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September 29, 2014

African nations need tools to fight Ebola

Paul Farmer and Joia Mukherjee

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As doctors with long experience in fighting epidemic diseases, we have just returned from the front lines of the Ebola crisis in Liberia and are dismayed by the scale of the outbreak. But we are also optimistic.

After months in which Ebola seemed to be winning a battle against the citizens and health-care providers in Liberia, Sierra Leone, and Guinea, the world's leaders are unleashing the first ambitious efforts to fight back.

Last week, the United Nations declared an all-out war against Ebola, saying that "we cannot afford delays; the penalty for inaction is high." It passed a resolution calling for every member state to accelerate its response to the outbreak and to lift travel restrictions on the most affected countries; with 134 votes, the resolution garnered more support than any previous one.

Meanwhile, the United States is dispatching 3,000 soldiers as well as medical and public health troops to Liberia with an unprecedented mission: Wage war on Ebola by helping the battered Liberian public-health and medical community, including setting up treatment units in each of Liberia's 15 counties. U.S. President Barack Obama called for a "campaign for community care."

Community care could, when coupled with infection control, stop the epidemic. Of course, the region needs more treatment units for the sort of care that can only be provided in an in-patient setting. And hospital care can be improved long-term only by training and equipping Sierra Leoneans and Liberians: the staff and the "stuff'' required to save lives. But it also needs to provide the tools that smaller clinics and front-line health workers need to fight the virus in their neighbourhoods and villages.

The health systems in West Africa, which were already weak before the outbreak, are now decimated by it. A group of physicians from Partners in Health, a Boston-based medical non-profit affiliated with Harvard Medical School and its teaching hospitals, along with Last Mile Health and the Wellbody Alliance, two community-based health care delivery organizations in rural Liberia and Sierra Leone, saw these weakened systems first-hand in both countries. It is clear that the region lacks the "staff, stuff, space and systems'' required to stop Ebola.

Meanwhile, the outbreak is spreading. More than half of the reported 5,843 cases were logged in the past three weeks alone. In addition, many other cases are either not diagnosed or reported. On Tuesday, the U.S. Centers for Disease Control and Prevention reported that Liberia and Sierra Leone could register up to 550,000 cases by Jan. 20 unless there are significant and immediate efforts to accelerate the delivery of services across the region. These services include efforts to stop the transmission of Ebola within households, clinics and hospitals.

The irony of Ebola is that it is those who provide care who are most at risk of falling ill: not only nurses and doctors, but mothers and sisters and caregivers in general. It's no accident that up to 75 per cent of those afflicted with Ebola are women.

This is why strict levels of infection control need to include what's called PPE — personal protective equipment, which includes clothing, gloves, and goggles. This equipment and other protective tools have been largely absent from not only homes and villages but also public clinics and hospitals. This is one of the reasons why so many facilities were shuttered; they became sites of transmission and death rather than of care that might have stopped an epidemic.

Some hospitals have already lost a majority of their nurses and doctors to Ebola — in a region with far too few of them to begin with. This means that patients who are sick with more common afflictions, including malaria, typhoid and pneumonia, are dying in greater numbers than prior to the explosion of Ebola. More women are dying in childbirth. Ebola worsens old problems as it causes new ones, including a burgeoning epidemic of fear.

So is this tension between prevention and care unresolvable? Must all patients thought to have Ebola be shut up in their homes or removed to isolation units without the requisite staff, stuff, space, and systems? Absolutely not.

Years ago, when Partners in Health first engaged in fighting another deadly epidemic — drug-resistant tuberculosis — our colleague Jim Yong Kim (now president of the World Bank) and others referred to it as "Ebola with wings." We learned then, in settings from the slums of Lima to the mountains of Lesotho, that community-based care, delivered in large part by community health workers, was not only safer than facility-based care, it was also more effective. This was true when caregivers had the staff, stuff, space and systems required to prevent, diagnose, and treat tuberculosis with the tools of the trade. "Community-based care'' does not mean "community-based no care'': that, we're providing already, and on a large scale.

The countries fighting Ebola need to have the tools to treat patients closer to their homes and communities. They also need more Ebola treatment units, and we were encouraged last week to see our Liberian colleagues put the finishing touches on a large and well-laid out unit in Monrovia. On Sunday, there was a large crowd in front of the visitors' entrance; a Liberian priest was about to bless the building, as a Ugandan doctor working with the World Health Organization looked out over the crowd.

"They're volunteers from across the country," she explained to us. "They're being trained to help."

Some were nurses, but most were not medical professionals. They will be before this war on Ebola is over. They are at the front line of building stronger community-based health systems to stop this epidemic.

Paul Farmer is a professor at Harvard University, special adviser to the UN secretary general on community-based medicine, and co-founder of Partners in Health. Joia Mukherjee is chief medical officer of Partners in Health and associate professor at Harvard Medical School. Both are infectious disease physicians in Boston. (The Boston Globe)

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