From PEPFAR to Ebola response, to Zika, to next pandemic, panel looks at returns on U.S. investments in global health

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Lesson: “We’re only as safe as the most vulnerable people in the most vulnerable places in the world”

Two years after Médecins Sans Frontières advised the world to pay attention to the unprecedented spread of Ebola across West Africa, and a little more than a month after President Obama asked Congress to provide $1.8 million in emergency funding to respond to the spread of Zika virus in the Americas, a group of global health watchers gathered in Washington, DC  last week to talk about progress, stakes, and next steps needed to confront outbreaks of infectious diseases world wide.

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Dr. Ashish Jha of the Harvard Global Health Institute at a March 8 Washington, DC discussion presented by the Bipartisan Policy Center

They included Dr. Ashish Jha, director of the Harvard Global Health Institute, which with the London School of Hygiene and Tropical Medicine, assembled a panel last year to look at the global response to Ebola. When that panel began work year before last year that led it to recommend “Ten essential reforms before the pandemic,” Jha noted, its members little thought that the next public health threat of global proportions would emerge within the next 14 months.

The spread of Zika in countries lacking in basic and necessary components of public health responses, has, Jha and other panelists noted, caught the world not much better prepared than it was two years ago.

“We are only as safe in America as the weakest country in the world,” Jha said. And as tragic as the fallout from each of the most recent infectious disease outbreaks has been (from 90 to 95 percent of Ebola deaths could have been averted with a prompt international response, Jha said) the spread of both viruses has been relatively slowed by the mechanisms through which they were transmitted, compared, for example, to the speed with which airborne viruses can spread. “We’ve gotten lucky with both of them, Jha said, “and might not get that lucky again.”

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Ashish Jha, Karl Hofmann and Anand Parekh at the March 8 discussion. Hofmann is showing a mock-up of a “safe pregnancy kit” including insect repellent, condoms and informational materials to be distributed to women in low-resource areas where Zika outbreaks are occurring.

While the average Ebola case transmitted the virus to two other people, Jha added, the average measles case spreads to 18 other people.

Also there were Dr. Anand Parekh, a senior advisor of the Bipartisan Policy Center, which produced a report last year examining the President’s Emergency Plan for AIDS Relief, making The Case for Strategic Health Diplomacy, and Karl Hofmann, a former ambassador to the West African nation of Togo and now leader of Population Services International.

Both noted that the successes of the President’s Emergency Plan for AIDS Relief inspire optimism for effective global health interventions, showing as Hofmann put it, “that we can get this right,” but it is optimism with limitations, the panelists agreed.

“For strategic health diplomacy, you have to invest in the long term,” Parekh said.

And while recognizing the gains brought by the President’s Malaria Initiative as well as PEPFAR, and affirming they should continue, Jha added, “We have to make broader investments in health systems. Countries will only be safer if they have a health system that works, not an HIV system that works.”

The need for the broad and bipartisan support that made PEPFAR success possible presents another reality, though, Hofman said.

“If PEPFAR had been the President’s Emergency Plan for Health System Strengthening, it would have failed [for lack of broad and bipartisan support]” he said. “I would rather take that vertical system that works,” he said, alluding to the “silos” through which efforts to address specific diseases channel resources, “than a horizontal system that doesn’t.”

In the meantime, panelists agreed, the World Health Organization responded promptly this year to Zika, convening a panel that recognized the spread of the virus with the accompanying rising incidence of microcephaly and other neurological conditions as a public health threat of international concern. But while the response was an improvement over the agency’s response to Ebola, during which local, regional, international entities as well as WHO itself “all failed miserably at what we said we’d do,” Jha is not reassured. “There’s a spotlight on WHO,” he noted. “When the spotlight is off, will it have changed?”

He referred to the Harvard/LSHTM panel’s recommendations, which included developing international strategies to improve national response capacities, creating an accountable entity within WHO to lead and coordinate emergency preparedness and response, as well as a standing, independent committee to recognize and declare global public health emergencies, and building adequate financing for the agency to lead and coordinate appropriate responses.

Until systemic reforms are in place, he added, “I’m not going to sleep any better at night.”

One thought on “From PEPFAR to Ebola response, to Zika, to next pandemic, panel looks at returns on U.S. investments in global health

  1. David Fedson

    Ashish Jha is surely correct when he says “We are only as safe in America as the weakest country in the world”. But the crisis now unfolding over the Zika virus is unlike the Ebola crisis in West Africa or the threat of a severe global influenza pandemic. Overcoming Zika will depend initially on reducing the spread of infection through effective mosquito control and eventually on vaccination, starting with women of childbearing age. Ebola and pandemic influenza are different. Ebola was controlled by rigorous isolation of infectious cases, but it won’t be possible to contain the spread of pandemic influenza. Vaccines against both pandemic influenza and Ebola will be not be available in time to prevent infection in those at risk. Moreover, experience has taught us that antiviral treatment of patients with influenza only modestly reduces its impact on mortality. The same seems to be true of antiviral treatment of Ebola, as shown by the results of the JIKI trial in Guinea. Yet there is reason to hope. The mortality from pandemic influenza and other new emerging virus diseases like Ebola might be markedly reduced by adopting a new approach to patient treatment that targets the host response to infection, not the viruses themselves. The scientific rationale underlying this approach is rock solid, and many clinical studies have shown that inexpensive generic drugs can modify the host response to severe, life-threatening infection. In Sierra Leone, combination treatment with a statin and an angiotensin receptor blocker brought about remarkable improvement in Ebola patient survival (mBio 2015; 6: e00716-15). Treatment counteracted the microvascular dysfunction that caused massive fluid losses in these patients. The same sort of problem is responsible for the acute respiratory distress seen in patients with fatal influenza. Influenza and Ebola scientists have been reluctant to accept (or have actively opposed) treating the host response to these infections, and global health officials (including those at WHO and MSF) have accepted their views without question. For example, several “lessons learned” reports have been issued by groups of global health experts criticising the international Ebola response, yet none has mentioned the Ebola treatment experience in Sierra Leone. Instead, each report has offered a list of very expensive “top down” recommendations for reforming the infrastructure for global health. All assume that implementing these recommendations will reduce the community impact of the next infectious diseases crisis, but none offers any hope for reducing mortality among those who become infected. In contrast, a “bottom up” approach to patient treatment based on inexpensive generic drugs that are available to physicians and patients in any country with a basic health care system could improve survival, and in doing so make an immense contribution to global equity and security. Sadly, global health experts remain ignorant of (or chose to ignore) this possibility, yet the science that supports it won’t go away. These experts need to ask themselves how many more patients with be allowed to die before this approach to patient treatment gets the attention and support it deserves.

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