Ebola –Mano River Union, a marriage in crisis
January 2015 – J Boima Rogers
When the leaders of Guinea, Liberia and Sierra Leone decided to form the Mano River Union (MRU), they were formalising a relationship between countries that are intertwined in geography, economics, history, ethnicity, culture and cuisine, held together by the Mano River like an umbilical cord that weaves through them. Health issues were not paramount and so were not included in the protocols, rather the focus was economic development and politics. Perversely, Ebola has highlighted the common destiny of these countries. The spread of Ebola, starting in Guinea was therefore not surprising given the formal and even stronger informal ties between these countries. Ebola had first been identified in Sudan and Uganda in 1976 but the epidemic in these three countries is an entirely new phenomenon in terms of the speed, ferocity and duration. It spread like wildfire from Guinea to Liberia and Sierra Leone and then to Nigeria, Senegal and Mali although these other countries have since been declared free of the disease. This paper looks at the magnitude of the epidemic, why it has been so devastating in these countries, some encouraging developments and the way forward.
An Epic and long lasting damage
Ebola has killed thousands, exposed and devastated the fragile health and wider infrastructure and cost billions in lost economic output of these three countries, two of which, Sierra Leone and Liberia, are still recovering from the ravages of civil wars in the 1990s and the early part of this millennium. The West African region and Africa as a whole are suffering economically.
As can be seen from the table above, the epidemic has been devastating with 21,614 infections and a mortality rate of 40% as of 20th January 2015. Some interesting patterns have developed. Guinea, where the epidemic started has had the lowest number of cases and deaths although it also had the highest mortality rate of 65%. Liberia which had for a long time reported the highest number of cases has seen a dramatic reduction in cases reported and has now been surpassed by Sierra Leone although the mortality rate is lower in the latter.
The economic cost of the epidemic is huge to these countries, the region and the continent. It is really sad because these countries and Africa as a whole had been looking forward to rosy economic growth rates, with the economy in Sierra Leone for example forecasted to grow by 11.4% in 2015 by the World Bank before the outbreak. In 2013, seven of the ten fastest growing economies in the world were in Africa and that trend was expected to continue in 2014. The latest World Bank estimates for foregone GDP output are US$ 180 million for Liberia, U$540 million for Guinea and US$ 920 million for Sierra Leone bringing the total to US$ 1.66 Billion for the three countries. The World Bank forecasts the epidemic to cost Sub-Sahara Africa up to US$ 6 Billion, which although much less than the initial estimate of US$ 25 Billion, is still substantial. These costs are very much on the low side as economic activities have come to a standstill in the three most affected countries and the effect on Africa as a whole has been underestimated. In particular, the estimates for the three countries do not appear to take into account the loss of output through other diseases like Malaria, which have been ignored because of the overwhelming focus on Ebola. The estimates are also unlikely to take into account the loss as companies avoid trade and investment in the region and Africa as a whole. This is partly the result of biased media, which routinely reports the epidemic as a West African or even African issue ignoring the fact that the epidemic is concentrated in those three countries.
Why such a devastation?
In a paper by the World Health Organisations (WHO), the magnitude and spread of the disease was attributed to insufficient number of qualified health workers; inadequate surveillance and information systems; absence of and/or weak rapid response systems; few laboratories, all of which are in urban centres; unreliable supply and procurement of PPEs and other supplies; lack of electricity and running water in health facilities; few ambulances; limited health education, community outreach and engagement health programmes.
The main reason why earlier cases did not spread out as widely and ferociously as this epidemic is because they occurred in isolated communities. The spread of the current epidemic is largely because of the much better transport network and strong links between these three countries. These strong links fostered the spread of the disease but since there was no formalised structure in the MRU treaty for health issues the countries did not have the mechanism to take appropriate measures.
The deficiencies in the health infrastructure of these countries are reflected in statistics provided by WHO. Government expenditures on health per PPP at $7 in Guinea, $10 in Liberia and Sierra Leone are much lower than the $63/PPP for the African region as a whole. The number of physicians and nursing and midwives as a proportion of the population are abysmally low as the table below shows.
|Health Expenditure and Workers|
|US$/PPP||Doctors/10,000||Nurses and Midwives/10,000|
|Source: The World health Organisation|
Some Encouraging Developments
While the epidemic is still ravaging these countries, there are some encouraging developments with infection rates down sharply in Liberia and Guinea. The strong and swift actions by Nigeria, Mali and Senegal show that this scourge can be defeated through prompt and resolute actions. After some procrastination by major powers, recent efforts, led by the US, the UK and France have undoubtedly been very helpful in the significant progress in the fight against the epidemic. The speed at which governments and organisations are taking measures to find vaccines and a cure for the disease is unprecedented. This paper was inspired by a presentation by Professor Trudie Lang, Director of The Global Health Network (GHN), a unit set up by Oxford University to deal with such health issues. This unit has set up regional centres in developing countries, including one in Kenya, with the objective of capacity building, making use of the digital platform and networking of government and health organisations. In the few years since the unit has been set up, it has notched up some very impressive gains that are helping in the fight against the epidemic. Its focus on community health workers, the frontline troops, has seen a dramatic engagement of these workers using the digital platform to share information. These efforts have led to increased utilisation of health resources, notably equipment used for projects that have been completed that would otherwise lie idle. GHN’s digital platform works like a dating website, allowing transfer and sharing of technology and expertise. The unit has been in the forefront of mobilization of health workers in the UK for Liberia and Sierra Leone. Dr Lang reported that the setting up of a Clinical Trial Platform (CTP) for Ebola drugs has taken three months, a sixth of the normal time of eighteen months.
