10.06.14

Medical evacuations for West African Ebola patients: The unspoken possibility

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Time and again, the global community finds a way to express its collective view – the view of the powers-that-be – that some members of our community are worth less than others, that lofty rhetoric and human rights law to the contrary, your life means less to the world if you are poor. And so we see it again in the response to Ebola.
I refer to policies on medical evacuations of Ebola patients from West Africa. Foreigners who are infected are evacuated to their home country, where they have an enhanced chance of surviving. Citizens of Liberia, Sierra Leone, and Guinea, though, have no such lifeline. Medical evacuation is not an option even if there is no bed for them in a treatment center, and they are to be sent back to their community, more likely than not to perish. Home they will go, to communities where they will be shunned, and where lack of isolation means that they may further spread the virus, contributing to the exponentially growing number of deaths and infections in Liberia and Sierra Leone, the hardest hit countries.

medical evacuation plane inside CDC Reuters Sept 2014

Inside of jet equipped for medical evacuations of Ebola patients. Image courtesy of CDC/Reuters.


The possibility of medical evacuation of West Africans does not appear to be receiving serious consideration. Even as the United Nations has, to its credit, recently stepped in to fill a leadership gap, its September 16 overview of requirements to confront the epidemic includes medical evacuations as among the non-financial needs, but explicitly for international staff. Likewise, the UN Security Council includes the need for medical evacuation facilities in a section of its September 18 resolution that is about international medical and humanitarian relief workers.
I find it hard not to conjure up images of Western troops swooping into Rwanda in 1994 to rescue their nationals, leaving behind the Rwandans who were their friends and co-workers, who were seeking shelter in the same places, and who left behind had little chance of escaping the ongoing genocidal slaughter.
Yet particularly for a world that was devastatingly slow to respond, and with the number of new infections in Liberia and Sierra Leone continuing to rise quickly, medical evacuation of citizens from those two countries, and if needed those of other countries in the region, deserves serious consideration – and I would say, action. There are at least four reasons; you, the reader, might think of more. Here they are:

First, this will save lives. While there is no cure for Ebola, good medical care, including providing patients fluids and electrolytes, maintaining blood pressure and oxygen levels, and treating any other infections, all increase the chance of survival. (There is some reason to believe that transfusions of the blood or blood plasma of Ebola survivors, with antibodies against the virus, will help increase survival, but this is not scientifically confirmed.) When Ebola patients are turned away from treatment centers because they are already full (or for those who never arrive), such treatment is not an option, and they are less likely to survive. Notably, while most medical evacuees in the present outbreak have survived, a recent estimate of the overall fatality rate for this outbreak is about 70%.
Second, medical evacuations of members of local populations will reduce transmission, thus slowing the spread of Ebola, helping end its harrowing rise. When people who may have Ebola return to their communities because there is no room at treatment centers, they may very possibly spread the disease – unless they return to community settings that minimize this risk, such as having care units (where they can be safely and humanely isolated) and having adopted safe burial practices. A recent CDC study used the speed at which countries reach the 70% level of Ebola patients in treatment centers or other settings that reduce the risk of transmission in charting two vastly different paths, from getting the virus’s spread under control within several months to the number of new infections continuing to spiral out of control, into the hundreds of thousands and beyond. Yet as of late September, only 18% of Ebola patients in Liberia were in hospitals or other settings with reduced chance of transmission. The more the disease spreads, not only is the toll greater in every way, from lives lost to economies ruined, but the cost to the world of treating it – and risk of unplanned transmission to other countries – increases.
Third, helping save a particular set of people – local health workers – is a critical component of slowing the epidemic, as a shortage of health workers is one of the major obstacles to an effective response. Just last month, for lack of funding, WHO was unable to facilitate transport of an Ebola-stricken Sierra Leonean doctor to a medical facility in Germany that was ready to receive her. Doctors are terribly few in Sierra Leone (and Liberia and Guinea). Dr. Olivet Buck soon died, the fourth doctor in Sierra Leone to die of Ebola. This is a country that had only 136 doctors as of 2010.
Dr Olivet Buck

Dr. Olivet Buck. Image courtesy of Picasa.


