Preparing for the Future: Developing a Global Health Risk Framework Forum on Microbial Threats March 25, 2015 Victor J Dzau, MD President, Institute of Medicine 1
Global Health Risk Framework Ebola: Updates (week leading to March 15, 2015) >24,000 reported cases >10,000 reported deaths Sierra Leone: 55 new cases vs 58 the previous week Difficult to manage o Movement of virus out of Freetown o Less than 2 months to manage large geographic area before the rainy season Strong community engagement Liberia: No new cases for the third consecutive week Guinea: 95 new cases vs 58 the previous week Unclear path to zero cases Broken triangle of trust between community, government, and responders 2
"It took a thousand dead Africans and two Americans who were repatriated to the US because they were infected. There's no excuse for that... it took too long, we wasted too much precious time." -Peter Piot, Microbiologist, one of the scientists who discovered the virus The international community has failed miserably in its response to Ebola. -Jim Kim, President, World Bank 3
March 2014 Guinea notified WHO of outbreak. Ebola spreads to Liberia Médecins Sans Frontières begins response WHO published formal notification of Ebola outbreak in Guinea August 2014 USAID deployed DART team of staff from USAID, CDC, DoD, and Forest Service. WHO declares the epidemic a public health emergency of international concern Now Cases Deaths 122 70 383 211 3,707 1,808 7,492 3,439 24,000 10,000 December 2013 First traceable case, Guinea May 2014 First reported case in Sierra Leone September 2014 US announces increased response led by military and expected to cost up to $750 million over 6 months. April 2014 Japan donates $520,000 through UNICEF to support outbreak response in Guinea. July 2014 At Ministerial meeting in Accra, Ghana, affected countries and international community expressed expectations for WHO to lead and coordinate response. EU sets target of 1 billion in assistance (has contributed over 1.2) Germany announced that its contributions had reached 17 million. 4
International Response
Commitments to the Response Source: World Bank Global Ebola Response Resource Tracking 6
US Response Sent more than 3,000 DOD, CDC, USAID, and other U.S. health officials to Liberia, Sierra Leone, and Guinea Constructed 15 Ebola treatment units in the region Provided more than 400 metric tons of personal protective equipment and other medical and relief supplies Operated more than 190 burial teams in the region Conducted aggressive contact tracing to identify chains of transmission Trained health care workers and conducted community outreach Worked with international partners to identify travelers who may have Ebola before they leave the region Source: White House, President Obama Provides an Update on the U.S.-Led Response to Ebola. https://www.whitehouse.gov/ebola-response 7
What Went Wrong? Residents react as volunteers take away the body of a woman who died of Ebola in Waterloo, Sierra Leone. Photo: Getty Images
Major Problems International Level Slow and uncoordinated response (MSF, Samaritan s Purse, and some CDC workers provided most support until August 2014) Country Level Failure of traditional surveillance Lack of resources Weak public health and health care systems Community Level Breakdown of trust Lack of information about disease, especially in rural areas 9
The Gaps: Governance Weak governance, leadership, and coordination of health systems at all levels and across and between all sectors of government, charitable organizations, private sector entities and other NGOs. WHO Slow response. WHO received first report on Guinea s Ebola cases in late March and took over three months to convene regional health ministers and open a regional coordination center. Confusion over outbreak response leadership. Disconnect between headquarters and country offices. oregional heads are not chosen by Director-General but by secret vote oheads do not directly report to chief ohead of Guinea office refused to help obtain visas for incoming Ebola team oinitial hesitancy on the part of WHO-AFRO to accept CDC assistance Bureaucratic barriers prevented $500,000 from reaching Guinea response effort. Absence of policy to harmoniously mobilize public/private/civil society partnerships. International Health Regulations (Oblige countries to notify WHO of public health emergencies) Lack of financing and accountability mechanisms to ensure implementation and monitoring. Lack of guidance. Countries are left to self-report their progress on core capacity development, such as surveillance, diagnostic, and containment demands. Countries Lack of financing for public health. Disconnect between public health and clinical care. Lack of coordination between sectors and agencies.
