Of Predictable Surprises and Haitian Nightmares

Insanity is often defined as doing the same thing over and over again yet expecting different results. It is disputable where the saying originated. Albert Einstein, Mark Twain and Rita Mae Brown have all, at some point, been associated with this quote. Whichever mouthpiece you prefer, there is no denying the universal wisdom this line articulates. With global health generally, and public health emergencies in particular, global leaders lend this quote remarkable legitimacy. I understand the grand nature of this accusation but allow me explain, first by introducing yet another name many of you may be familiar with; Dr Paul Farmer.

For those unfamiliar with his work, Paul is a physician, anthropologist and co-founder (together with current World Bank President, Jim Kim) of Partners in Health (PIH), an international social justice and health organization. Recently, he spoke to the US Senate Foreign Relations Committee about the lessons that must to be learnt from the current Ebola epidemic ravaging parts of West Africa. His committee submission was noteworthy in and of itself, but the insight he shared in an exclusive interview thereafter is what inspired my pen. ‘We have met the enemy [to global health] – and he is us.’ At this point, you may wish to pause, read the interview and reflect on your individual role in aiding the less-than-satisfactory state of global health today.

The bold statement attempts to suggest that each one of us – and especially those of us active in the global health movement – have, in one way or another, contributed to the squalid state of contemporary global health. Paul does not attempt to exclude himself from this responsibility. He asserts, and I agree with him, that international NGOs often seek Western aid to ‘build local capacity’ in recipient countries. However, it is often used inefficiently (e.g., organizing one-two day workshops, instead of building long-term programs) with the largest chunk going to overheads and administrative costs.

Now, depending on the subject matter, a workshop isn’t necessarily such a bad idea. However, Paul argues, it is common knowledge that it does not take two days to train an infection control nurse or health manager. Residency exchange programs and investing in local teaching hospitals would be Paul’s solution to the Human Resources for Health challenges facing poorer nations. While you may not agree with Paul’s proposed solution, you will certainly agree that the status quo is not serving us well. Albeit Paul’s submission was largely within the context of the current Ebola crisis on which he had just given testimony, his wisdom appears largely applicable to many of the global health questions confronting us today. The short-term fixes we often prefer only encourage recurrence and persistence of otherwise dispensable global health menaces.

Predictably, I must return to Ebola as an example. Public health experts have known about Ebola since 1976; when an outbreak in Sudan led them to classify it as a particularly aggressive, highly infectious zoonosis that killed its host in a matter of days. It was believed at the time that an outbreak could recur, as it did later in 1976, in 1995, 2000, 2003, 2004, 2007, 2012 and 2014. Yet in each of these instances, global health actors were ‘surprised’ and ‘caught off-guard’ by the respective outbreaks.

The current epidemic is, of course, the most devastating on record and has rattled the global health establishment much more significantly. But as Dr. Julie Gerberding (the former Director of the CDC, now with Merck) stated at a recent CSIS symposium to discuss the way forward on an Ebola vaccine, it is simply inexcusable that a virus that has demonstrated such consistency still attracts panicked symposia and hurried vaccine research every time it visits. With the geographical hotspots well-known and its cross-border mobility appreciated from previous encounters, researchers, global health entities and donors had enough to go on to act decisively on Ebola; not once but eight times. Yet, like Paul says, Ebola outbreaks are often met with brief workshops on infection control and little else. Sustainable investments in health systems and human resources for health seem to elicit little appetite.

The scarcity of monetary resources is an often-cited obstacle to such investments. But when one considers the cost of inaction, this argument fails to withstand scrutiny. So far, the current epidemic has slapped a direct bill of close to $1 billion. As it is still a long way from resolution, a lot more is anticipated in direct costs. The U.S. government has already secured an additional $6.2 billion in predicted Ebola spending. The indirect costs are even more astronomical and are not restricted to just the affected countries. The World Bank initially estimated that the eventual cost of Ebola could top $32 billion; a figure that was later revised to slightly less. Disruption of air travel, cancellation of vacation plans, and slumps in airline stocks are just a few of the indirect costs associated with the current outbreak.

Now I am no economist, but I am certain that with $32 billion, even $1 billion, one could transform health systems in the three affected countries, train health workers and retain a tidy surplus to equip and pay them for more than five years. In times of tranquility, these suggestions do not attract funding as they fail to demonstrate direct and immediate palpable results that so many global health donors seek. The results they promise are long-term and do not make for beautiful graphs and quick statistical analyses. Yet in crises, health systems failure is made to sound new, as the principal cause of global health panic.

There is no telling with certainty if global health architecture will adapt after this outbreak. One would have thought that the previous outbreaks would have been sufficiently instructive. My hope, with the current outbreak, is that valuable lessons are forced onto the global health community. It is a bold kind of hope that has me dreaming of changes in the politics and financing of the WHO, in better coordination of emergency responses, and in mutual recognition that now, more than ever, our livelihoods as individuals and as nations depend not on the strength of domestic health policy but on the unified aspiration and robustness of global health policy.

The end of Ebola in West Africa will surely come. The mere definition of ‘epidemic’ suggests that time will see it through. Yet as we get closer to this desired end, the question of what happens after becomes more prominent. One inevitably starts to think of Haiti, and the uncanny parallels that are beginning to emerge.

The 2010 earthquake that devastated Haiti justifiably attracted a decisive international humanitarian response. Estimates put eventual direct expenditure at $9 Billion. Like Ebola, the disaster necessitated the deployment of the U.S. military and inspired the creation of a UN Office of the Special Envoy for Haiti. Yet when The Guardian recently analyzed the numbers, it was revealed that 94% of the funding ended up in donors’ own civilian and military entities, UN agencies, international NGOs and private contractors.[1] There is no dependable evaluation report of what the money did or achieved. Ordinary Haitians have yet to recover from the earthquake. Many still live in tented camps while basic services and access to clean water remain a challenge. Today, cholera is proving more devastating than the earthquake.

With Haiti in mind, an array of questions inevitably preoccupies the solitary mind. Will the current wave of enthusiasm for building health systems and investment in Human Resources for Health continue post-Ebola? Assuming the epidemic is controlled before a vaccine is approved, will vaccine research continue to be funded and prioritised? Will there be transparency and accountability for the funds expended? Will global health architecture change at all? Will countries be more proactive in investing in domestic health programs? Brand me a pessimist if you must but a failure to resolve these and related questions makes another ‘Haiti’ a distinct possibility; the very prospect that makes me fail to sleep at night.