This post was written by Eric A. Friedman, O’Neill Institute Associate, Lawrence O. Gostin, O’Neill Institute Faculty Director, Sarah Roache, O’Neill Institute Law Fellow and Daniel Hougendobler, O’Neill Institute Law Fellow. For questions or comments about this post please contact Lawrence Gostin at firstname.lastname@example.org.
Yesterday, on the same day that the United Nations issued an appeal for nearly $1 billion to control Ebola, President Obama announced several new U.S. measures in the global fight, focusing on the worst-hit country, Liberia. The President’s pledge is commendable, encompassing perhaps the first major military deployment to stem an ongoing epidemic. The U.S. military is uniquely positioned to provide sorely needed logistical support and engineering know-how, with troops well trained in dealing with the risks of hemorrhagic fevers. But even with a surge response by the U.S., global efforts are still wholly incommensurate with the enormity of the needs on the ground.
The health systems in the most affected states – Liberia, Sierra Leone, and Guinea – are shattered and must be rebuilt and strengthened, which will require investments well beyond new Ebola treatment facilities. Beyond immediate needs, the U.S. and the international community have failed to confront medium and longer-term needs. Further, there is no “plan B” such as contingency planning if the Ebola virus spreads to megacities in the developing world. Or consider what might happen if this Ebola strain mutated to become airborne, threatening the entire world, including the U.S..
The U.S. will, for the first time in this pandemic, draw on the renowned capacity of its military for aiding humanitarian relief efforts. Based in Liberia, 3,000 military personnel will help construct 17 new Ebola treatment facilities with 100 beds each, for which the U.S. will also help recruit and organize medical personnel, and train up to 500 local health workers each week. In addition, the U.S. and partners will distribute protection kits to 400,000 of the most vulnerable households in Liberia. The White House reports having spent more than $100 million on the Ebola response, with USAID planning to spend up to $75 million more. Meanwhile, the Administration is reprogramming up to $1 billion in Defense Department funds to the Ebola response. And Congress seems likely to authorize $88 million for the CDC’s response as well as for research and development for Ebola vaccines and treatments.
Wisely, the United States is limiting its military response to logistic and medical support, rather than deploying troops in a security role. Community distrust of authorities has been a significant barrier to an effective response; a security role for U.S. forces that could put them in seeming opposition to the population could extend distrust to the U.S. troops as well. As it is, Liberians are welcoming the prospect of a greater U.S. presence.
Questions remain about the U.S. and overall international response, however, with significant needs remain unmet and actions untaken. Accelerating and Expanding the Immediate Response
1. Accelerating Mobilization. The U.S. and the international community are already very late in responding, with the President’s announcement not coming until a half year after the first cross-border spread of Ebola. Now the question arises, how quickly will the U.S. military arrive, how quickly will they construct the treatment facilities, and how quickly can they be staffed? If efforts are delayed, there is the risk that health facilities will, as they have before, turn away people suspected of having Ebola, to return to their villages and possibly spread the disease further. As the New York Times reports, “Liberian officials say that 1,000 beds are needed in Liberia in the next week alone,” yet U.S. military officials have said it could take two weeks before the first military personnel arrive to set up the treatment centers.
2. Medical Evacuation for Those in Need. WHO has emphasized the urgent need to develop community “care units,” community-based facilities that can be a stop-gap measure to prevent people suspected of having Ebola from spreading the virus while they await admission to a treatment facility. These might not, however, be sufficient to give Ebola patients the greatest chance of survival. And how quickly will these be developed? The United States and others in the international community would do well to offer medical evacuation for infected patients for whom treatment beds are unavailable, helping to both contain the disease and save lives.
3. Bolstering Tattered Health Systems. Among the most conspicuous weakness of the global response is the failure to address broader health system strengthening, helping to build up affected countries’ health systems – including bolstering their small and beleaguered workforces. The U.S. will help recruit and directly provide health workers for new treatment facilities, and the UN response plan includes a call for 656 foreign health workers to staff new treatment facilities and meet other Ebola-specific needs. Yet existing hospitals and other health facilities also need shoring up. Liberia and Sierra Leone have among the world’s fewest health workers compared to their populations, health workforces that have been further battered by Ebola itself. Many health facilities in Liberia have closed as health workers have left, fearing infection. Personal protective equipment and financial incentives from the United States, the World Bank, and others may entice some workers back; incentives should be generous. In addition, the United States and other countries should provide supplemental health workers to enable these facilities to be quickly re-opened and fully staffed.
