)

A. There are many versions of perfect, but what we need is ‘good enough’.

Ebola is not the most difficult of diseases to manage. The worst viruses (like HIV/AIDS) cause people to become infectious long before they are symptomatic. In Ebola, symptoms and infectivity develop about the same time, which makes it much easier to control.

What’s needed is that cases of Ebola are identified, isolated, treated and cared for by health workers who are equipped and trained to protect themselves from the infection. In a ‘good enough’ health system, the requirements of that will all be in place.

If Ebola appears in a ‘good enough’ health system, the international community doesn’t have to get involved, the health system will cope. Of course, the outbreak we’re dealing with emerged in three not good enough health systems and international support was needed.

WHO is the key organisation that provides that support and it has done so successfully on multiple previous occasions. It has helped local health workers set up treatment centres and ensured protective equipment is available. It has isolated communities affected, treated all cases until the last one runs its course and then packed up – that’s good enough, if not perfect.

What went wrong this time is that the WHO response was slow and weak as a leaked report over the weekend admits. This seems to have resulted from a WHO official in the African regional office seeking to downplay the outbreak to avoid economic damage and relates to larger problems of the functioning of that office, and the overall governance of WHO in which regional offices are fully autonomous. Erosion of funding to WHO over a long period is also a factor.

The virus also hit a population in a more densely settled area than it has before, and across 3 national boundaries, making co-ordination more difficult.

What US, Australian and other international governments need to do is 3 things:

  1. Get the current outbreak under control – it is far from that. This is now going to require a massive effort of resources, troops and international health staff. Apparently this is still not happening.
  2. Recognise that this is not a one-off. If future similar events are to be avoided, there needs to be international investment in strengthening health systems – something hugely neglected despite unprecedented levels of health related aid, because that has been narrowly targeted on individual diseases rather than system strengthening.
  3. Strengthen the UN system which has been allowed to lose potency because of its governability difficulties. It needs reform but it also needs to be maintained with adequate levels of funding if global threats – health among them – are to be effectively managed.

Q. How can a common man help out in such cases of crisis? (Asks: ataturk1993)

A. As far as emergency response is concerned, I don’t think this requires a large scale participatory effort. What ordinary folks can do is become active citizens in debate on global health. Most people only wake up to major issues when there’s a crisis. Those issues are daily realities for populations in poor countries in Africa and Asia, and if there were more consistent and considered concern from the general populations of richer countries, funds that originate from our taxes might be better used. Also, we can all contribute to keeping the current crisis in proportion – keep images of the Walking Dead at bay and encourage others to do the same.

Q. How does society react to and contend with Ebola where it actually a problem? The meltdown, freakout panic I’ve seen here over two or three cases makes me shudder to think how this country would handle a genuine crisis, health or otherwise. (Asks: CMarlowe)

A. I have a research partnership with a team based in Freetown, Sierra Leone. Their office is in the Connaught Hospital where Ebola cases are bring brought. I met one of the team in the UK a few weeks ago and she describes a society in which people are staying indoors as much as possible, no longer embracing or even shaking hands, trying to keep their circles of contact as small as possible. People are very scared and it sounds miserable. But in Sierra Leone, people have weathered many crises and they are robust. I doubt we would manage so stoically here, but I also don’t see mass disturbance of any kind because any mass activity would expose people to risk they would best protect themselves by avoiding.

Q. Do you think that health systems in fragile states and post-conflict settings get the attention that they deserve from donors and international agencies? If not, why not? (Asks: Kate Hawkins, for it is I. Rather naively using by own full name. I wish I had been more imaginative now.)

A. No they don’t. The main reason is that international agencies are in a bind. They’re expected to show that their aid is effective, but also that it goes to the places where it’s most needed. It’s most needed in fragile and conflict affected states but those are usually the most difficult to achieve results in. Without a good understanding, funders may not have the patience to allow things time to be effective in these kinds of states.

You can read the whole discussion by clicking on this link…

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