H5N1

The Ebola effect: The economic impacts of a public health crisis

Via ReliefWeb, Mercy Corps has published The Ebola Effect: The economic impacts of a public health crisis. Click or tap through to download the full report as a PDF. The overview:

The Democratic Republic of the Congo (DRC) is currently battling the second worst ever outbreak of Ebola, in the conflict-affected and densely populated provinces of North Kivu and Ituri. As of 4 August 2019, more than 2,763 people have been infected, and 1,849 people have died from Ebola virus disease (EVD). Twenty-six health zones in the country have registered cases, with almost 6,145,000 people in these health zones affected - more than half of the population in North Kivu and Ituri provinces. 

Active conflict and insecurity make this epidemic one of the most complex ever faced, with the disease anchored in areas with decades of endemic mistrust and violence. 

Mercy Corps has been a key partner in the DRC’s Ebola response since 14 August 2018, responding with water, sanitation and hygiene, infection prevention control, and community engagement and mobilization, reaching almost 1,395,000 people. Mercy Corps’ experience of community mobilization and engagement is based on our response during the 2014-2016 Ebola epidemic in West Africa. Mercy Corps led a consortium of local and international partners in the largest community mobilization program in Liberia that reached more than 2.4 million people - half of the country's population, which ultimately helped to halt the spread of the disease in that country. 

Mercy Corps’ research during the West Africa Ebola Crisis from 2014-2016 proved that any response to the Ebola outbreak must seek to save lives as well as livelihoods. Border closures and any measures that would see international trade suspended should be avoided at all costs. 

This paper presents a brief summary of our learnings and experience from the West African epidemic on the economic impact of EVD outbreaks, and lays the foundation for future research into the DRC experience.  

During the 2014-2016 West Africa epidemic, Mercy Corps conducted two market studies in Liberia and Sierra Leone. These findings, in particular the Liberia market assessment, contributed to the re-opening of markets - a key gain for economic stability of the most vulnerable households in EVD affected areas. 

Mercy Corps’ research demonstrated that efforts to control Ebola can have severe, unintended consequences on already struggling local economies. In Liberia, where Mercy Corps’ analysis indicated that 66 percent of households reported a loss in income, dedicated efforts to share research findings were instrumental to the government’s decision to declare local marketplaces open after months of closures. 

In Sierra Leone, results from Mercy Corps’ assessment highlighted that negative economic impacts of the crisis were significantly larger in local areas that had heavy restrictions on movement compared to those with fewer restrictions.

Friday thoughts on the mobility of Ebola cases

Via Thomson Reuters: Ebola spread to new Congo area shows flawed response - aid workers. Excerpt and then a comment:

DAKAR, Aug 16 (Thomson Reuters Foundation) - Ebola's spread to a new part of Democratic Republic of Congo is a disturbing sign that health workers are failing to keep track of high-risk people on the move, aid agencies said on Friday.

A woman and her child were confirmed to be the first two Ebola cases in Congo's South Kivu province this week, after travelling more than 700 kilometres (430 miles) south from where they likely caught the disease, according to officials. 

The outbreak had previously been contained to North Kivu and Ituri provinces, with a few cases in neighbouring Uganda. 

Ebola has killed at least 1,900 people in the past year, the biggest toll after 11,300 died in West Africa in 2014-2016.  

The 24-year-old woman had been identified as a high-risk contact of an Ebola patient in the city of Beni last month, but travelled with her children by bus, boat and road for hundreds of miles before she died on Tuesday night. 

"This highlights a disturbing trend of cases originating from current hotspots which then leave the area and, despite the control measures in place along the corridor, are not detected," said Whitney Elmer, country director for charity Mercy Corps. 

"It is very concerning, especially given the efforts over the last few months to scale up the response," she told the Thomson Reuters Foundation. 

Ebola causes vomiting, bleeding and diarrhoea and spreads via contact with bodily fluids of the infected.  

A breakthrough this week showed there may be a cure as two experimental drugs were found to boost survival rates.  

But stopping the outbreak still depends on tracing and monitoring people who might have been exposed to the disease to prevent is spreading further, health workers said. 

"This is very indicative of one of the challenges we face, which is that people are so mobile," said Margaret Harris, a spokeswoman for the World Health Organization (WHO).