New technology can be a powerful tool in the fight against Ebola and other similar epidemics but this has yet to be fully embraced. Big Data and the mobile phone revolution are pivotal in the fight against such epidemics. The potential of Big Data in interrogating data, as a predictive tool and facilitating procedures, is yet to be fully realised. This potential relates to the size and speed of data that can be analysed, the fact that unlike traditional statistical tools which have linear or other fixed relationships between variables this tool is free style and it operates in real time.
A comment at the seminar that inspired this paper illustrated the challenges in the full utilisation of Big Data, it was noted that “data is not knowledge, it still needs analysis and how do you get rid of the clutter”. Another issue for health workers relates to privacy. The solution with regards to Big Data is for stakeholders to index and document procedures and for health workers and computer experts to work together in defining and standardising indexes, procedures and queries. As Dr Stefano Bonfa and I noted in our paper, smart city is a smart move, the privacy issue can be resolved by making data anonymous and imposing strict limits on accessibility. In any case, in a situation like the current Ebola epidemic, the privacy issue is of little importance. Mobile telephone technology can also play a big role in the fight against Ebola and other epidemics, notably, in developing early warning systems, mobilising and targeting resources.
A bright spot in the fight against the epidemic is the prompt and exhaustive victories by Nigeria, Senegal and Mali in eradicating Ebola. This is significant for a number of reasons. Firstly, it demonstrates that prompt and resolute action can defeat the spread of the disease. The measures taken by these countries can be used as a template for future epidemics. Finally, it demonstrates that African countries, with limited resources, can overcome this scourge.
The way forward
The Ebola epidemic is a game changer for the affected countries, region and the world. We live in an increasingly interconnected world where Ebola and such epidemics are and will not be just a problem for those countries affected but can reverberate across the globe. Ebola will occur again and Africa and the world must be prepared. Lessons can be learned which can benefit the affected countries, rich countries and health care organisations and companies.
The countries affected must apportion larger proportions of their budgets and resources to the health sector and develop and maintain their health and wider infrastructures. These improvements, according to WHO, should include more and better paid nurses and doctors, integrated health systems, laboratories and early warning systems covering the whole country, including rural areas. They should ensure “national ownership, local action and full support of development partners”.
Regional groupings must include health in their protocols so that they can coordinate efforts to avoid and/or minimise the rapid spread of such epidemics. It should be noted that none of the sixteen regional groupings of African countries has a health protocol in their agreements, Ebola should change that. Development partners in rich countries can assist with aid for health systems, in particular, they should assist African countries to develop their capacities. The GHN initiative is an excellent example and the Kenyan centre should be replicated in other regions on the continent. The focus, as Dr Lang stated, should be on capacity building and technology transfer so that these centres can build roots in the communities they serve.
Greater use should be made of technology, notably, digital platforms. Big Data can be used in accelerating CTP, improving the efficiencies of processes, bringing new drugs into production and targeting affected areas. Policies and procedures must be indexed and standardized by all stakeholders; health care workers must work closely with computer experts to make full use of new technology. This policy can start now but will be paramount when a review is made of the epidemic. Greater use can be made of mobile phone networks for sharing information and establishing early warning systems. Rich countries will benefit from their efforts on Ebola and other similar epidemics because it will prevent such diseases reaching their shores.
Organisations and health care companies can benefit a lot from the data and procedures in such efforts. The phenomenal reduction in the time taken to set up the CTP for Ebola by Oxford University has huge positive implications for the university, other organisations and companies in the health sector and future epidemics. Firstly, even though it was the result of concerted effort by all stakeholders, working flat out, it showed that it can be done and creates a precedent that will encourage the health sector to facilitate procedures for other CTPs even when there is no crisis. Furthermore, Big Data, which was not used in this instance, is increasingly being used by companies to rationalise the workflows for such processes. This means that in the event of a similar epidemic, a combination of concerted effort, as was the case this time and use of Big Data could result in even further efficiencies, quicker responses and more lives saved.
J Boima Rogers is the Principal Consultant at Media and Event Management Oxford ( MEMO). MEMO provides policy, marketing and project, event and media management services. http://www.oxfordmemo.co.uk.