Ebola epidemic reveals critical weaknesses in global public health system

In the year since the World Health Organization (WHO) was first notified of an outbreak of what proved to be Ebola virus disease in the west African country of Guinea, more than 24,000 cases have been reported and over 10,000 individuals have died - primarily in Guinea, Liberia and Sierra Leone. Moreover, countless non-Ebola deaths have occurred as a result of the closing of health systems in those countries, and an international aid effort has invested billions of dollars in control efforts.

In a paper published in the open-access journal PLOS Medicine, experts in global health from the Massachusetts General Hospital (MGH) Center for Global Health and the O'Neill Institute for National and Global Health Law at Georgetown University, write that, while the international response to the epidemic included unprecedented measures that appeared to be gaining control of the outbreak by the end of 2014, the past year has also revealed critical weaknesses in the global public health system.

"Had (the WHO and the United Nations) responded earlier and more effectively after the first signs of an uncharacteristic outbreak, it is likely that the number of lives lost, the impact on health infrastructure, and the magnitude of the eventual response could have been drastically diminished," the authors write. "It is incumbent upon the global public health community to identify gaps revealed during the early stages of the epidemic so that we improve our collective ability to detect and respond early to the inevitable next emergency disease."

Specific recommendations made by the authors - lead author Mark Siedner, MD, MPH, and Hilarie Cranmer, MD, MPH, MGH Center for Global Health; and Lawrence Gostin, JD, and John Kraemer, JD, MPH, O'Neill Institute - include the following:

• Greater attention to the specific capabilities of health systems in affected localities when determining the presence of a public health emergency.
• Adjustment of WHO criteria for public health emergencies of international concern to give greater weight to a country's need for international assistance, less to the potential for spread across borders, and the flexibility to tailor recommendations to the particular situation.
• Greater involvement of local authorities, organizations, public health and community leaders to develop culturally appropriate measures and maintain public trust.
• Providing sufficient resources - financial and personnel - to mount an adequate response, possibly through the establishment of a permanent global emergency fund and corps of health workers trained to respond to international crises.
• Supporting the development of health systems in sub-Saharan Africa and other low-income countries capable of providing both the routine services required to maintain a population's health and an adequate initial response to public health emergencies.

In their conclusion, the authors note that the delayed response to the early stages of the epidemic illustrates "not only the danger posed by disease outbreaks in states with weak health systems but also their widespread impact in an increasingly globalized world. . . . The power of global health law and global health institutions will remain seriously unrealized and deeply compromised if the Ebola epidemic does not spur fundamental reform."