Learn about the evolving Ebola epidemic and its various aspects including disease prevention, management and treatment, response to the epidemic, ethical considerations, and the post-Ebola global health landscape.
The State of Global Health Pre-Ebola, Part 1
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埃博拉病毒：疫情发展
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Introduction to Ebola
Upon completion of this module, learners will be able to:
Review the state of global public health prior to the 2014 Ebola epidemic.
Explore the etiology of Ebola and other viral hematic fevers.
Explain the epidemiology of the 2014 Ebola epidemic and why this outbreak is different than previous ones.
Explain why tropical forest-associated zoonotic pathogens like Ebola are emerging at an ever-increasing rate.
Recognize drivers of disease spillover from wildlife to people and discuss how to mitigate disease spillover.
與講師見面
Dabney P. Evans, PhD, MPHAssistant Professor
Hubert Department of Global Health. Rollins School of Public Health. Director, Center for Humanitarian Emergencies.
Carlos del Rio, MDChair
Department of Global Health at the Rollins School of Public Health
Welcome to our first session, where we will provide an introduction to Ebola.
I'm Dabney Evans, Director of the Center for Humanitarian Emergencies.
And with us today is my co-instructor, Dr.
Carlos Del Rio, and Professor of African Studies, Dr. Pamela Scully.
Before we talk about Ebola specifically,
let's begin by talking about the state of global health.
>> You know 2003, 2004 when Ebola started, global health was in a transition.
We are nearing the end of the millennial developmental goals.
A lot of effort has been made globally to decrease maternal mortality,
to improve child mortality.
We've gained a lot from immunizations, from safe water.
HIV/AIDS has really been dramatic what public health has done.
But there's still many, many areas in which we haven't made advances, and
one of them is clearly in strengthening healthcare systems.
Surveillance is still incredibly weak throughout many counties.
Healthcare systems are weak.
There's a very poor healthcare force, very few doctors,
nurses, public health practitioners in many countries.
So I think the challenges are,
is that as we try to finish the goals of the millennium development agenda,
we are seeing that we're falling short in many of the areas.
And one of the major areas where we're falling short is the area
of strengthening health care system.
We have all talked about how important that is, but
very little has really been done to do that.
And therefore you are at a point that you
could potentially see the emergence of an epidemic, of an outbreak.
And that's exactly what we've seen at this point.
>> So within public health,
we talk about a focus on populations as opposed to individuals.
And so, the health care systems element of this conversation
becomes really important.
There's also kind of the double burden of non-communicable diseases that we also see
on the rise in Africa and other developing countries.
How do you think that impacts on the Ebola epidemic?
>> But the problem is that public health which is population health and
individual health which is clinical care, are not really separate.
If you don't have clinical care where people can go and
get their care, you don't have a way to diagnose diseases.
In this country somebody shows up in the emergency room with
a disease that we don't know what it is.
It's worked up, it's figured that it's Influenza.
Public health is then notified.
People don't go to the Public Health Department with Influenza.
The Public Health Department finds out about Influenza from the clinical system.
If there's not a clinical system,
you don't have that detection system in place to pick up diseases, and
therefore it takes a long time for things to be picked up.
We learned that in HIV/AIDS.
How many years did we have AIDS in Africa
before it was finally picked up here in America?
We thought it was a disease here, but in fact it had been going on for
years in Africa.
We just simply had not picked it up because people hadn't seen it,
hadn't thought about it in the clinic.
So I think what's really interesting about global health is
global health is that combination of clinical care and public health.
And that is where I think many of those diseases are.
And therefore the need to bring clinical strengthening
into public health strengthening,
is something that we see very clearly as we try to combat those diseases.
And the same thing happens with the non-communicable diseases.
No matter which disease you're looking at, at the end, people with hypertension or
diabetes are gonna have to go to clinical care.
It's not just a matter of counting cases.
It's a matter of really offering therapy in order to confront those diseases.
>> So one of the things you mentioned is the counting cases, which is surveillance.
So we hear a lot of different terms thrown around when we talk about Ebola.
Can you differentiate between what is an outbreak and what is an epidemic?
Those are two words that we hear a lot around Ebola.
>> So an epidemic is when the number of cases is above a certain threshold, and
the number of deaths from a disease, for example, is above a certain threshold.
It's a term used by the WHO,
by CDC to describe when there's more cases than expected.
An outbreak is when you have a higher incidence within a specific area,
so an outbreak is less than an epidemic.
Once you get to a certain threshold, you get an epidemic.
Once that epidemic extends to multiple other places,
then you talk about a pandemic.
So for example, with Influenza,
we may have an outbreak of Influenza, and then eventually
the number of cases is high enough that now you talk about epidemic Influenza.
And if it starts effecting multiple countries like it did in 2009,
then you have a pandemic.
