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Partnerships for Prevention & Care Africa Health Conference
Strengthening Partnerships between Africa's Health Communities and International Health Care

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Creating Innovative, Responsive Health Systems
Creating Innovative, Responsive Health System
Applying the lessons from Ebola in the struggle against antibiotic-resistant epidemics. By Garance Upham, Safe Observer International.
"My main task in Guinea was to head several teams of grave diggers to bury Ebola victims who are more contagious when they are dead. The problems are many; people don't trust their government, the social fabric is coming apart, and an health system very different for urban and rural populations, and for rich and poor. The Ebola crisis brings these problems to the fore." Elhadj As Sy, General Secretary, Federation of the Red Cross and Red Crescent Societies.

The Ebola Outbreak
Estimates of 21,000 cases and 8,000 deaths from Ebola in Guinea, Liberia, and Sierra Leone, have led to many conclusions. However, the good news is that the Center for Disease Control (CDC) Bulletin epidemiologists' mathematical model predicting that Ebola could reach 1.4 million cases by the end of January, 2015, and the World Health Organization's (WHO) forecast of 10,000 new cases weekly were both proven wrong. As of January 2015, there are only a dozen new cases of Ebola appearing each week, and the trend is falling. Less encouraging is that the health systems in the three affected West African nations have further deteriorated. Health professionals are insufficient and overwhelmed giving serious cause for concern if Ebola or another epidemic were to return.

As is often the case during an epidemic, people with ailments other than Ebola have died or are suffering unduly, unable to reach healthcare systems which are burdened by Ebola under worsening social and economic conditions.

WHO's future
The crucial question about the WHO's global responsibility might now be taken more seriously along with the decision to build strong health systems. WHO's 34-member-Executive Board (EB) plans to hold an all-day Special Session on Ebola on January 25, 2015. It will be only the third time in the organization's 60-year history that the EB has held a 'Special Session'. High-level representatives will be in attendance, and ground-breaking decisions on the future of disease management will be made and issues surrounding the WHO's operational capacities and global initiative.

Military-like Preparedness
According to Laurie Garrett, Council on Foreign Relations Health Expert, China was able to contain the Severe Acute Respiratory Syndrome (SARS) epidemic within two months by building a first class hospital inside 10 days and repeating the pattern in every region with the disease. Check-points for fever and quarantines were also set up. This appears a good way forward for epidemics in Africa, but would be difficult to implement for many reasons, including lack of finance and skills capacity.

In the wake of the first Macroeconomic and Health Summit at Geneva in 2003, former WHO Director General (DG) Dr. Lee Jong-wook, said that he advised China to learn from SARS and rebuild public health structures to enable the building of a strong public health system to control epidemics. He also said that it was unwise of macroeconomic institutions to force entrenchment of health personnel in Africa, because vertical disease programs cannot work without solid horizontal foundations, with strong and well-staffed health systems.

Macroeconomic institutions still reason that poor countries could manage epidemics with outside, case-by-case funding and without public health systems. But Dr. Margaret Chan, WHO's current DG, says that it is doubtful if Official Development Assistance (ODA) and private philanthropy alone is enough to achieve this, especially in the 'post-antibiotic era'.

If African healthcare systems were 'amplifiers' of Ebola, it is because they are weak, and in some countries barely existent. Both national authorities and macroeconomic institutions have neglected the need for good public health. Poor levels of public health, weak infection control, and insanitary environments could result in major pandemics.

Beyond Ebola: threat of civil unrest
In addition to Ebola, a food crisis is growing in the three Ebola-hit countries, and destabilization has jeopardized industrial production in a region where the threat of terror from Boko Haram looms. In Guinea, the Ministry of Health explained how they thought the epidemic had been brought under control and considered closing treatment centers, only for Ebola contact cases to escape leading to new outbreaks and hunger through loss of employment. It is a situation from which political instability could arise.

Dr. Remco Van de Pas, of the Antwerp Tropical Medicine Institute who is carrying out Ebola research in Guinea, reported his shock at the lack of healthcare facilities in the disease's epicenters, and points to the link with palm oil productions, where workers come into contact with contagious animals, further adding to the risk.

A major problem is the tendency to think that Ebola in another country is not one's concern. In the wake of Ebola, large epidemics of antibiotic-resistant bacterial infections are growing and it is dangerous to think that problems in Africa are not problems for the US or Europe.

When he discovered the 'NDM-1' gene, which confers resistance to the latest class of antibiotics, in the New Delhi water system, Dr. Timothy Walsh rang alarm bells and called for investment banks to pay attention to the need for safe water systems in India. Since his declaration, Dame Sally Davies, England's Chief Medial Office at the WHO stated that NDM-1 had travelled to 18 other countries in 13 months. She declared that antimicrobial resistance is as urgent a matter as climate change.

