Journal of Public Health Policy – Volume 36, Issue 1 (February 2015)

Journal of Public Health Policy
Volume 36, Issue 1 (February 2015)

Lessons from the public health response to Ebola
Journal of Public Health Policy (2015) 36, 1–3. doi:10.1057/jphp.2014.51; published online 11 December 2014
Anthony Robbins Co-Editor and Ruth Berkelman Member, JPHP Editorial Board

Anything we say today about Ebola is likely to seem dated by the time it is posted online in weeks or appears in print in months. So we look back, to consider missed opportunities, and into the unknown future to avoid worldwide ‘surprise’ again.

How could the public health world have been so ill prepared for this year’s Ebola virus disease outbreaks in Guinea, Sierra Leone, and Liberia? Although these outbreaks have grabbed the whole world’s attention, we can only describe the response as ‘scrambling to catch-up’.

The hemorrhagic fever caused by the Ebola virus was first described in 1976 in what was then Zaire. There have been additional small outbreaks in sub-Saharan Africa. Uganda and other countries controlled outbreaks, but not without resources and an organized response.

It looks like not everyone was asleep. Lab researchers did what they are good at, and the molecular biology of the Ebola virus is rather well described and advanced in understanding.1 Promising candidate vaccines and antiviral therapies have been developed but they have not progressed to licensure.2, 3 Was testing and licensure left largely to an industry that saw no profit selling an Ebola vaccine to the world’s poorest countries?

Research in the field has been less robust than in the laboratory. Months into the epidemic, there still seemed to be confusion about how the virus was spread. The question of whether some people are more likely to spread the disease than others, so-called ‘super-spreaders’, has lingered. More applied research is surely needed. We learned recently that management of waste disposal – from bodily fluids to personal protective equipment and mattresses – remains inadequately studied. Does everything need to be buried or burned? What works efficiently?

Perhaps it is unfair to expect the world’s major research institutes – the Institut Pasteur, the Karolinska, or the US National Institutes of Health – to put more researchers in the field. But, is there an explanation for the World Health Organization’s (WHO) failure to organize assistance for countries with inadequate resources; to help them prepare for Ebola and other infectious disorders? In the case of Ebola, WHO knew that with preparation and resources, the disease had, in the past, been successfully contained. New global interest in noncommunicable diseases4 must not absolve public health officials for their failure to prepare for infectious disease outbreaks.

Médecins Sans Frontières (MSF) has sent doctors and nurses into the field to help where resources are scarce. They also conduct field research. MSF’s applied research, organized by Epicentre MSF in Paris. Epicentre studies field operations of MSF to learn what works and what does not. They learn what knowledge, strategies, and resources are needed, and how to provide care and protection. MSF developed guidance for the use of personal protective equipment.

In June 2014 MSF was outspoken, calling for a robust response and stating that the outbreak was ‘out of control’ and that they had reached their limit in being able to care for patients with Ebola virus disease in 60 locations across Liberia, Guinea, and Sierra Leone. Was anyone listening? It took 6 weeks until WHO deemed Ebola a ‘Public Health Emergency of International Concern’ and called for a coordinated international response. Countries facing occasional imported cases were in a panic about how to respond at home, while thousands of people in West Africa became infected with Ebola.

Our list of ‘pending’ infectious challenges is far from exhaustive, but it confirms that there are many threats out there. Influenza has received some attention. The coronaviruses – Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome – and the paramyxoviruses – Nipah virus – remain serious threats to health globally.5, 6 Current efforts to control multi-drug resistant tuberculosis are dangerously ‘out of step’ with this grave peril.7, 8 Mosquito control needs to be reinforced so that Chikungunya and Dengue can be prevented. We must look ahead at the full range of threats.

Can we learn from Ebola? We must make sure that lab research, plus applied research and field studies, and the resources for care and prevention will be developed now so that we will not be ‘surprised’ in the future as we seem to have been with Ebola.

Commentary: Ebola: The haves and the have-nots
Adolfo Martínez Palomoa
aCenter for Advanced Studies, Molecular Pathogenesis, Avenida IPN 2508, Mexico City (D.F.) Journal of Public Health Policy (2015) 36, 4–6. doi:10.1057/jphp.2014.50; published online 27 November 2014
The Ebola epidemic exemplifies the importance of social determinants of health: poverty and illiteracy, among others.

Viewpoint: The role of sanitation in malnutrition – A science and policy controversy in India
Madhumita Dobea
aDepartment of Health Promotion & Education, All India Institute of Hygiene & Public Health, 110, Chittaranjan Avenue, West Bengal, Kolkata, 700073, India.
Over the past decade, India’s economic growth has been remarkable – yet almost half of India’s children under 5 remain stunted. The National Food Security Bill is the country’s response to this critical situation. Studies reveal that Indian children are chronically undernourished, not only because of lack of food but also because of recurring gastrointestinal infections. The stunting problem revolves more around lack of sanitation than food insecurity. Despite acknowledging that malnutrition is ‘complex and multidimensional’, government action has consisted largely of nutritional interventions and subsidized food. Although improvements in sanitation would be the most effective way to reduce excessively high levels of chronic undernutrition and stunting, a review of policy formulation and implementation reveals deficits and disconnects with available scientific evidence. It is time to change these mistaken assumptions and focus on improving access and use of safe sanitation facilities to achieve India’s nutritional goals.