4. From a Post-Colonial Legacy to a Regional Response. As a consequence of post-colonial thinking, major Western powers have targeted their assistance to states with a shared history: the British and Sierra Leone, the French and Guinea, and the U.S. and Liberia. Liberia is the only country in Africa that emerged from U.S. colonialism, meant as a home for African-Americans, most of whom were freed slaves. American support, however, as that of France and the United Kingdom, needs to go well beyond a single country to become a regional strategy, and for several of the longer-term measures, even beyond West Africa.
5. The UN Security Council Should Act Now. Another key issue that the international community must address is the fragmented international response, beleaguered by a lack of leadership and coordination. Josh Michaud, of the Kaiser Family Foundation, bemoaned this failure: “there is no one who is really in charge with the capacity and the ability to completely lead the international response.” This has led to delayed shipments, inefficient use of resources, and a response that is “three to four months behind where it should be.”
The United Nations Security Council should take charge to establish UN leadership in coordinating the Ebola response, from the international level, encompassing all actors and organizing a response based on need rather than historic colonial ties, to the ground level, ensuring that supplies are quickly distributed to where required. Recent developments are encouraging. President Obama confirmed Tuesday that the U.S. will set up a Joint Force Command in Monrovia “to provide regional command and control support to U.S. military activities and facilitate coordination with U.S. government and international relief efforts.” The U.S. will also set up a regional staging base to transport personnel, equipment and supplies. On the same day, the UN Security Council passed a resolution extending the UN Mission in Liberia (UNMIL) until December 31, 2014. UNMIL will continue monitoring human rights and maintaining security, and will facilitate humanitarian relief efforts in response to the Ebola crisis. In response to calls from the U.S., the UN Security Council will hold an emergency meeting on Ebola today—only the second public health crisis to be considered in the Security Council’s history (the other was HIV/AIDS). According to Samantha Power, U.S. Ambassador to the UN, “At this moment, it is crucial that Council members discuss the status of the epidemic, confer on a coordinated international response and begin the process of marshaling our collective resources to stop the spread of the disease.” Although these are steps in the right direction, this health crisis and global security threat demands decisive UN leadership.
6. Now Required: Proactive Planning. Another gap is in preparation. This Ebola outbreak has consistently outpaced the international response. This pattern appears to persist. Remarkably, the UN appeal is based on the August WHO roadmap’s estimate of 20,000 possible cases, even as predictions now reach into the hundreds of thousands of cases – a possibility President Obama himself raised on Tuesday. Clearly the United States recognizes insufficiencies of the UN proposal; the 1,700 treatment center beds for Liberia it will provide are more than double the number called for in the plan for the three most affected countries combined. But as conditions continue to worsen will even this be enough? Further, the risk of spread to additional countries remains. Now is the time to help strengthen Ebola response capacities in unaffected countries, both of their health systems and within their communities. Yet this is only a small part of the funding appeal. And this is to say nothing of further nightmare scenarios, such as an uncontained outbreak in a megacity, or a mutation of the virus to make it more transmissible. It will be far less costly – in money, and more importantly, lives – to plan and take measures now to prepare for these possible scenarios than to hope that they do not come to pass.
Looking Forward: Innovative Solutions
7. Emergency Contingency and International Health Systems Funds. Over the longer term, the United States should support several measures that would have prevented the tragically delayed response of the present outbreak. First, the United States should support WHO establishing two new funds. One, proposed by a commission reviewing implementation of the International Health Regulations, would establish an emergency contingency fund for future health emergencies so that, next time, money will be immediately available. This should help ensure that the initial slow pace of financial commitments and disbursement, one factor in the delayed response to the present pandemic, will not be repeated. A global reserve health corps, trained health workers who can deploy to supplement local health workers where outbreaks occur, should accompany it. And two, as we have proposed earlier, WHO should establish a multi-billion dollar International Health Systems Fund to meet persisting health workforce and other health system needs. Bearing much resemblance to a proposed Global Fund for Health, this could be modeled on (and perhaps ultimately merge with) the Global Fund to Fight AIDS, Tuberculosis and Malaria, and be based on national health strategies.
8. Toward a Framework Convention on Global Health. The U.S. should support a new binding legal global health framework – a Framework Convention on Global Health. As described in detail elsewhere, such a treaty would set standards with clear responsibility to strengthen health infrastructure and include measures to build health services accountability – and in the process, improve trust between health workers and communities. It would also clarify international responsibilities to respect, protect, and fulfill the right to health – which along with funding would include, for example, refraining from closing airports when doing so would preclude the shipment of health supplies and personnel to countries facing epidemics.
The United States took a major step forward yesterday. But at the UN Security Council meeting today and the Global Health Security Agenda meeting next week, and beyond, there is still a long way to go. Let’s use this crisis as an opportunity to build a healthier future.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.