This is all too reminiscent of West Africa, 2013-2016, but on a larger scale. Ebola took months to emerge from the forests of Guinea to Monrovia and Freetown, but then it exploded. It used urban alleys and dirt roads and cross-border trails. If it wasn't on foot, it could move by motorcycle taxi or airliner. Lagos and Dallas learned that the hard way.

No doubt the drivers of the Range Rovers and SUVs of WHO and the NGOs reflect on the irony: while they force their vehicles down muddy parodies of roads to treat victims, other victims are whizzing down blacktopped highways to spread Ebola in big cities.

 

West Africa showed us that cultural practices like bathing the dead can spread the disease to dozens in a matter of hours. And it also showed us that even individual victims could behave in a seemingly irrational way—escaping from Ebola treatment centres that offered their best hope of survival, whether on foot or by motorcycle or by airliner.

 

Again, I suspect this is Ebola taking advantage of a cultural element in the people it's attacking. The peoples of northeast DR Congo have been traumatized by centuries of foreign exploitation followed by a quarter-century of local violence by militias, Islamic terrorists, and exiled Rwandan genocidaires—none of which has drawn the slightest attention from the developed world.

 

Understandably, the people trapped in this war zone have fallen back on trusting only their own—their own family, their own village, their own tribe. So when a bunch of foreign whites and equally foreign blacks from Kinshasa show up warning of a weird new disease, the likeliest response of the locals is profound cynicism.

 

And when you yourself contract what looks like the disease, your first impulse will be to head straight to your own people. 

 

As Robert Frost observed, "Home is where, when you have to go there, they have to take you in." Surely it's better to die among those you love than in a transparent plastic cube being treated by strangers.

 

It's beginning to dawn on governments like the DR Congo's that trust isn't gained by a big smile by a guy in a European suit. If the whole Congolese healthcare system had been functional and free for the past 20 years, Congolese mums would be marching their big strapping kids to the nearest clinic for every fever and ache and vaccination, and bragging to one another when those kids became healthcare workers themselves.

 

But the system wasn't functional, and the mums dealt with their kids' health problems with traditional healers or folk remedies, or simple patience. 

 

Meanwhile, development wasn't a matter of healthcare or education. It was a matter of blacktop roads that made travel easy once you got out of the village and into a city. People who defined themselves as part of a tight collective were pulled apart to find work in cities or factories or mines. That in itself has been a terrible stress on many African and Asian and Latin American societies.

 

Stress brings out our true character. When a new stress comes in the form of Ebola, many of us will ignore the best medical advice and head straight for what looks like home.

North Kivu: Ebola response agents unpaid since April

Via Radio Okapi: North Kivu: Ebola response agents unpaid since April. The Google translation:

Employees recruited for the Ebola response in Mungurejipa, in Lubero territory (North Kivu) triggered Thursday, August 15 a dry strike to claim the payment of their premiums, not collected since April. 

They made that decision a week after the ultimatum issued to officials of the International Organization for Migration (IOM), which had expired Wednesday (August 14th).  

These approximately 20 employees, recruited and posted at the point of entry at Mangurejipa, work at the Subcommittee of the Point of Entry for Surveillance.  

"We are asking the caregivers, especially at IOM, because we have been told that we are being dumped on IOM's account. The first month, we were paid by WHO, IOM arrived, she took care of us. But until today, she does not want to concretize what she promised us. We want IOM to give us back our rights. If we are not paid, we will not continue to work at the point of entry," said Deputy Chairman Timothée Mayengo. 

The Chief Medical Officer of Mangurejipa Health Zone and coordinator of the sub-coordination in the response, Norbert Muhongya, confirms this information. He said he feared the harmful consequences that this strike could generate, the health zone of Mangurejipa being one of the hot spots of this epidemic. He said he had advised the coordination at Butembo and said wait for the next. 

Contacted by Radio Okapi, the coordinators, they call these agents to patience. According to them, efforts are being made to get them paid.

Pandemic bonds: Designed to fail in Ebola

Thanks to Mary Marshall for sending the link to this op-ed in Nature: Pandemic bonds: designed to fail in Ebola. Excerpt:

The final toll of the Ebola outbreak in West Africa in 2014–16 was more than 11,000 lives, plus an estimated US$53 billion from economic disruption and collapse of health systems. In the outbreak’s wake, the global health community scrambled to deliver initiatives for increased health security. 