With Ebola we started with an outbreak in a couple communities and
then rapidly became an epidemic.
It hasn't become pandemic because we haven't seen really
an increase in cases outside that area of West Africa where the cases occurred.
>> And I think that that's really important thinking about where these cases
are occurring.
So, there are some other features of this particular epidemic that are important.
And one of those has to do with the relationship between human beings and
nature, so can you talk a little bit about that?
>> This disease, Ebola,
like many others that we're now seeing are actually what we call zoonosis.
So they're diseases that exist normally in animals.
But it's because of our incorgement into the ecology,
into deforestation, into getting into areas where we normally haven't been.
That population starts settling there,
that you see these diseases in animals then start affecting humans.
And this again has happened with Influenza where we see increased
numbers of birds and pigs, populations close to each other.
Influenza is a zoonosis that then goes to humans.
We're seeing this with Ebola, and we're seeing it more and more.
So zoonosis will increasingly be a problem.
And this is something that the WHO and
many other organizations have recognized and
now when we talk about approaching health, we talk about this one health approach.
It's not enough about doing surveillance in humans.
We really need to do surveillance in animals and in the environment.
It's really bringing those three things together.
Because the great majority of the infections that we're gonna see and
again AIDS is a good example AIDS started in nonhuman primates it didn't
start in humans.
So AIDS is also a zoonosis.
>> So this is really important for us to think about because
the growth of zoonosis is something where we're going to be encountering more and
more in the field of public health.
Our increasing human interaction with animals may have contributed to this
outbreak since we think that the host for the Ebola virus is actually a bat.
But where did Ebola occur prior to this particular outbreak?
>> So the previous outbreaks of Ebola had occurred
in Zaire now called Democratic Republic of Congo and Uganda and
in certain countries in Africa, but not what we are seeing it right now.
West Africa, in Liberia, in Guinea, in Sierra Leone, have never seen
cases of Ebola, therefore, this disease has now moved to this new territories, and
one of the questions people ask is why.
Why did this, was it the bats that brought it over?
What happened that the disease that wasn't there is now seen there?
And this is what we call emerging infection.
So Ebola emerged in West Africa as a new infection that we had not
previously seen there.
That in itself was very unique.
Now the number of cases and the spread has also been very unique.
So this outbreak that we're confronting right now,
it's very unique for multiple reasons.
But one of them is obviously a new area of Africa where it has never occurred.
And number two is the number of cases which is unprecedentedly high.
>> So, we have to bear in mind a couple of really interesting and
important points about this particular outbreak.
First, that this is the first time that we've seen
Ebola in the particular of Africa, in West Africa.
And so, I wanna invite Pamela to join us in the conversation
because she's an expert in African Studies.
And I think that it's important that we think about some of the contextual
components about the three Ebola affected countries.
So what should we know about these country contexts as we talk about this outbreak?
>> Thanks, Dabney and Carlos.
Well I speak as an historian, an African historian,
and I think one of the things we need to know about is history, obviously.
Is that all this region,
as in most regions in Africa, has a colonial histories.
Britain used to be a colonial power in Sierra Leone, France in Guinea, and
America had complicated semi-colonial relationship's with Liberia in the 19th
century.
So there's a long history of tensions in the region as again in many other
places in Africa between colonial paths and indigenous authorities.
Whose independence were taken away and who have historically,
even in the post-colonial era, seen the state not as a beneficent welfare state
as von Marten mentioned in Scandinavia, but as a vampire state, as a state
that comes to take things away from people rather then to give them to people.
This region also suffers from what some economists have called the resource curse,
in that it's very, very rich in natural resources, in palm oil,
in gold, in iron ore.
And over the course of history, multinationals have made deals with
governments which, again, have disadvantaged your average person
in communities and have to some extent, brought some advantage to their elites,
but most of the profits have gone elsewhere.
I know best about Liberia, and the classic example in Liberia is
a agreement made with Firestone, the rubber company, the tire company, in 1925,
where Firestone came to control 4% of Liberia's lands with rights to all
the natural resources discovered there, and the state guaranteed labor.
That has also continued today, and we have to talk about, but you also have,
because of the natural resources, in the 80s and 90s and into the early 2000s, this
whole region experienced terrible wars, both civil wars and wars across borders.
The most famous individual being Charles Taylor,
who became president of Liberia in 1997.
And so this whole region was devastated by war.
Guinea received refugees from the surrounding areas,
was a participant, to some extent, in funding militias.
And so you have a damaged relationship between the government and people.
And even, again, in Liberia since 2006, Ellen Johnson Sirleaf,
who won the Nobel Peace Prize, has been president and has made many reforms.
But she too has, in a sense, had to deal with this history
of relationships with multinationals and how to get money for her country.
And so between, for example, 2006 and 2012, the government has signed
$19 million worth of concession agreements in mining, agriculture and forestry.