We have entered the "Post-Antibiotic Era" Margaret Chan stated at the joint WHO-WTO-WIPO meeting in 2013. Responses to Ebola and the threat of antibiotic-resistant bacterial diseases, notably the imminent threat of enteric diseases, are similar in many ways. They all demand strong, clean, universal healthcare systems with clean water, and sanitized infrastructure.

Infection Prevention and Control in Healthcare Systems
Lack of infection control has been the weak link in Ebola according to Dr. Babacar N'Doye. The CDC study, 'Cluster of Ebola Cases among Liberian and US Healthcare Workers in an Ebola Treatment Unit 2014', admitted to the 'amplification' of Ebola by unsafe healthcare settings. There is general agreement on the need for Infection Prevention and Control (IPC) but very little action.

Response to Ebola tends to lean too much on the side of medicines and too little on the preventative side. Africa's big problem is IPC. The rate of nosocomial (disease care) infections is far too high and efforts should be made in this decade for better infection control. A person with flu comes into a health system and catches pneumonia, another with pneumonia comes in and gets Ebola, or HIV. This is unacceptable according to Dr. Abdulsalami Nasidi, Project Director, CDC Nigeria.

In the study 'Lessons from nosocomial viral hemorrhagic fever outbreaks', Dr. Susan Fisher-Hoch arrived at a similar conclusion. Poor people, she said, are uneducated, not stupid: even in remote communities they quickly grasp that the hospital are where people become infected with VHFs, so they shun them and hide the sick from medical personnel. This is a major reason why case finding can prove difficult. With the knowledge of these practices and consequences of poor practices in Africa, and some parts of Asia, she concluded that transmission of blood-borne viruses in medical facilities is probably common within the endemic care of hemorrhagic fever viruses.

Hope for an Ebola-free Africa today rests with the general public in West African communities who are mounting a great effort to contain Ebola and the medical staff who deserve our highest regards for their determination and courage.

From Ebola to antibiotic-resistant enteric diseases
Very advanced and very old technologies and methods need to be used for comprehensive IPC which is returning as a priority in the Post-Antibiotic Era. Dr. Precious Matsoso, Director, South African Health Services speaking at the Norwegian Institute of Public Health meeting last year, says that in order to prevent the spread of antibiotic-resistant infections in health systems, we need to place emphasis on IPC globally, because it is central to Health as a Human Right.

Members of other delegations from Africa at the same meeting firmly believed that an Africa-wide effort is long-overdue to fight infection control. Some countries were keen to undertake such an initiative.

Strong health systems with adequate resources
Health personnel need to be trained rapidly by the hundreds of thousands and be provided with decent wages.

Much talk abounds about the development of treatments and vaccines for Ebola, with multimillion dollar promises and special protection sets. Yet, there is insufficient attention to the reinforcement of health systems and how and what types are required. It is because of the weaknesses of these systems in Liberia, Sierra Leone, and Guinea that has given rise to the Ebola crisis according to Dr. Marie-Paule Kieny, WHO's Assistant DG (for Health Systems and Innovations), and that there is a need for emphasis on strong health systems and infection prevention if collapses of health systems are to be averted, and the Millennium Development Goals achieved.

Going Beyond
Africa could leapfrog into a new era of healthcare systems if required resources are put in place. Mobile health delivery systems which can access patients in remote areas; mobile surgery, laboratories, and diagnostics and procedures such as endoscopies at a distance should become an integral part of African health systems. Robotics, mobile health delivery systems and the internet are a vital part for this to be achieved.

Healthcare systems characterized by mobility should become the norm. There is a real need to create blueprints with contribution from public representatives, innovation companies, engineers, universities, and field-based NGOs. Such new systems would combine primary community-based care with very advanced mobile technologies. It could be built from the bottom up with advanced technologies down? This is feasible, is in everyone's interest, and offers the best protection in line with a well-resourced WHO.

Garance Upham is an economist with 30 years' experience in public health, HIV, TB and infection control. She is the President of Safe Observer International and a founding member of the World Alliance Against Antibiotic Resistance (WAAAR) and "Patients for Patient Safety", a branch of the World Health Organization Patient Safety Program (2004 – Jan, 2014). The views expressed above are entirely her own and have not been reviewed by the NGOs mentioned.

What is the current deployment behind international aid?
- 3000 US soldiers are building Ebola isolation treatment centers, mostly in Liberia.
- 3000 medical staff have been deployed by Médecins sans Frontières (MSF) in Guinea, Liberia, and Sierra Leone.
- 600 medical staff have been pledged by Nigeria.
- About 250 medical staff are committed by Cuba as are smaller numbers from other countries.

Key areas:
- Infection control, equipment and supplies, and training.
- Water and sanitation, key infrastructure for cities, and toilet facilities everywhere (including recycling contaminated industrial food production producing waste and pharmaceutical waste as relevant).
- Development and use of robotics.
- Building advanced mobile health delivery systems equipped with modern technologies.
- Recruiting and training health care staff by the hundreds of thousands into a modern delivery system as fast as possible.
- Enlisting communities with the proven concept of Patients for Patient Safety and patient engagement in health care.

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