One flagship programme was the World Bank’s Pandemic Emergency Financing Facility (PEF). Under the scheme, investors who buy pandemic bonds receive generous ‘coupons’, which annually pay about 13% interest. This compensates investors for the risk that the bonds will make ‘insurance’ payouts to fight pandemics under certain conditions. Otherwise, cash returns to the investors when the bonds mature in July 2020. 

The world’s second-largest Ebola outbreak, in the Democratic Republic of the Congo (DRC), has now entered its 13th month and has caused at least 1,800 deaths. In July, the World Bank announced that it would, independently of PEF mechanisms, mobilize up to $300 million towards the Ebola outbreak. 

Meanwhile, the PEF has cost much more than it has brought in. The World Bank, where I worked for 3 decades as an economist, has not advertised the bonds’ exact terms, but I have ploughed through the confusing 386-page bond prospectus. The PEF has already paid around $75.5 million to bondholders as premiums, but has not disclosed how much they have been paid in interest — and it is set to pay much more. 

However, outbreak responders have received just $31 million from the PEF, and the much-touted potential payout of $425 million is highly unlikely. Twice as many investors signed up to buy pandemic bonds as were available. It was a good deal for investors, not for global health. Absurdly, discussions on a second PEF are under way. 

The PEF was backed by about $190 million in donations from 3 countries and the World Bank’s International Development Association (IDA), a fund that provides around $20 billion to the world’s 75 or so poorest countries each year. All the resources devoted to the PEF would have been better used elsewhere. Instead of spending its funds and attention on partnering with reinsurance firms, the IDA should have focused on improving public-health capacity directly or on building up the Contingency Fund for Emergencies at the World Health Organization (WHO) so that all money would go to countries in need. 

Former World Bank chief economist and US treasury secretary Larry Summers described the PEF as “financial goofiness” motivated by government and World Bank officials eager to boast about a creative initiative that engaged the private sector.

World Bank mobilizes US$300 million to finance the Ebola response in DR Congo

A World Bank news release: World Bank Mobilizes US$300 Million to Finance the Ebola Response in Democratic Republic of Congo. Excerpt:

WASHINGTON, July 24, 2019—The World Bank Group today announced that it is mobilizing up to US$300 million to scale up support for the global response to the Ebola epidemic in the Democratic Republic of Congo (DRC). The announcement follows the declaration by the World Health Organization (WHO) that the current outbreak constitutes a Public Health Emergency of International Concern.  

“Together, we must take urgent action to stop the deadly Ebola epidemic that is destroying lives and livelihoods in the Democratic Republic of Congo”, said World Bank Chief Executive Officer Kristalina Georgieva. “The communities and health workers on the front line of this outbreak urgently need more support and resources from the international community to prevent this crisis from worsening inside the country and from spreading across borders.” 

The US$300 million in grants and credits will be largely financed through the World Bank’s International Development Association (IDA) and its Crisis Response Window, which is designed to help countries respond to severe crises and return to their long-term development paths. The financing package will cover the Ebola-affected health zones in DRC and enable the government, WHO, UNICEF, WFP, IOM and other responders to step up the frontline health response, deliver cash-for-work programs to support the local economy, strengthen resilience in the affected communities, and contain the spread of this deadly virus. 

This amount is approximately half of the anticipated financing needs of the Fourth Strategic Response Plan (SRP4), which is expected to be finalized in the coming week by the Government and the international consortium of partners working on the response. The World Bank has been supporting programs to combat DRC’s ongoing battle with Ebola since May 2018, with resources going to the frontline response, health system strengthening, and preparedness to reduce the risk of spread.  

The US $300 million in World Bank financing announced today comes in addition to the US$100 million disbursed by the World Bank and the Pandemic Emergency Financing Facility (PEF) in response to the current Ebola Outbreak in DRC since August 2018.

Ebola funding needs to triple as international risk escalates

Via Bloomberg: Ebola Funding Need to Triple as International Risk Escalates. Excerpt:

The Ebola emergency in the Democratic Republic of Congo will require about three times more money than currently provided, the United Nations agency leading the public-health response said. 

The World Health Organization estimates $324 million is needed to fund its response and preparedness in the Africa region over the next six months. Additional funds will be required to support other functions outside the WHO’s remit to help stop transmission of the deadly hemorrhagic virus, the Geneva-based agency said in an email Tuesday.  

The money sought is on top of the $114 million contributed since August and will largely support the massive scale up of dozens of teams administering protective vaccines to vulnerable Congolese communities, undertaking disease surveillance and reporting, and bolstering capacity at treatment centers, said Margaret Harris, a WHO spokeswoman, in a telephone interview Tuesday.