Along with the medical urgency of keeping alive health workers treating Ebola is the fact that, like foreign health workers, local health workers ultimately are choosing to put themselves on the front line of the disease. After all, as understandably many have, they can choose not to show up to work due to fear of infection. Guaranteeing the best possible medical care may prove a powerful – and much deserved – incentive to draw them back to their health facilities.
And fourth, evacuating West Africans is a necessary moral statement. That the international response seemed to ramp up only months into the outbreak after several American aid workers (who were evacuated and recovered) became infected is a double stain on the international conscience. The first was the delay itself, and the second was that it at least appeared to take infections of Americans – rather than far greater numbers of people in poor countries in West Africa – to mobilize a greater response. The current disparity in how medical evacuations are handled – foreigners, yes, Africans, no – only furthers this evident differential value given to lives of people from poor countries, people from Africa, compared to people from wealthy countries, from the West. (At least two Africans who were part of the Ebola response in Sierra Leone – a Ugandan doctor with an Italian NGO and a Senegalese expert with WHO – have been medically evacuated, to Germany.) The moral – or rather, immoral – impression this leaves, that of the global community (and its most powerful actors) viewing lives of people from poorer countries and certain regions of the world as less valuable than those of other people, stands to be another awful legacy of this Ebola outbreak. Medical evacuations of West Africans themselves could mitigate this message, moving closer one of respect for the rights and dignity of all people without discrimination.
Now, the scale of medical evacuations that would do the most to save lives and stifle the spread of infection is, admittedly, daunting, given the need for specially equipped planes and medical teams to evacuate patients, as well as isolation wards ready to house them. (If you are interested, the Spanish government provides a detailed protocol for Ebola medical evacuations.) With the growing rate of infections, the number of people who would need to be evacuated to have the best chance at life and to avoid (further) transmitting the disease would likely reach into the thousands before sufficient numbers of new treatment facilities in Liberia and Sierra Leone are built.
But these obstacles could be overcome, at least in significant part. For example, hospitals in the United States frequently have isolation wards where patients with Ebola can be treated; the Dallas hospital where the person diagnosed with Ebola in the United States is being cared for is a case in point.
We know that the lack of health workers, including foreign health workers, has been a major impediment to the response. A large-scale medical evacuation effort would require a significant number of medical teams, which could risk diverting already scarce human resources from where they are most urgently needed, staffing the treatment centers in the affected countries (and performing other functions, such as community education and contact tracing).
But are there untapped human resources? What about calling military health workers? The U.S. army alone has more than 5,000 doctors and 11,000 nurses in their Medical and Nurses Corps, respectively, along with thousands of combat medics and other health professionals – and the additional health professionals in the other branches of the U.S. armed services. And there are of course additional health workers in the armed services of other countries.
And perhaps there are other foreign health workers who could be tapped, to add to those already volunteering. Would financial incentives or other measures (e.g., ensuring their jobs will remain if they volunteer, medical/nursing school debt forgiveness) lead to more? Indeed, apart from the health workers needed for medical evacuations, would these measures or deploying military health workers help fill the current gap?
There are very few planes equipped for medical evacuations of Ebola. According to a private company that the State Department has contracted with for Ebola evacuations, it had the only two planes in the world so equipped, and was preparing a third. Even if this is this case, other planes can be prepared for such evacuations. In August, the Spanish military prepared an Airbus A310 overnight to evacuate an infected Spanish priest. The Italian military, Red Cross, and health workers used a self-contained isolation unit on a cargo plane in a full-scale training exercise to prepare for a possible Ebola evacuation. If lack of runway space for medical evacuations, on top of other growing demand for airports in the area as the international response ramps up, is an obstacle, the military is quite experienced in repairing and creating airstrips; indeed, they will be repairing [requires password] and expanding the airport in Monrovia.
Other logistical challenges would need to be worked through, such as how to handle people, suspected of having Ebola but for whom there is no room at treatment facilities, while they wait for testing to confirm that they have Ebola, before possible medical evacuation? Perhaps one of the treatment facilities soon to be constructed in Liberia could, at least for Liberia, serve as a transit point for patients before being evacuated, or another facility built for very short-term, humane, isolation, and where some initial care could be provided. Mobile labs, reducing the time of diagnosis from several days to only several hours, may obviate this concern.
Then there is money. Each of the August medical evacuations of two U.S. aid workers cost $200,000. There would also be consider costs of treatment in isolation units in hospitals in the United States and elsewhere. Expensive? Sure. But affordable? Absolutely. Take the cost of medical evacuations themselves, and assume that 1,000 West Africans were medically evacuated – far below the need, but still not an insubstantial number. That would be $200 million (plus care upon arriving in the United States and elsewhere). Consider that U.S. investments in the Ebola response are now in the $1.2-$1.3 billion range. The costs of medical evacuations are substantial, but not out of proportion to current spending.
