Dadwal, V

Harris, MJ

Syed, S

Wu, A

Globalization and Health

English

PubMed

Matthew Harris

Viva Dadwal

Albert Wu

Shamsuzzoha B Syed

Crossref

Harris et al. Globalization and Health  (2015) 11:16 DOI 10.1186/s12992-015-0102-3EDITORIAL Open AccessIt takes threat of Ebola to see lessons from lowincome countriesMatthew Harris1*, Viva Dadwal2, Albert Wu3 and Shamsuzzoha B Syed4In his recent perspective in the New England Journal ofMedicine, the head of the United States (US) Centers forDisease Control and Prevention (CDC), Thomas Frieden,and colleagues, were concerned that the arrival of theEbola virus (EVD) in Lagos, Nigeria heralded a concern-ing escalation of the epidemic in West Africa [1]. By24th September 2014, a total of 20 EVD cases (19 la-boratory confirmed, one probable) had been reported inNigeria. All 20 cases stemmed from a single index pa-tient, a traveller returning from Liberia on 20th July2014. Unless Nigeria responded quickly and effectively,the virus would spread rapidly in Africa’s largest city andinto the country beyond [2].The subsequent successful containment of the virusin Nigeria led to a flurry of declarations in the mediathat much could be learned from Nigeria’s approach[3-6]. What was done right? Almost immediately afterthe first case was diagnosed, the Nigerian governmentdeclared a Public Health Emergency and centralised thecommand structure through an Ebola Response IncidentManagement Center [7]. Furthermore, they developed arobust and coherent Social Mobilization strategy that in-cluded multiple response teams spanning across severalcities [7]. These teams conducted over 26, 000 rapidhouse-to-house, in-person visits to assess Ebola symp-tom development and ensure that community membersunderstood risks and preventive steps [7-9]. Suspectedpatients were triaged and the areas they inhabiteddecontaminated [7]. Finally, to control and counter theoutbreak of anxiety and hysteria triggered by early, in-accurate information [3,7], strong public awarenesscampaigns were deployed, making use of accurate andtimely messages that were relayed not only by the na-tional media [4], but also social media [8], Short Mes-sage Service (SMS) platforms [8], and traditional,religious and community leaders [4,6,9]. To sum it up,* Correspondence: mjh599@nyu.edu1Commonwealth Fund Harkness Fellow in Healthcare Policy and Practice,New York University, New York, USAFull list of author information is available at the end of the article© 2015 Harris et al.; licensee BioMed Central. TCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Nigeria’s outbreak response was vigorous, effective andcoordinated.Pleasing, though it is, to see successful experiences froman emerging economy given broad exposure, we believethat to fully embrace the potential learning two importantissues ought to be addressed.First, we must not assume automatically that the keyfeatures of the Nigerian response do not apply to more‘advanced’ health systems like that of the US. Althoughthe US boasts some of the world’s leading class hospitals,the healthcare delivery system here is also somewhatfragmented, with a primary care infrastructure that canbe significantly strenthened [10]. This multiplies thelikelihood for errors and system vulnerabilities. Thehandling of the first domestically diagnosed Ebola casein Dallas, Texas raised immediate concerns about USpublic health preparedness. Federal Public Health offi-cials do not have the authority to command and controlthe kind of rapid, preventive and contact tracing activ-ities deployed by Nigeria. Instead, the CDC must be ex-pressly invited by a State government in order to effectpublic health responses at a local level. Perhaps as a re-sult, we have seen everything from misdiagnoses, to de-layed treatments, accidental in-hospital transmissions,and quarantine policy reversals regarding quarantine forhealthcare workers returning from West Africa, and aregrettable politicisation of the public