The Gaps: Financing $5 billion: Amount committed so far to the Ebola response. $32.6 billion: epidemic s cost to the West African economy by end of 2015 if outbreak spreads (World Bank estimates) ($15 billion: combined 2013 GDP of Guinea, Sierra Leone, and Liberia) Absence of an easily mobilized reserve of pooled funds to jump-start the financing of emergency response supplies, logistics, and personnel expenses. Few funds for IHR implementation Too much risk for reinsurance industry Under-resourced WHO Modest initial USG response until the Sept 2014 Underfunding from other higher income countries WHO: http://apps.who.int/ebola/
The Gaps: Public Health Delayed diagnosis and reporting of the earliest cases. Many unrecognized cases. Poor understanding of community culture and traditions, leading to mistrust and slow uptake of disease control measures. Shortage of public health professionals. Misperception by some that the military is the answer to expert workforce shortage. Burial team in Waterloo, Sierra Leone. Photo: Getty Images 12
The Gaps: Clinical Care Shortage of diagnostics, supplies, and facilities. Difficulties delivering basic clinical care (e.g. hydration). Ethical and scientific challenges with allocation of scarce resources and testing of unproven vaccines and drugs. Closure of many clinics. Deficient financial safety nets for nongovernmental providers (e.g. liability protections). Severe shortage of indigenous and volunteer physicians, nurses, laboratory officers, logisticians, community health workers, epidemiologists, and health care administrators. Redemption Hospital, Monrovia, Liberia. Photo: Michel Du Cille/The Washington Post/Getty Images 13
The Gaps: Diagnostics, Treatment and Research Little incentive for industry to invest in products to address Ebola. Slow and cumbersome diagnostic tests that require high levels of lab safety and staff expertise. o $100 per test o Samples must be transported to labs Lack of multinational collaboration on R&D financing for neglected diseases. Pharma is investing, but nothing expected to materialize until later this year. Slow clinical trial process. 14
The flexibility and agility for a fast, hands-on emergency response still does not sufficiently exist in the global health and aid systems. Lessons that should have been learned in the mass cholera epidemic in Haiti four years ago were not. Joanne Liu, MSF s International President 15
Need for a Global Health Risk Framework Successful containment requires timeliness. Response should be informed by good planning and evidence, not fear or politics. Need to avoid a patchwork response. Responders need to move as one to avoid mistrust, stigma, or miseducation of communities. Before the outbreak occurs, we need to identify leaders and roles, resources, appropriate times for responding. Need to learn now, before memories fade. 16
GHRF IOM Initiative Discussion with Jim Kim WB in September 2014 Support from Rockefeller Initial joint planning with WB, WHO, Rockefeller December 2014 meeting chaired by Margaret Chan March 5, 2015. Planning for Global Health Risk Framework Support from Rockefeller, Gates, Wellcome Trust, Ford, USAID 17
Planning Element Synthetic and Deliberative Element (15 commissioners) IOM managed but independently branded Evidence Gathering Element (15 commissioners + 15 other workstream members + approx. 80 speakers) IOM managed and branded
Workstreams Governance Review current responsibilities and constraints of countries, regional (non-un) institutions, WHO, other relevant UN agencies, and International Health Regulations. Assess options for changes to international governance frameworks. Finance Focus on specifications for financing mechanisms required to achieve global infectious disease surveillance and to ensure sustainable response capability to emerging infectious disease events with a minimal amount of transactional cost delays. Health Systems Strengthening Consider the characteristics of and optimum approaches to achieve effective, resilient, and sustainable health systems in countries, with particular attention to the public health functions, infrastructure, human resources, institutions. Research Examine issues related to ensuring the global capacity for relevant research and development, acquisition, and dispensing of both countermeasures and diagnostics. 19
Timeline & coordination April, International Oversight Group April, Appoint Commissioners May Aug, Workshops Nov-Dec, Commission report In coordination with UN Panel 20
21
Looks hopeful From: WHO, http://apps.who.int/ebola/ but decline is not enough. Must get to zero cases.
IOM Advantage Convening, Deliberating, and Consensus is primary work Wide global reach (e.g. strong relationships with African Science Academies) Independent Credible 23