“This may seem like a lot of money to invest in this, but it’s going to cost the world a lot more if we don’t get this under control,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, in a telephone interview.  

“We have a gas-can with an Ebola match hitting it. If this gets into large metropolitan areas, it’s going to be like a gas-tanker with an Ebola match hitting it,” said Osterholm, who finished a yearlong term in May as a science envoy for health security on behalf of the U.S. State Department. 

$53 Billion Legacy 

The economic and social burden of a 2014-16 outbreak in three west African countries that sickened more than 28,600 people, killing some 11,325, cost an estimated $53.2 billion, a study in October found. In the current outbreak, 2,498 people are confirmed to have been infected with Ebola, causing 1,737 deaths, since it began in Congo, sub-Saharan Africa’s biggest country, in May 2018. 

Cases doubled from April to June 2019, according to humanitarian group Medecins Sans Frontieres, with about 75 to 100 infections occurring weekly.

North Kivu / Ebola: Civil society fears that WHO's health emergency is fatal for regions affected by the epidemic

Via 7sur7.cd: North Kivu / Ebola: Civil society fears that WHO's health emergency is fatal for regions affected by the epidemic. "Civil society" means municipal governments. The Google translation:

In a statement on Saturday, July 20, the civil society / forces of North Kivu reacted to the decision of the World Health Organization of Wednesday, July 17 in Geneva, establishing the Ebola virus disease in North Kivu and in Ituri as "a health emergency of international concern". This, after the detection of a first positive case in the city of Goma.  

Through this media outlet, the North Kivu forces are expressing their concern about the attitude that neighboring countries can show in relation to the areas affected by the virus.  

They fear that the WHO decision will produce and / or become a new concern for populations already suffering from Ebola. 

"Civil society is concerned that this measure will be a new burden that will once again weigh on poor people in the affected areas, and on repetitive and permanent wars, and on Ebola virus disease in the case of neighboring countries. would benefit to restrict the movements of Congolese," they fear. 

However, the civil society says "take note of this so decisive step", while considering "that it will not be a matter of simply being able to mobilize more partners but rather an opportunity to refine new and effective strategies. and efficient in order to achieve the desired result, the eradication of this epidemic."  

Moreover, calling on the actors in the response to focus more on the gaps in the interventions and the quality of these, the driving forces urge that the different problems that impede public health actions in the field of health are also taken into account in the fight against Ebola. 

For them, these problems are insecurity, lack of road infrastructure, poor water supply, lack of electricity, mismanagement of health policy, etc.

DRC Ebola: Cash flow problems of the response

Via ReliefWeb, the DRC Ministry of Health has published an infographic on the cash flow of the Ebola response in the past month. As this excerpt shows, many operations are running serious shortfalls, including surveillance, medical support, salaries, infection control, and psychosocial care:

Vaccination and communication seem to be adequately funded, but the shortfalls are alarming.

WHO Director General briefs member states on Ebola in DRC

A WHO news release: WHO Director General briefs member states on Ebola in DRC. Note the financial shortfall described in the third paragraph.

The Ebola outbreak in the Democratic Republic of the Congo will only end with bipartisan political cooperation and community ownership, according to the World Health Organization’s Director-General, Dr Tedros Adhanom Ghebreyesus. He was speaking to Member States in Geneva after returning from a visit to DRC, where he reviewed the health response and met with leaders from multiple sectors to galvanize their commitment. The organization is also facing a severe funding gap for the response.  

Political cooperation must come from across party lines and across borders,” said Dr Tedros. “Bipartisan political leadership in DRC is the only way that communities will eventually understand the threat of Ebola and take ownership in ending the outbreak. Meanwhile, other countries have a global responsibility to support the dedicated health responders—from DRC, from across Africa and across the world—who are bravely working to save lives.”  

WHO’s funding needs for the response are US$98 million, of which US$44 million have been received, leaving a gap of US$54 million. The funding shortfall is immediate and critical: if the funds are not received, WHO will be unable to sustain the response at the current scale. Other partners are also facing shortfalls that have led some to reduce or stop operations. The response risks being driven by decisions related to financial capacity rather than operational needs. 

