The West African Ebola epidemic is still far from over; but it’s never too early to start reflecting on what we have learned. For me, this was the key message from Monday’s thought-provoking discussion ‘Ebola: inside an epidemic’.
Chief Medical Officer Dame Sally Davies was joined by an expert panel: Neil Ferguson (Professor of Mathematical Biology at Imperial College), Melissa Leach (Director of the Institute of Development Studies), Christopher Whitty (Professor of Public and International Health at London School of Hygiene and Tropical Medicine and Chief Scientific Adviser at DFID) and Jeremy Farrar (Director of the Wellcome Trust) each provided updates and insights and answered questions from the fully booked audience.
So, what are the key lessons so far?
Population ‘buy-in’ is key
Melissa Leach explained that caring for the sick, at home, is an extremely important aspect of the West African communities affected by Ebola. Formal health centres or treatment units are often mistrusted (often because people travel large distances to such units to find no drugs or staff).
Leach explained that the public health recommendations during the epidemic – don’t touch people, send your sick away to a treatment unit, cremate your dead – were often seen as anti-social. Therefore, getting population ‘buy-in’ was key to success.
Focusing on burial rituals, Neil Ferguson said they explained between a third and a fifth of all transmissions, with funerals of high-status individuals within communities acting as “super spreader events”. Leach outlined the importance however of engaging with communities. Government orders that all suspected Ebola victims be cremated, such as the decree in Liberia, led in some cases to people staying away from treatment centres, or covering up deaths (a black market in death certificates sprung up) – thus potentially doing more harm than good.
However, in time, communities have started to adapt their burial rituals, making the vital changes to prevent transmission (for instance by minimizing touching). As Leach explained, you can achieve community buy-in through respectful consideration of cultural practices; looking at how these can be adapted in response to proven infection and control needs. Top-down approaches rarely work, and often lead to mistrust. To succeed, people need to be involved in the decision making process from the beginning.
Clinical research needs to be able to respond more quickly
Jeremy Farrar questioned whether the clinical research community moved fast enough in response to the Ebola outbreak.
Having listed the therapeutics and vaccines currently in development, he asked why clinical research had not ‘stepped up to the mark’. He asked whether, in the 21st century, we were able to respond to the epidemic any differently to the way John Snow would have done in the 1800’s (for the classic tale of the broad street pump, read a summary from London School of Hygiene and Tropical Medicine).
Farrar highlighted various changes that need to be made to the clinical research processes – including regulatory processes, ethics procedures and trial designs – to allow faster responses to future epidemics; explaining that we need to take therapeutics to Phase I (i.e. safety trials) before outbreaks to allow a fast enough response.
Farrar reminded us of the shift of the AIDS pandemic of the 1980s, when it changed from a death sentence, to a treatable condition. This is the goal, and we need to be faster at reaching that goal in the future.
A fundamental health system is vital, and one that is trusted
Leach described the Ebola epidemic as a “crisis of trust”, explaining that community confidence in their healthcare system was sorely needed. To build this, it is important to work with the current infrastructure.
As Christopher Whitty explained, in West Africa, since state services are often absent, the health system relies heavily on the private sector. We must work with this system, adding in improvements and introducing any necessary regulation.
During the discussion session, the panel commented that crises such as the Ebola epidemic attract more people into healthcare, many of whom remain in these professions after the epidemic has passed. They concluded that we should use this to our advantage, take on the lessons learned, and establish solid healthcare systems, so that we are ready to face what the future holds.
A full recording of the event is available, and a video will be available from 16 March.