Friday, October 10, 2014

Ebola, our short sighted self-interest and the crisis of ad hoc

By Isabel Manuela Estrada Portales

To live now, as we believe human beings should live, in defiance of all that’s bad around us, is in itself a marvelous victory.
Howard Zinn

I have questions about Ebola. Questions that rub me the wrong way. Questions people who work in this field should have had asked and answered long ago.
From where I am standing, the Ebola crisis can be summed up as the surprising discovery of health systems’ dearth. We hear once and again that the epidemic caught us all by surprise. It would be laughable, in other circumstances.
Richard Brennan, director of the WHO's Department of Emergency Risk Management and Humanitarian Response, said in a Washington Post’s article:

In retrospect, we could have responded faster. Some of the criticism is appropriate. While some of the criticism we accept, I think we also have to get things in perspective that this outbreak has a dynamic that's unlike everything we've ever seen before and, I think, has caught everyone unawares.

What were the major surprises?  

People are more mobile than during previous outbreaks of Ebola. You know how that is. We were all sleeping and the XXI century sneaked up on us. Yes, of course, even in Africa everyone has become more mobile. Moreover, it has been quite apparent that people have increasingly moved to increasingly crowded urban areas with appalling infrastructure and living conditions that wouldn’t be out of place in a Dante’s hell circle. If I were a virus, I would certainly be living there.

What we, as shorthand, call hospitals and health centers in the affected countries – and others - are not equipped to handle a contagion of the common cold, let alone a lethal epidemic. It is wrong to see the Ebola disaster as a single event, unrelated to anything else. As if, were not for this stubborn virus, people in the affected African countries would be having a healthful picnic every day. As we all know, the situation in those countries is dire. The health situation is direr. And, Ebola becomes an untamable nightmare because the health system infrastructure would have trouble dealing with a mild flu epidemic. What part of this is news not only to us, mere mortals, but to the organizations that work on this is hard for me to fathom.

There was not enough medical personnel in those countries, and, in particular, those areas. As I was saying…  
But after six trips to Africa during the epidemic, he [Keiji Fukuda, former CDC official and not WHO’s assistant director-general for health security] has seen a more profound truth: Global organizations can provide epidemiologists and laboratory help, but what these resource-poor countries really need are front-line doctors and nurses, and basic resources. In Africa, patients told him, “We don’t have enough food.”(Washington Post)

Historically wretched and exploited communities are suspicious of Western institutions and of their own ineffectual and, in some cases, corrupt and violent governments. This leads, of course, to the all so surprising scenario – covered ad nauseam by the media – of people “biting the generous hand” that comes to rescue them. The killing of aid and health workers pains me deeply. But, we need to understand what those aid workers may have seemed to people who have never seen them before, and who have seen their family members walk out of the house with a fever and come back as corpses. This is a tragedy in more ways than one. But it remains, essentially, our failure; and, mostly, their suffering. 

Some of this distrust became patent in the voices demanding: “give us the serum,” as they believed the West, once again, was hogging the lifesaving treatment, while Africans were left to die. We know that is not the case. We know the clinical trials were not even properly concluded yet. People, such as I, concerned with the unethical experimenting in communities of color or non-Western countries with lax protections for the research on human subjects, would have been up in arms in any other circumstance at the thought of, basically, testing this new medicine in desperate people. And yet, those voices in Africa were demanding it. The understanding – not to mention, the trust - of the whole situation was completely out of whack…and there is a history that leads to that.

The currently affected countries have burial customs that may lead to the easy spread of certain diseases. This is not new. The international organizations in these countries should have known this. Health education would have prepared communities to be receptive to the need to adjust customs in emergency circumstances.

Where is the foresight?

That is my overall question, actually. Where is the foresight of the people and the many organizations that are there to foresee? This is not even a failure of imagination, to use the tiresome phrase of the post 9-11 world. This is a failure of planning for the most obvious eventuality: that a disease that is exceedingly contagious can overrun an already exhausted healthcare system. Did we not see what cholera did to Haiti, despite having armies – even literally – of aid workers and organizations in situ after the earthquake?
The questions mount, though.

How are the billions invested in global health and development put to work? This question arose when the earthquake shook Haiti to its core, and the core was shaky at best. How come a country that had received so much money in aid for so long, and had such a network of NGOs on site offering technical assistance had such a lacking infrastructure that was completely devastated after the earthquake? Granted, few countries could deal with a catastrophe of such proportions, but Haiti showed it couldn’t confront it at the most basic level, given the paucity of its infrastructure, after billions on aid for poverty and AIDS relief.  

Are we still stuck in the mind frame of the single-disease pattern? Why are these countries so lacking in the primary care front that are unable to contain even the slow paced epidemic as it started? Now people are dying of other conditions that were supposedly more under control because the health systems cannot deal with a crisis and the usual grind at once.
Why all the money that is now going to contain – as best we can – an epidemic that is running circles around us was not put towards actually strengthening the health systems of those countries? Just with all the money spent in AIDS relief, how come we do not have a better-equipped healthcare system in those countries? The truth is that the per capita healthcare expenditure there is $30 per year.

If those countries had a decent healthcare infrastructure, there would be health education, so healthcare and aid workers would not be coming in for the first time when the bodies are on the streets, and people’s suspicions and fears are heightened.

Let’s acknowledge that we are going to help now for our own self-interest. Ok. Let’s work with that. We will end up spending the same or higher amount of money now; and we do not know how much we will need because the spread of the epidemic is hardly containable. So, exactly, what did we save by not putting the money up front?

In the words of someone much smarter:
There is nothing wrong with acknowledging that we act in the interest of other humans while at the same time protecting the interests of the United States. Perhaps it doesn’t matter why we care, as long as we do. But it is also worth remembering that every expert agrees that Ebola poses little danger to America. If we had sent that money at any other time, and put it to work improving the health-care systems in West Africa, it would no doubt have prevented the worst effects of this epidemic and saved many lives. It would have blunted the impact of other plagues, too—including fear, the most infectious of all. (The New Yorker)

I believe we should help countries in need because it is the right thing to do, but we don’t much care about the health and wellbeing of poor people right here in the Appalachian, so, what to expect about people a world over? Therefore, even if we just focus on our self-interest, and our fear of contagion, wouldn’t we have been better served by tackling this beforehand? It would have saved a lot of pain to peoples that can ill afford more hurt. It may even have afforded us the benefit of a cleaner conscience… 
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