And there's a growing amount of Liberian land under the control of these foreign
companies which extend to something like a quarter of Liberia, which has changed,
back to Carlos's point, the relationship between people and areas.
So, for example, in the area at the border of Guinea and Liberia, one of the reasons
people are arguing there's been a spread of Ebola is the deforestation there, so
that animals are moving closely into contact with humans.
And so bats, for example, are coming into much greater contact with humans, and
particularly around issues of palm oil, which people use, and also they eat bats.
So historically, there are communities that have eaten bats and
bush meat for hundreds of years with no problem.
And so, given the historic distrust with the government,
including the current governments, and a history of being able to eat these meats,
there was real skepticism when experts came in telling communities that they
shouldn't eat bush meat and that there was this terrible disease.
Because as you had both indicated, this had never been the case.
So I think what I'm really interested in, as we discuss these
really important issues around global health, is to add to the discussion and
understanding of the political economy of the region and of the history so
that there are reasons why people are both skeptical of experts and
are very aware that things like healthcare infrastructures do not exist.
So they have right to worry about whether it makes sense to send their
sick relatives to healthcare centers that they know are very ill equipped and
where most of the healthcare workers have died.
So I think in understanding Ebola as a global health emergency,
I really appreciate the chance to think about how history and political
economy have helped shape the environment in which Ebola is ravaging this region.
But I also think the issues of civil rights and
of individuals, human rights, as citizens of their particular countries, and
also the way that individual countries relate to the world.
And so to me, this is both a political economic question,
a global health question, and a human rights question.
And Debbie, I know you deal with human rights and global health, and so
I'd love to hear your thoughts on that.
>> Well, I think for me one of the big questions that comes up, and you actually
mentioned it, is the relationship between individuals and the state.
And this is really the foundation for
human rights when we think about them in the modern context, is what is
the relationship between individual citizens and the state that governs them?
And we heard, as you talked about, the very complicated histories of these three
countries that have been ravaged by conflict.
And we think about the trust that does or doesn't exist between the state and
individuals.
And so that's a really important piece of this conversation, is that the whole
concept of human rights is based on this social contract between the individual
citizens who are giving power to those that govern, and the exchange.
What is it that government or the state provides for individuals?
And that takes many shapes and many forms, but I also think one of the other things
that we have to bear in mind is kind of the classic human rights debate,
which is between universalism, universal human rights, and cultural relativism.
So we do have to think about cultural specificities.
We do have to think about the practices that are particular to these
particular countries and these particular communities.
And one of the things that we know in the case of Ebola is that, in fact,
some of these practices may have exacerbated
the spread of the disease in the early days of the disease.
So we do have to think about that as we think about human rights as well.
I think another thing that we have to think about it is, then,
what are the obligations of the state to its citizens?
And the first thing is to respect the rights of citizens.
And as we've seen in several states,
including some of the developed states, there was a very quick response to
go to the most extreme public health measure that we have, which is quarantine.
And so this gets into issues of civil rights.
The second obligation of states is to protect citizens, so
protect them from state actors but also non-state actors.
And this becomes really important when we think about the role that NGOs have played
in the Ebola response.
As Carlos mentioned, we don't have health systems in place.
So, in fact, the health systems are really being run by nongovernmental
organizations and international organizations that are coming in.
The countries that we're talking about have been devastated.
Their health systems were weak before conflict, but
after conflict they've been virtually decimated.
In Liberia something like 93% of
healthcare facilities were completely destroyed.
So the capacity of the state itself, as well as the lack of trust between
the state and citizens, as well as the lack of systems,
all contribute to what amounts to human rights violations, in some sense.
And then the third obligation for states is the obligation to fulfill.
That is, what is it that states should be doing,
in the case of something like Ebola, to actually prevent the disease?
And so those are really important elements for us to think about.
We have to think about transparency, and we know that
in this particular epidemic there have been attacks on healthcare workers, and
there's also been a real resistance of people in the beginning of the outbreak to
go to the Ebola treatment units.
And this is based in part because of the history of these countries and
the lack of trust about what these camps were for.
And so that's something that we really have to bear in mind as well.
I also think there are a whole set of particular rights that we need to
consider.
We need to think about things like civil rights.
So as I mentioned, there were several fairly extreme
cases of quarantine that were put into place, particularly in Liberia.
And also wide isolation that took place over a couple of days.
And also we can zero in on the right to health so
we have to think about what we call the triple AQ of the right to health that
is affordable, available, accessible, and quality healthcare.
And I think if we look across these contexts at the outset of the outbreak
we really didn't have any of those elements in place.
So it's kind of a perfect storm of situations or circumstances
where things could really go drastically wrong in terms of human rights as well.
>> I mean, one thing I would just add to that is that especially in Liberia,
there's been billions poured in through development dollars for a whole host
of programs around gender-based violence, around healthcare, around politics.