It would be vital that such funds are not diverted from – or slow the additional funding that will be required for – other Ebola needs, for treatment, community education, contact tracing, and such within West African countries themselves. Similarly, such funds must not be diverted from other health and development needs. They should be additional funds.
Is there a risk that in one significant sense, evacuating large numbers of patients to a number of different countries would backfire from a public health perspective? Despite all the planning, could medical evacuations – intentionally transporting the virus across national borders – lead to outbreaks in additional countries?
Any risks of this are exceedingly minimal, and must be balanced against what would be, as described above, considerable benefits in slowing the spread of the disease where we know it is raging, and saving lives. Indeed, since some risk of another person with Ebola coming to the United States will remain as long as the Ebola epidemic persists in West Africa, doing all we can – including medical evacuations – might even reduce the risk of the virus coming here in an unplanned manner.
Medical evacuations from this outbreak, at the least to the United States, Spain, Germany, France, and the United Kingdom, have been almost without incident, apparently leading to no further spread until a nurse’s assistant in Spain tested positive for Ebola, as reported today. When someone with Ebola entered Senegal, no one else was infected. And while tragically there were further infections and deaths when someone with Ebola flew into Lagos, the virus was quickly contained. These successes occurred in countries with considerably weaker health systems than countries like the United States and where the person with the Ebola infection enters the country unexpectedly, rather than in a very well organized medical evacuation, where every step of the way is carefully planned.
Notably, the third cross-border unplanned transmission outside the most affected countries, the Liberian man who recently arrived in Dallas and has since tested positive for Ebola, so far appears not to have led to any further spread. And despite mistakes in the response, all possible contacts have since been identified, people for whom risk of infections remains are under watch, and in the case of four family members, quarantined. Further spread seems highly improbable.
There would remain the very difficult question of who gets evacuated, assuming that not everyone in need for whom a treatment bed in his or her home country is not available was going to be evacuated. There are no easy answers. Given their role in fighting Ebola (and other diseases), a particularly strong case could be made for health workers. Beyond this, one could posit various possibilities. People from communities without care units and safe burial practices – and thus who are more likely to transmit the disease – might be prioritized. So might people who are deemed more likely to survive if they receive quality care (perhaps those with the fewest symptoms). Would some process be needed to ensure equity within the process – so that women benefit proportionally, for example?
Going forward, it would be advisable for countries, through a highly inclusive, participatory approach, to tackle this question of criteria for determining priority in the event of an infectious disease outbreak where the medical resources – whether vaccines, treatment, or medical evacuations – are scarce and only some can benefit. (WHO put together a very thoughtful document during the early phase of AIDS treatment scale-up.) It is quite difficult, though, to see how such a process could be established now, in the middle of the pandemic.
I know that the odds of moving towards a policy of medical evacuations for West Africans are remote. As the epidemic continues to worsen, the costs and logistical challenges of large-scale medical evacuations aimed at significantly affecting the course of the pandemic only grow, hardly the setting for a bold shift in policy. If this crisis starts to come under control, then such a radical shift in policy may seem less necessary anyhow.
Perhaps it is the radical nature, in its own way, of this policy proposal that leads to the silence around it. If we are willing to medically evacuate among the poorest people in the world to help stop the spread of a killer disease and save lives, spending hundreds of thousands of dollars per person, will this raise uncomfortable questions for the global community about insufficient global health spending? Will the global community feel pressured to begin spending far more than we do presently to fight disease, save lives, and build health systems in lower income countries?
If wealthier countries began medically evacuating citizens of the most affected West African countries, would it cease to be acceptable to consider primarily only cost-effective interventions in the world’s global health actions more generally? A World Health Organization document (page 45, footnote 4) defines “very cost-effective” interventions: “Very cost-effective i.e. generate an extra year of healthy life for a cost that falls below the average annual income or gross domestic product per person.” In other words, the value of your life has a lot to do with where you live. And if you live in a poor country – like Liberia, Sierra Leone, or Guinea – it is worth less. And not very much – gross national income per person in Liberia, Guinea, and Sierra Leone in 2013 was $410, $460, and $680, respectively.
All the more reason, then, for a world that professes human rights and inherent human dignity, for a world that professes equity and non-discrimination, to live up to its values and add medical evacuations of Liberia, Sierra Leonean, and Guinean Ebola patients to the elements of a comprehensive response to Ebola.
The virus’s spread is most probably too great to create for medical evacuations to be the solution. That may even ultimately require a vaccine or treatment. But it can contribute to slowing the spread, saving lives, and creating a new narrative of global equality, the opening chapter of a new era in global affairs. In these terribly difficult and heart-wrenching times, that would be a legacy to cherish.
 

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