Why did it take an Ebola outbreak to realize the importance of health systems?

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Jason Nickerson
Jason Nickerson is an operational researcher who focuses on health systems in humanitarian emergencies and fragile states. He trained as a respiratory therapist and maintains a clinical practice in anesthesia in Ottawa, and completed a PhD in population health. Beyond health systems issues, Jason focuses on access to essential medicines, surgical care, and the treatment of respiratory diseases. Jason is a Clinical Scientist with the Bruyère Research Institute in Ottawa, Canada.

This post originally appeared on www.jasonnickerson.ca

I work in an area of research and practice that garners immense public interest when terrible things happen: wars, famines, disease outbreaks, natural disasters. There are far too many overlooked crises, and any opportunity to shed light on the needs of people affected by these events should be welcomed; But all of these events are incredibly complex, and there are no templates for how they are going to unfold. Regrettably, nuance often gives way to brevity in reporting and public discussions of these events, and the images that are presented are far too often simplistic representations of overly complex problems.

Take the current Ebola epidemic that is currently spreading across west Africa. As others have correctly pointed out, the current outbreak is yet another example of the failures of the global research and development architecture to prioritize the needs of low- and middle-income countries in drug and vaccine development. My colleague Steven Hoffman and co-author Julia Belluz write that:

Right now, more money goes into fighting baldness and erectile dysfunction than hemorrhagic fevers like dengue or Ebola

I certainly agree that global priorities are skewed for developing new drugs, and there is ample evidence that this is a train that has gone well off its rails. Furthermore, Hoffman and Belluz also note that healthcare spending in countries affected by Ebola is among the lowest in the world, a nod to the need for stronger health institutions. Other authors have also correctly pointed out the faults in the global research and development systems with regard to Ebola, and the ethical minefield that is the current landscape for testing the drugs in development. But, I disagree that the single biggest contributor to the spread of Ebola is the lack of new drugs; rather, I agree with Karen Grepin that:

Simply put, I think we are overestimating the “substantial” public health benefits and that they are not likely large enough to justify the relatively large fixed costs associated with developing any new medicine (which are at least a few billion a drug)

This statement should not be taken to mean that we should not be working to develop new treatments for Ebola; quite the contrary. Where I differ in my opinion is that I believe that the most effective treatment for Ebola likely does not lie in new drug development, but in establishing and maintaining well-functioning, accessible health systems in low-income countries.

The central features of health systems require strong leadership, drugs and technologies, health information, health human resources, service delivery, and mechanisms for financing all of the above. Within each of these, communicable disease control plays a strong role, whether it be through the establishment of an effective disease surveillance system, hospital-based infection control procedures, providing essential medical care, the handling of medical waste, or community-based education. Regrettably, health systems in most countries affected by Ebola are weak, and suffer longstanding shortages of health workers and other important resource constraints, in part due to low spending on the health system. Until this outbreak, few (if any) cases of Ebola had ever been treated in high-resource health systems where access to critical care medicine was possible, which limits our understanding of what proportion of the Ebola virus disease mortality can be attributed solely to the virus itself, and what proportion is attributable to a lack of comprehensive medical care.

The emergence of the ZMapp antibodies for the treatment for Ebola has prompted a focus on the drug and development process for rare and neglected tropical diseases. This scrutiny should be welcomed, as should the public attention that this often byzantine process is getting. At the same time, there is a need to bring the broader issue of weak health systems to light through more robust reporting than pictures of small hospitals or delapidated clinics. The Ebola outbreak is a necessary opportunity to report on the inequalities in access to healthcare around the world as a result of weak institutions and inequitable policies that can decimate or stall health systems, and to reflect on the interconnectedness of global health. For anyone from a high-income country seeking a justification for why international development and building of stronger institutions in low-income countries ought to be of concern to them, here you go.

But this begs the question of why it has taken this long for the world to realize the importance of strong health systems. By many accounts, health facilities in all of the affected countries are struggling, with some public services having collapsed, with little access to essential supplies such as gloves. Fundamentally, this collapse and the challenges in containing the spread of the virus is about weak health systems, and not solely the absence of a vaccine or treatment. As a thought experiment, consider the possibility that ZMapp was already shown to be effective, had regulatory approval, and was available at an affordable cost for low-income markets: would these health systems be able to distribute and administer it effectively?

We need better evidence and interventions to guide the treatment of Ebola patients. This likely includes the development of new drugs, but it unquestionably includes stronger health systems. We simply can not focus only on the interventions without acknowledging the systems that must be in place to guide them.