health response.Second, it should not take an epidemic of unprece-dented proportion, such as this Ebola crisis, to acknow-ledge that learning can run from the so-called “GlobalSouth” to the “Global North”. So deeply entrenched arethe expectations that technical expertise flows only oneway, that our mental blinders do not allow us to con-template anything else in reverse. Sadly, this mentalmodel has marked the global health dialogue on the sub-ject of Ebola. The World Health Organization, the CDC,Médecins Sans Frontières (MSF), and UNICEF, all workedalongside the Nigerian government during the Ebola out-break [7,9]. What were some of the lessons they learnedand how can those lessons be adapted in other settings,his is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Harris et al. Globalization and Health  (2015) 11:16 Page 2 of 3including in the US? This should be a critical compo-nent of the development agenda, particularly as wemove into intense dialogue around sustainable devel-opment goals in 2015. This journal’s dedicated open-access series on reverse innovation in global healthsystems aims to challenge conventional thinking bycollecting evidence of bidirectional learning beyond theEbola response [11,12]. Only by harvesting and actioningsuch questions will we be able to recognize the true po-tential of global innovation flow for health systems butperhaps beyond [13].Since the outbreak began, there have been 24,247 re-ported Ebola cases and 9,961 reported deaths in ninecountries [9]. On 20th October 2014, Nigeria was de-clared Ebola free [14] (WHO). Nigeria was able to winthe battle against Ebola not only as a result of “doing theright things” but also because it drew on its strengthsfrom past successful experiences, such as recent polioeradication campaigns [7]. With a dense population andoverburdened infrastructure, Nigeria’s case prompts therecognition that preparedness depends on the corestrengths of health systems. Indeed, increasing attentionis now being placed by global partners and national au-thorities across Africa on health systems resilience forboth Ebola affected countries and those seeking to bol-ster their abilities to respond to all potential hazards. Forexample, infection prevention and control – a core attri-bute of patent safety laid bare during the Ebola outbreak – requires strengthening of “everyday” health ser-vices. This needs to take into consideration issues relatedto workforce capacity, supplies of essential consumables,data & information, organization of health services alongwith quality improvement processes. Nothing comeseasy in health systems strengthening but the gains arelong term.Clearly, not enough has been done to support well-functioning health systems in many African countries,but the US too is no exception to this rule. As each ofthe three high-transmission countries now moves for-ward on the immediate priority of getting to zero cases,a simultaneous emphasis is being placed on early recov-ery with a specific attention on the re-activation ofessential health services. Multiple priorities emerge –immunization, malaria control, integrated managementof childhood illness, maternal health to name a few.The challenge is to integrate these priority interven-tions within a comprehensive, people centred approachto re-designing service delivery with people and notdiseases. Further, efforts to strengthen preparedness forfuture outbreaks needs to be integrated with the deliv-ery of services using a “one health system” approach.Might there also be lessons that emerge from thisupcoming effort here for the world? We believe thatharvesting insights from these experiences will beimportant for the global pool of knowledge, for allcountries.Rare, novel infections like Ebola will continue to testour ability to respond to diseases. When the currentcrisis dies down, we might realise that strengtheninghealth systems is actually a good plan for any disease oroutbreak, not just for Ebola. At