Overcoming distrust to deliver universal health coverage: lessons from EbolaBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5482 (Published 23 September 2019) Cite this as: BMJ 2019;366:l5482
All rapid responses
“Insanity is doing the same thing over and over and expecting different results.” Einstein
The analysis of the Ebola outbreak in Liberia highlighting the role of distrust in health systems should have performed a root cause analysis, focusing on the biosocial complex (i.e. interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction) and questioned the trust in WHO and International organizations.(1)
First, 42 (76%) of the 55 outbreaks of viral haemorrhagic fevers affected West Africa.(2) Coincidentally, West African people suffer from trust in religious or cultural obscurantism: Guinea and Sierra Leone rank top for prevalence of female genital mutilation in the world!
Second, Liberia’s “corruption perception index” decreased to 32/100 in 2018, ranking it 120th among 180 countries. Liberia is the world second maritime ‘tax haven’ and corporations can be registered online without obligation to declare owners or file annual reports and issue “bearer shares”, an instrument for money laundering banned everywhere else. In 2014, the US Ambassador dare to state "Corruption remains a serious problem in Liberia” (http://allafrica.com/stories/201402211033.html)
Third, during 2011-2107, Liberia military spending was over $15 million/year vs $5 in 2007. Health expenditures decreased from 14% of GDP in 2009 to 10% thereafter. In 2014 Liberia’s ambassador to the US said the country has closer to 50 doctors (1/90,000 citizens) (https://www.washingtonpost.com/world/africa/liberia-already-had-only-a-f...) As there are 54 soldiers/100,000 people, the UN Security Council should have called for deploying military personnel to fight the healthcare crisis.(3)
Fourth, the problem is also outside Africa when considering the role of Monetary Financial Institutions and the WHO:
a) On May 21, 2014 the Ministry of Health for Guinea reported 258 cases (174 deaths) of Ebola. Meanwhile (May 19–24), WHO held its annual meeting at the “Palais des Nations” with more than 3,500 participants. Its first statement about the outbreak was issued on 8 August 2014 (http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/)
b) Then after, the WHO issued a “new guideline for rapid advice guidelines” (4), a desperate headlong rush of an opulent bureaucracy with a puzzling record.(5) Indeed, in 2019 the Lancet most rapidly published on July 5th correspondence from Giesecke, on behalf of WHO STAG-IH ,(6) explaining the WHO Director-General's decision “the Ebola virus outbreak in DR Congo does not constitute a Public Health Emergency of International Concern (PHEIC)” but not answering four questions, (6) two positive responses being enough for PHEIC: a) Is the public health impact potentially serious? b) Is this event unusual or unexpected?; c) Is there the potential for international spread; d) Is there the potential for travel and trade restrictions?(7)
A month before, Maxmen and Reardon questioned why WHO enduringly resisted _third time, then_ declaring Ebola emergency despite: a) 1,400 deaths on June 12th; b) virus spread into Uganda; c) 50 people being killed during a surge of violence in a province with Ebola.(8)
Last, WHO said it needs at least another $54 million in donations against Ebola. In 2017 it spent $200 million on travel costs vs $71 million on AIDS and hepatitis, $61 million on malaria and $59 million on tuberculosis (https://nypost.com/2017/05/21/who-spends-more-on-five-star-hotels-than-f...)
Corruption may be the cornerstone with two sides. On July 4th Transparency International issued its report about Africa with a specific highlight for DR Congo’s record: “findings are far worse than in most other African countries”.(9) For the 2009 H1N1 outbreak classified PHEIC by WHO, a bonanza for Big Pharma, experts claimed their decision was not related to their links of interest.(10)
1 Woskie LR, Fallah MP. Overcoming distrust to deliver universal health coverage: lessons from Ebola. BMJ 2019;366:l5482.
2 Pigott DM, Deshpande A, Letourneau I et al. Local, national, and regional viral haemorrhagic fever pandemic potential in Africa: a multistageanalysis. Lancet 2017. Online Oct 11. doi: 10.1016/S0140-6736(17)32092-5.
3 Braillon A. Ebola and the UN's responsibility to protect. Lancet 2014;384:2208.
4 Garritty CM, Norris SL, Moher D. Developing WHO rapid advice guidelines in the setting of a public health emergency. J Clin Epidemiol 2017;82:47-60.
5 Braillon A. Global health challenges facing bureaucracy: democratization or revolution? Public Health 2014;128:1134-5.
6 Giesecke J on behalf of STAG-IH. The truth about PHEICs Lancet 2019. Online July 05. doi.org/10.1016/S0140-6736(19)31566-1
7 Durrheim DN, Crowcroft NS, Blumberg LH. Is the global measles resurgence a "public health emergency of international concern"? Int J Infect Dis 2019;83:95-97.
8 Maxmen A, Reardon S. World Health Organization resists declaring Ebola emergency - for third time. Nature 2019;570:283-284.
9 Transparency International. Why do DRC citizens report such high levels of corruption? 2019 July 11.
10 Butler D. Flu experts rebut conflict claims. Nature 2010;465:672e3.
Competing interests: No competing interests