During his most recent visit to DRC, Dr Tedros met with Prime Minister Sylvester Ilunga Ilunkamba and opposition leaders—including Martin Fayulu and Mbusa Nyamwisi—as well as religious leaders and partners in Kinshasa, followed by meetings in Butembo, one of the outbreak’s hotspots, with community, religious, business leaders and partners, including non-governmental organizations and other UN agencies. Dr Tedros said, “I met with many leaders from all sectors of society. They agreed that they all have a role to play to help people understand the gravity of this disease. The virus steps between the gaps when we do not join hands.”  

This was Dr Tedros’ ninth mission to the country. His most recent visit to Butembo was in late April after multiple attacks on health workers and facilities, and the death of colleague Dr Richard Mouzoko left staff fearful but still determined to end the Ebola outbreak. 

“The last time I was in DRC it was a very difficult time,” said Dr Tedros. “But the hundreds of responders working to end this outbreak are committed because the people of DRC need their help. So we sat together to find ways to revitalise and strengthen the response. I returned this time to review progress, and to see whether the changes needed have been made and are working.” 

Clear needs were identified at that time, for a more secure working environment, and for more participation by other UN partners and non-governmental organizations. Another clear need was better use of the Ebola vaccine, which is a very effective tool if provided to all people who have been in contact with a confirmed case. 

Vaccination is being stepped up and offered to more people, including pregnant and breastfeeding women, and children over six months old (rather than only 1 year and older). The new protocol was launched by Dr Tedros on Sunday in Katwa, another Ebola hotspot. The adaptation of the strategy is now showing signs of paying dividends, with better trends in Butembo and Katwa, though Mabalako is becoming a new hotspot.  

In two days of meetings in Uganda, Dr Tedros met with the Ugandan President Yoweri Kaguta Museveni, Minister of Health, Dr Jane Ruth Aceng, the leadership of Uganda Virus Research Institute, UN Resident Coordinator Rosa Malango, US Ambassador Deborah Malac and others.  

The country has been in response mode since last week when they confirmed Ebola in three people who had been infected in DRC. Since then, sadly all three of those cases have died, while no further cases have been confirmed. Dr Tedros noted that the country’s investment in preparedness had led to the rapid response.  

“After seeing the rapid response in Uganda, I can only urge the international community to continue to support the preparedness activities ongoing there and in neighbouring countries,” said Dr Tedros. “We have seen concretely how this investment saves lives by controlling the spread of a dangerous pathogen."

Austerity to blame for 130,000 ‘preventable’ UK deaths – report

Via The Guardian: Austerity to blame for 130,000 ‘preventable’ UK deaths – report. Excerpt and then a comment:

More than 130,000 deaths in the UK since 2012 could have been prevented if improvements in public health policy had not stalled as a direct result of austerity cuts, according to a hard-hitting analysis to be published this week.  

The study by the Institute for Public Policy Research (IPPR) thinktank finds that, after two decades in which preventable diseases were reduced as a result of spending on better education and prevention, there has been a seven-year “perfect storm” in which state provision has been pared back because of budget cuts, while harmful behaviours among people of all ages have increased. 

Had progress been maintained at pre-2013 rates, around 131,000 lives could have been saved, the IPPR concludes. Despite promises made during the NHS’s 100th birthday celebrations last year to prioritise prevention, the UK is now only halfway up a table of OECD countries on its record for tackling preventable diseases.  

The report is concerned with preventable diseases or disorders such as heart disease, lung cancer or liver problems, which can be caused by unhealthy lifestyles and habits, formed often at a young age. It finds evidence of disturbing reductions in physical activity in schools and chronic underfunding of health visitors. 

The lead researcher and author, Dean Hochlaf, said: “We have seen progress in reducing preventable disease flatline since 2012. At the same time, local authorities have seen significant cuts to their public health budgets, which has severely impacted the capacity of preventative services. 

“Social conditions for many have failed to improve since the economic crisis, creating a perfect storm that encourages harmful health behaviours. This health challenge will only continue to worsen.” 

The IPPR calls for a “radical new prevention strategy” involving a renewed and increased commitment to the state’s role in preventing disease. 

“No longer can we place the burden of responsibility exclusively upon the individual, while turning a blind eye to a social environment which makes healthy lifestyles difficult to achieve. This means investing in public health and ensuring the government takes a greater responsibility to create a healthy environment.”

This is not exactly breaking news. I reviewed a book on the subject back in 2013, and Rupert Virchow, the author of this blog's catchphrase, said much the same thing almost 150 years ago.