the same time we mightalso recognize that the fluid and rapidly evolving healthsystems in African countries may hold multiple ‘goldennuggets’ that can be utilized to strengthen systems inthe US and elsewhere in the world. This requires agreater appreciation that examples of best practice cancome from anywhere and flow anywhere, includingfrom the “global south” to the “global north”.Author details1Commonwealth Fund Harkness Fellow in Healthcare Policy and Practice,New York University, New York, USA. 2Visiting Scholar, Johns HopkinsUniversity Bloomberg School of Public Health, Baltimore, USA. 3Center forHealth Services & Outcomes Research, Johns Hopkins University BloombergSchool of Public Health, Baltimore, USA. 4Johns Hopkins UniversityBloomberg School of Public Health, Baltimore, USA.Received: 22 January 2015 Accepted: 23 March 2015References1. Frieden T, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014— NewChallenges, New Global Response and Responsibility. N Engl J Med.2014;371:1177–80. September 25, 2014DOI: 10.1056/NEJMp1409903.2. Fasina FO, Shittu A, Lazarus D, Tomori O, Simonsen L, Viboud C, Chowell G.Transmission dynamics and control of Ebola virus disease outbreak inNigeria, July to September 2014. Euro Surveill. 2014;19(40). Available online:http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20920.3. Courage K. How Did Nigeria Quash Its Ebola Outbreak So Quickly? ScientificAmerican. Oct 18 2014 Available online: http://www.scientificamerican.com/article/how-did-nigeria-quash-its-ebola-outbreak-soquickly/AccessedDecember 2014.4. Kroll D. An Ebola Outbreak Contained: What U.S. And Other Nations CanLearn From Nigeria. Forbes Magazine Oct 20th 2014 Available from http://www.forbes.com/sites/davidkroll/2014/10/20/what-can-africas-ebola-containmentsuccesses-teach-other-nations/. Accessed December 20145. Poon L and Qusit-Arcton O. I'll (Gag) Drink To That: Oral Rehydration KeyFor Ebola Patients. National Public Radio October 23, 2014 Available atwww.npr.org/blogs/goatsandsoda/2014/10/23/358108367/ill-gag-drink-to-that-oral-rehydration-key-for-ebola-patients. Accessed December 2014.6. Neporent L. Valuable Ebola Lessons the US Can Learn From Nigeria. ABCNews Oct 20, 2014 Available at http://abcnews.go.com/Health/valuable-ebola-lessons-us-learn-nigeria/story?id=26323556 Accessed December 2014.7. Shuaib F, Gunnala R, Musa E, Mahoney F, Oguntimehin O, Nguku P, et al.Ebola Virus Disease Outbreak — Nigeria, July–September 2014. Morbidityand Mortality Weekly Report (MMWR). 2014;63(39):867–72.8. UNICEF. In Nigeria, texting to prevent Ebola. 13 October 2014 Available athttp://www.unicef.org/infobycountry/nigeria_76251.html AccessedDecember 2014.9. WHO. Ebola Response Road Map Situation Report. March 11th, 2015. http://www.who.int/csr/disease/ebola/situation-reports/en/ accessed March 14th2015.10. Starfield B. Is US Health really the best in the World? JAMA July 26, 2000;284(4):483-485. doi:10.1001/jama.284.4.483.11. Syed S Dadwal V, Rutter P, Storr J, Hightower J, Gooden R, et al. Developed-developing country partnerships: Benefits to developed countries? http://www.globalizationandhealth.com/content/8/1/17.12. Globalization and Health. (2013, February 5). Reverse innovation in globalhealth systems: Call for papers. Retrieved March 9, 2015, from BioMedCentral Blog: http://blogs.biomedcentral.com/on-health/2013/02/05/reverse-innovation-in-global-health-systems-call-for-papers-2/Harris et al. Globalization and Health  (2015) 11:16 Page 3 of 313. Syed S, Dadwal V, Martin G. Reverse innovation in global health systems:towards global innovation flow. http://www.globalizationandhealth.com/content/9/1/3614. WHO Mediacentre is an online source. I suggest the citation read as follows:WHO. Media Centre. WHO declares end of Ebola outbreak in Nigeria. 20October 2014 Available from www.who.int/mediacentre/news/ebola/20-october-2014/en/ Accessed December 2014Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

