The Ebola Outbreak, Fragile Health Systems, and Quality as a Cure

  • JAMA
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In September 2014, the United Nations Security Council unanimously approved a resolution establishing the UN Mission for Ebola Emergency Response (UNMEER) with 134 cosponsors—the most support for any resolution since the founding of the United Nations in 1946. This commitment, however, comes many months into an outbreak that has already become one of the most devastating health crises of the 21st century. And the need is immense: the World Health Organization (WHO) now reports more than 5300 infections and 2600 deaths across Guinea, Liberia, and Sierra Leone,1 with broad consensus that the true burden of disease is far greater.
Yet if the Ebola virus surfaced in Boston or Toronto, there is little doubt that their health systems, despite shortcomings, could effectively contain and then eliminate the disease with far lower case-fatality rates than those reported now in West Africa. Why the disparity when there is no proven drug or vaccine available? The answer lies not with the virus, but in the collective failure to ensure the availability of adequate health care staff, resources, and systems required for the delivery of high-quality health care services. The Ebola epidemic has placed this failure into stark relief, exposing the pathology of chronic neglect amid broad global inequalities.
Rid and Emanuel2 made a compelling ethical case for action, and Gostin and colleagues3 urged a sub stantially accelerated international response to halt this Ebola outbreak. However, for that response to be effective and sustainable, it needs to be thoughtfully crafted—not only to provide critical aid in the short term, but also to invest in creating systems that provide enduring security.

The scarcity of health care workers in western Africaposes a serious challenge. Even before the outbreak,Liberia’s 4.3 million people were served by just 51physicians2—fewer than many clinical units in a typicalmajor US teaching hospital. Many more physicians areneeded, but focusing on physicians will not be enough.Successful integration of prevention and treatment efforts requires a comprehensive strategy, including community health workers, who can encourage sick patients to come to health care institutions, and nurses,who provide lifesaving supportive care, such as intravenous rehydration and electrolyte management, in an environment that is safe for both practitioners andpatients.4
With patients increasingly turning their frustration toward health care workers, an essential component of any strategy must include ensuring and insome cases restoring trust. A key to this goal should beto recruit and train local workers, many of whom will befrom the most affected communities. Survivors, likel yimmune, can play a role in this regard and in communicating the importance not only of isolation but also of earlydiagnosis.

Health Care Resources
The Ebola epidemic is a battle of basic medical care,and future epidemics in these and other countrieswith poorly developed health care systems are likelyto require similar services. While experimental therapeutics have garnered significant attention, vaccinesor monoclonal antibodies that have yet to enterclinical trials are no panacea for the current outbreak.However, appropriate supportive carecan help reduce many unnecessarydeaths.5Currently, the lack of basichealth care resources—such as protective gloves and gowns, intravenous fluids, and straightforward protocols andguidelines—has limited front-linehealth workers who risk their lives tocare for those affected with Ebola. Thehealth systems of high- and middle-income countriesare awash in basic health care materials and guidelines, and there is no good reason these fundamentalhealth care resources cannot be provided to front-lineworkers in West Africa to save lives.
Lacking the necessary healthcare resources, the current approach is to warehouse patients in depleted hospitals or public buildings repurposed as isolation centers. Many affected patients who arrive at such facilitiesin Liberia receive no intravenous rehydration and extremely limited monitoring of hematocrit and liver andkidney function. Other affected patients wait, and maydie, outside the closed gates of overwhelmed facilities.Is it any wonder, then, that so many individuals are losing confidence in the ability of their health systems tocare for them?

In 1967, an outbreak of Marburg hemorrhagic fever—adisease closely related to Ebola—occurred in Germanyand Yugoslavia. At the time, almost nothing was knownabout the virus, and the health systems of both countries werestill recovering from the destruction of World War II. Despite thesechallenges, the case-fatality rate associated with the outbreak was23%.6Nearly half a century later, the case-fatality rate for Ebolaacross West Africa is 2- to 3-fold higher. Is this all because of a lackof health care staff and resources? It is more than that. Fundamentally, this high mortality is related to lack of adequate systems in whichthe health care staff and resources can be effectively deployed.
The problems of inadequate systems reach far beyond WestAfrica. Despite a recent global movement to expand access to healthcare, the Ebola outbreak is a cogent reminder to carefully consider2 simple questions: What kind of care are people going to access? Isthat care worth having, and can it be made better? A focus on accountability, especially for quality, is critical. Over the past decade,many countries have committed to spend more money on healthcare, but spending more is not enough. There has been little effortto understand the quality of care that such spending buys and howthat care might be made better. While some might see tradeoffsbetween interventions to stem the Ebola epidemic and investments in health systems for the long run, these 2 notions can coexist. Indeed, building systems that provide high-quality care in thiscrisis can be used to provide effective disease management andchronic care once the epidemic has subsided.
Quality is often thought to be as nebulous but involves 3 main components: care that is safe, effective, and delivered in ways that respect the dignity of individuals in the context of their own “local moral worlds.”7An insufficient focus on quality bymany global health initiatives has, at times, created distrust—andthat distrust fuels epidemics like Ebola. Some have suggestedthat quality cannot be a priority when countries are poor andunderinvesting in health care. However, it is precisely whenresources are insufficient that useful health care spendingbecomes even more critical.
Evidence from settings such as Rwanda suggests that safer, moreeffective, and more respectful care need not be more expensive.8
This has specific implications for the global response to the Ebolaepidemic. Ensuring that systems are built or rebuilt centered on basic principles of quality assessment and improvement is imperative. Moreover, this must be done in ways that build trust with thelocal communities by treating patients with dignity. When peoplereceive care that is unsafe or ineffective, or they are not treated withrespect, it is little surprise they avoid further care.9Preventing such“betrayals of trust” through a systematic focus on quality is crucial,for both the current epidemic and the next.10

Ebola represents a pressing global health crisis, but more are certain to follow. The outcomes of the next several months will revealthe capacity to forge effective partnerships across borders and disciplines, and the extent of the commitment to value all human livesequally. By responding to the crisis with a surge of stopgap solutions, it is possible (although unlikely) that such an approach couldeventually stem the epidemic and end the morbidity and mortalityfor this current outbreak. Alternatively, responding to Ebola with abroader approach that involves meaningful investments in the provision of health care staff, resources, and systems could succeed nowand help create sustainable models for the future. If the approachinvolves reengineering health systems around the patient, there remains an opportunity to bring lasting progress for those who needit most.