Not so much around healthcare, though.
And so one of the reasons why I think Liberians are feeling so
frustrated is that so much money has been spent.
So we have to start thinking not so much about money, as about, as you just said,
sort of, ethical relationships.
What actually works in particular countries, and
develop a whole different approach, really.
Cuz money has not been an answer.
And I think that to piggy-back on that,
part of that has to do with accountability and transparency.
So we already have places where there's a real lack of trust between the government
and individuals, and then throw a bunch of aid on top of of that,
without transparency, and it's really a recipe for disaster.
>> And we have to recognize the role of the word corruption into this process.
I mean I think millions of those dollars that have been poured in,
have gone in to enriching the bank accounts of very few in those countries.
So again, there's a lot of skepticism in the population that anything is going to
make a difference except make a few individuals in power rich.
And therefore, why should you trust people in power?
>> I think on a broader issue,
the other issue around human rights that frequently comes up
whenever there's an epidemic, is what happens in the rest of the world, right?
So the rest of the world says, hey, let's close our borders,
let's stop flights, let's do whatever it takes to keep it there.
Instead of thinking about look, in order to get supplies there, in order to get
things there, we actually need to continue engaging with the country,
we need to continue engaging with the economy.
We need to continue providing the necessary interconnectivity
that communications brings.
But automatically, we humans have this way of thinking that sort of magically,
if we close the borders, we're not gonna see the disease come to us.
And I think this one of the big errors that as societies we make, and
unfortunately that has consequences.
When SARS happened in China, it took many months for China to recognize there was
something there, because they were very concerned about the economic consequences.
So even a fairly wealthy country like China says, well,
you know If they close our borders, if they stop taking Chinese products
as imports into those countries, it can really ruin our economies.
So the interconnectivity of health outbreaks,
global economy is really something that we cannot forget.
And governments at the end of the day want to preserve their economies and,
therefore, you are reluctant to recognize there's an outbreak or
there's an epidemic.
Because this leads to this international response that we immediately see.
You know, Congress saying we need to stop flights from Liberia.
Many Congressmen asking for that didn't realize that there's no flights from
Liberia directly to the United States.
We need to also be careful about what we ask for
and think in more geography terms, right.
Most of the people coming to this country were actually going though Europe.
They had to fly to Brussels, or they had to fly to Paris or
some other place in Europe.
And therefore, it is impossible to think that you can control an outbreak
by closing your borders.
But this continues to be an ongoing issue that we all face,
as we deal with this epidemic.
So when the WHO sees an epidemic and calls a public health
emergency of international concern, they have these issues in mind.
They have to think about what are the economic consequences?
What are the travel restrictions that are gonna come as a result of this?
And that's something that unfortunately we have not been able to resolve
in this rapidly changing world of global health.
Because as the international regulation say,
you shouldn't do this, the reality is most countries do that.
>> And I think that goes on both sides of the equation in terms of affected states
and unaffected states.
So I think the natural instinct is to protect one self.
So if you're in an effected country, the natural response might be,
let's not talk about this,
let's brush this under the rug, because we need to protect our economy right?
There was a booming, or about to be booming or growing, surfing industry
that was coming up in Liberia, and now that economy has disappeared.
And so here also we have the self-interest of states that are affected, but
also states that are worried about getting Ebola and
this is one of the characteristics of global health right?
Disease knows no boarders, and so diseases will come, and one of the important things
that we have to think about here is things like supply chains.
So as you mentioned if you cut off flights to other countries,
not only can you not fly supplies there, not only can you not fly personal there,
but all of those personal protective equipment that people that were treating
patients in the Ebola-affected countries would need.
What if those things hadn't been able to get to them because of supply
chain issues?
So those are very serious considerations that we have to bear in mind.
>> Absolutely.
And we have to think that in this changing world of global health,
one has to see that something happening in Liberia, or
something happening in China, should be a concern to all of us around the world.
And the best way to deal with this kind of outbreaks is actually
by improving healthcare systems in those countries and
actually by addressing the issues in those countries.
It's not by closing our borders.
It's not by putting travel restrictions.
But it's actually by really thinking how are we addressing the increasing
disparities in healthcare access that you well mentioned, if there's less and
less access in many of those countries there's going to be more and
more outbreaks and they're going to be a concern to us, and
to other people in more resource rich countries.
>> And I think that that's a constant kind of identity
crisis that public health faces.
You know, if we're doing our jobs, nobody knows what we do.
But as soon as there's an outbreak or an epidemic,
everybody's worried about public health and everybody's asking the questions.
Where were public health systems?
But it's really hard work to build health systems, right?
And especially in these contexts that have already been ravaged by a lot of
destruction, not only in the health care system.
So these are major challenges and
there's really a long term investment that needs to be made.