It takes threat of Ebola to see lessons from low income countries

Spiral - Imperial College Digital Repository

Harris et al. Globalization and Health  (2015) 11:16 DOI 10.1186/s12992-015-0102-3EDITORIAL Open AccessIt takes threat of Ebola to see lessons from lowincome countriesMatthew Harris1*, Viva Dadwal2, Albert Wu3 and Shamsuzzoha B Syed4In his recent perspective in the New England Journal ofMedicine, the head of the United States (US) Centers forDisease Control and Prevention (CDC), Thomas Frieden,and colleagues, were concerned that the arrival of theEbola virus (EVD) in Lagos, Nigeria heralded a concern-ing escalation of the epidemic in West Africa [1]. By24th September 2014, a total of 20 EVD cases (19 la-boratory confirmed, one probable) had been reported inNigeria. All 20 cases stemmed from a single index pa-tient, a traveller returning from Liberia on 20th July2014. Unless Nigeria responded quickly and effectively,the virus would spread rapidly in Africa’s largest city andinto the country beyond [2].The subsequent successful containment of the virusin Nigeria led to a flurry of declarations in the mediathat much could be learned from Nigeria’s approach[3-6]. What was done right? Almost immediately afterthe first case was diagnosed, the Nigerian governmentdeclared a Public Health Emergency and centralised thecommand structure through an Ebola Response IncidentManagement Center [7]. Furthermore, they developed arobust and coherent Social Mobilization strategy that in-cluded multiple response teams spanning across severalcities [7]. These teams conducted over 26, 000 rapidhouse-to-house, in-person visits to assess Ebola symp-tom development and ensure that community membersunderstood risks and preventive steps [7-9]. Suspectedpatients were triaged and the areas they inhabiteddecontaminated [7]. Finally, to control and counter theoutbreak of anxiety and hysteria triggered by early, in-accurate information [3,7], strong public awarenesscampaigns were deployed, making use of accurate andtimely messages that were relayed not only by the na-tional media [4], but also social media [8], Short Mes-sage Service (SMS) platforms [8], and traditional,religious and community leaders [4,6,9]. To sum it up,* Correspondence: mjh599@nyu.edu1Commonwealth Fund Harkness Fellow in Healthcare Policy and Practice,New York University, New York, USAFull list of author information is available at the end of the article© 2015 Harris et al.; licensee BioMed Central. TCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Nigeria’s outbreak response was vigorous, effective andcoordinated.Pleasing, though it is, to see successful experiences froman emerging economy given broad exposure, we believethat to fully embrace the potential learning two importantissues ought to be addressed.First, we must not assume automatically that the keyfeatures of the Nigerian response do not apply to more‘advanced’ health systems like that of the US. Althoughthe US boasts some of the world’s leading class hospitals,the healthcare delivery system here is also somewhatfragmented, with a primary care infrastructure that canbe significantly strenthened [10]. This multiplies thelikelihood for errors and system vulnerabilities. Thehandling of the first domestically diagnosed Ebola casein Dallas, Texas raised immediate concerns about USpublic health preparedness. Federal Public Health offi-cials do not have the authority to command and controlthe kind of rapid, preventive and contact tracing activ-ities deployed by Nigeria. Instead, the CDC must be ex-pressly invited by a State government in order to effectpublic health responses at a local level. Perhaps as a re-sult, we have seen everything from misdiagnoses, to de-layed treatments, accidental in-hospital transmissions,and quarantine policy reversals regarding quarantine forhealthcare workers returning from West Africa, and aregrettable politicisation of the public health response.Second, it should not take an epidemic of unprece-dented proportion, such as this Ebola crisis, to acknow-ledge that learning can run from the so-called “GlobalSouth” to the “Global North”. So deeply entrenched arethe expectations that technical expertise flows only oneway, that our mental blinders do not allow us to con-template anything else in reverse. Sadly, this mentalmodel has marked the global health dialogue on the sub-ject of Ebola. The World Health Organization, the CDC,Médecins Sans Frontières (MSF), and UNICEF, all workedalongside the Nigerian government during the Ebola out-break [7,9]. What were some of the lessons they learnedand how can those lessons be adapted in other settings,his is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Harris et al. Globalization and Health  (2015) 11:16 Page 2 of 3including in the US? This should be a critical compo-nent of the development agenda, particularly as wemove into intense dialogue around sustainable devel-opment goals in 2015. This journal’s dedicated open-access series on reverse innovation in global healthsystems aims to challenge conventional thinking bycollecting evidence of bidirectional learning beyond theEbola response [11,12]. Only by harvesting and actioningsuch questions will we be able to recognize the true po-tential of global innovation flow for health systems butperhaps beyond [13].Since the outbreak began, there have been 24,247 re-ported Ebola cases and 9,961 reported deaths in ninecountries [9]. On 20th October 2014, Nigeria was de-clared Ebola free [14] (WHO). Nigeria was able to winthe battle against Ebola not only as a result of “doing theright things” but also because it drew on its strengthsfrom past successful experiences, such as recent polioeradication campaigns [7]. With a dense population andoverburdened infrastructure, Nigeria’s case prompts therecognition that preparedness depends on the corestrengths of health systems. Indeed, increasing attentionis now being placed by global partners and national au-thorities across Africa on health systems resilience