09.04.14

Ebola and September 11: National traumas, heroes, enduring legacies, and a Framework Convention on Global Health

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Josephine Sellu, a nurse survivor in Sierra Leone. Courtesy of the New York Times [http://www.nytimes.com/2014/08/24/world/africa/sierra-leone-if-they-survive-in-ebola-ward-they-work-on.html]

Josephine Sellu, a nurse survivor in Sierra Leone. Courtesy of The New York Times

343. For many Americans, that number will always be shorthand for heroism and sacrifice, for risking your own life to save others. It is the number of firefighters who died in the September 11 attack on the World Trade Center, among the 414 emergency workers killed that day. (The actual toll due to increased levels of cancer and respiratory illnesses among first responders is higher.)
134. That number, almost sure to grow, represents the health workers in Liberia, Sierra Leone, Guinea, and Nigeria who have fallen victim so far to Ebola during the present West African outbreak.
The firefighters of September 11, the health workers on the frontline of Ebola, both have placed the lives of others above their own, risking all to carry out the life-saving responsibilities of their chosen professions. A New York Times article details the tragedy, resilience, and heroism of workers at one government hospital in Sierra Leone, which lost 22 health workers to Ebola. Fifteen nurses died there, most early in the outbreak when they lacked the full body personal protective equipment that health workers treating people with Ebola require. We are reminded, too, of the commitment of often forgotten members of health teams, such as cleaners at high risk of coming into contact with body fluids of Ebola victims, drivers who bring Ebola victims to the hospital, and people who handle the bodies of those who have succumbed to the virus.
Josephine Finda Sellu, the hospital’s deputy nurse matron, is one of only three nurses who were at the hospital at the start of the Ebola outbreak and have managed to avoid infection. She captures the courage of so many health workers who have remained at their posts despite the immense risk: “You have no options. You have to go and save others. You are seeing your colleagues dying, and you still go and work.”
After September 11, New York City took steps to create a safer future for NYC firefighters, giving them and other emergency workers a greater chance of surviving a future disaster by improving the NY Fire Department communications systems, including better integration with the police and other emergency services.
What will be the legacy of Ebola? Will the legacy be akin to that of September 11, with focused, important steps – such as the improved communication systems – but with a broader legacy of missed opportunity and even misdirected responses?
The response to September 11 was largely of a traditional security paradigm, from the military response to greater airport security and efforts to identify and stop funding to terrorist groups. This was not surprisingly, even as the dominance, length, and difficulties of the military campaigns, much less the chain of events that has followed, were not part of anyone’s plan. And it led to actions, from torture and indefinite detention to a war that might have been avoided and drone strikes that have killed many innocents, that are deeply at odds with our values.
I remember back after September 11 the hope so many had that the United States would seize on the tragedy to do more than try to root out terrorism, to pull that poisonous plant out of the ground. Rather, our nation would be a model of positive proactivity, leading a global effort to address root causes, to transform the soil that nourishes hatred and a willingness, even desire, to kill, into something better, into fertile ground for hope, for successfully facing some of our greatest challenges.
After September 11, the United States could have chosen to mobilize the world for a clean energy future, mitigating climate change while shifting global power dynamics away from oil-producing states that finance activities contributing to extremist ideologies. We might have looked to the conditions that drive people to join extremist and terrorist organizations, factors like alienation and the poverty. In response to an act of evil, we could have responded through the force of good, focusing on integrating people and communities who feel that their dignity is not respected into national fabrics, and stepping up efforts to fight poverty and its manifestations, including ill health and lack of education.
Returning to Ebola, the world would do well to respond at both the narrower and broader levels. At the narrower level, as the communication system changes in New York made for a safer New York Fire Department, simple measures to ensure effective infection prevention and control will create safer working environments for health workers and their patients. These include ensuring adequate supplies, along with appropriate training, protocols, and vaccination (in particular, for Hepatitis B). Protecting themselves from Ebola requires health workers to wear spacesuit-like personal protective gear, but in many developing countries, even far more basic protections, such as gloves, are in short supply. Other forms of protections that should be standard, like injection devices with safety features to protect against an infection-transmitting needlestick injuries, might not be available at all.
This alone, though, will be would hardly be a fitting legacy to a disaster where countries have seen ordinarily life come to a halt, where before the outbreak is over thousands, almost surely many thousands, will be dead. It would hardly be a sufficient legacy for Josephine Sellu and her colleagues, those who have survived and those who have not. Perhaps most of all, it would be an opportunity lost, in particular, to create strong health systems and a broader framework for global health.
Rarely does the world give much attention to the severe health system deficits that have enabled this Ebola outbreak to wreak such widespread destruction. Consider, for example, that Sierra Leone would need nearly 20 times its present number of doctors, nurses, and midwives (based on health workforce levels in 2010) to reach minimum threshold of health worker levels proposed by the International Labour Organization (see page 17 of the document) to provide essential health services to all people. Or that if Liberia’s population were the same as that of Washington, DC, that country would have fewer than 15 doctors. (Washington in fact has about 4,000 practicing physicians, nearly 3,000 who practice more than 20 hours a week, yet this is considered a shortage.)
What about, then, building well-functioning health systems as the broader legacy, with investments, policies, and actions that would save literally millions of lives?
Perhaps this could occur through a proposed Health Systems Fund. As lower-income countries must also step up their own investments, wealthier countries should rapidly and massively scale up support to ensure the funds required to enable all countries to develop the capacities to quickly contain disease outbreaks and to ensure quality health systems that can provide rights-based universal health coverage to all people.
And too, what of a Framework Convention on Global Health? A treaty that would establish a framework for these investments, but would do far more: empowering people to more effectively claim their right to health, ensuring participatory and accountable health-related policies and processes, addressing the national and global drivers of health inequities — inequities that we see so starkly today as we look to West Africa. As addressed in this AllAfrica.com posting on the FCGH and Ebola, an FCGH would catalyze actions to build the well-functioning health systems and community trust that have been so tragically lacking. And an FCGH would establish a platform for and send a message of global health trust and cooperation. It would establish in binding law upon all nations that adopt it what should be a basic commitment that has been startlingly absent in the current pandemic: The health of all people is a common concern and mission of all nations, and we will cooperate in taking all necessary measures – from responding to crises to enduring actions – to achieve that mission. (You can endorse the need for such a treaty at: http://www.globalhealthtreaty.org/endorse-the-fcgh-platform/.)
Now this would be a legacy worthy of the scale of the crisis, of the health workers who have given their lives to their fellow human beings, of heroes like Josephine Sellu, of the pain and suffering of the untold thousands who have become for the world a statistic in a growing toll of infected and dead, but who lived as people, not numbers.
Will an FCGH, a new global drive for ensuring the health of all people, as matter of right, be a legacy of Ebola? It’s in our hands to determine.

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