forboth Ebola affected countries and those seeking to bol-ster their abilities to respond to all potential hazards. Forexample, infection prevention and control – a core attri-bute of patent safety laid bare during the Ebola outbreak – requires strengthening of “everyday” health ser-vices. This needs to take into consideration issues relatedto workforce capacity, supplies of essential consumables,data & information, organization of health services alongwith quality improvement processes. Nothing comeseasy in health systems strengthening but the gains arelong term.Clearly, not enough has been done to support well-functioning health systems in many African countries,but the US too is no exception to this rule. As each ofthe three high-transmission countries now moves for-ward on the immediate priority of getting to zero cases,a simultaneous emphasis is being placed on early recov-ery with a specific attention on the re-activation ofessential health services. Multiple priorities emerge –immunization, malaria control, integrated managementof childhood illness, maternal health to name a few.The challenge is to integrate these priority interven-tions within a comprehensive, people centred approachto re-designing service delivery with people and notdiseases. Further, efforts to strengthen preparedness forfuture outbreaks needs to be integrated with the deliv-ery of services using a “one health system” approach.Might there also be lessons that emerge from thisupcoming effort here for the world? We believe thatharvesting insights from these experiences will beimportant for the global pool of knowledge, for allcountries.Rare, novel infections like Ebola will continue to testour ability to respond to diseases. When the currentcrisis dies down, we might realise that strengtheninghealth systems is actually a good plan for any disease oroutbreak, not just for Ebola. At the same time we mightalso recognize that the fluid and rapidly evolving healthsystems in African countries may hold multiple ‘goldennuggets’ that can be utilized to strengthen systems inthe US and elsewhere in the world. This requires agreater appreciation that examples of best practice cancome from anywhere and flow anywhere, includingfrom the “global south” to the “global north”.Author details1Commonwealth Fund Harkness Fellow in Healthcare Policy and Practice,New York University, New York, USA. 2Visiting Scholar, Johns HopkinsUniversity Bloomberg School of Public Health, Baltimore, USA. 3Center forHealth Services & Outcomes Research, Johns Hopkins University BloombergSchool of Public Health, Baltimore, USA. 4Johns Hopkins UniversityBloomberg School of Public Health, Baltimore, USA.Received: 22 January 2015 Accepted: 23 March 2015References1. Frieden T, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014 — NewChallenges, New Global Response and Responsibility. N Engl J Med.2014;371:1177–80. September 25, 2014DOI: 10.1056/NEJMp1409903.2. Fasina FO, Shittu A, Lazarus D, Tomori O, Simonsen L, Viboud C, Chowell G.Transmission dynamics and control of Ebola virus disease outbreak inNigeria, July to September 2014. Euro Surveill. 2014;19(40). Available online:http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20920.3. Courage K. How Did Nigeria Quash Its Ebola Outbreak So Quickly? ScientificAmerican. Oct 18 2014 Available online: http://www.scientificamerican.com/article/how-did-nigeria-quash-its-ebola-outbreak-soquickly/AccessedDecember 2014.4. Kroll D. An Ebola Outbreak Contained: What U.S. And Other Nations CanLearn From Nigeria. Forbes Magazine Oct 20th 2014 Available from http://www.forbes.com/sites/davidkroll/2014/10/20/what-can-africas-ebola-containmentsuccesses-teach-other-nations/. Accessed December 20145. Poon L and Qusit-Arcton O. I'll (Gag) Drink To That: Oral Rehydration KeyFor Ebola Patients. National Public Radio October 23, 2014 Available atwww.npr.org/blogs/goatsandsoda/2014/10/23/358108367/ill-gag-drink-to-that-oral-rehydration-key-for-ebola-patients. Accessed December 2014.6. Neporent L. Valuable Ebola Lessons the US Can Learn From Nigeria. ABCNews Oct 20, 2014 Available at http://abcnews.go.com/Health/valuable-ebola-lessons-us-learn-nigeria/story?id=26323556 Accessed December 2014.7. Shuaib F, Gunnala R, Musa E, Mahoney F, Oguntimehin O, Nguku P, et al.Ebola Virus Disease Outbreak — Nigeria, July–September 2014. Morbidityand Mortality Weekly Report (MMWR). 2014;63(39):867–72.8. UNICEF. In Nigeria, texting to prevent Ebola. 13 October 2014 Available athttp://www.unicef.org/infobycountry/nigeria_76251.html AccessedDecember 2014.9. WHO. Ebola Response Road Map Situation Report. March 11th, 2015. http://www.who.int/csr/disease/ebola/situation-reports/en/ accessed March 14th2015.10. Starfield B. Is US Health really the best in the World? JAMA July 26, 2000;284(4):483-485. doi:10.1001/jama.284.4.483.11. Syed S Dadwal V, Rutter P, Storr J, Hightower J, Gooden R, et al. Developed-developing country partnerships: Benefits to developed countries? http://www.globalizationandhealth.com/content/8/1/17.12. Globalization and Health. (2013, February 5). Reverse innovation in globalhealth systems: Call for papers. Retrieved March 9, 2015, from BioMedCentral Blog: http://blogs.biomedcentral.com/on-health/2013/02/05/reverse-innovation-in-global-health-systems-call-for-papers-2/Harris et al. Globalization and Health  (2015) 11:16 Page 3 of 313. Syed S, Dadwal V, Martin G. Reverse innovation in global health systems:towards global innovation flow. http://www.globalizationandhealth.com/content/9/1/3614. WHO Mediacentre is an online source. I suggest the citation read as follows:WHO. Media Centre. WHO declares end of Ebola outbreak in Nigeria. 20October 2014 Available from www.who.int/mediacentre/news/ebola/20-october-2014/en/ Accessed December 2014Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

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It takes threat of Ebola to see lessons from low income countries

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