By Joana Cook, Managing Editor, Strife
Interview conducted on 19 August 2014
Edwin Trevathan, M.D., M.P.H. is Dean of the College for Public Health and Social Justice at Saint Louis University (SLU), and Director of the Institute for Global Health and Wellbeing, where he is also Professor of Epidemiology, Pediatrics, and Neurology. He was Director of the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention (CDC) in Atlanta, where he was responsible for many of the CDC’s activities in areas of maternal and child health as well as neurological, developmental, and genetic disorders. Under his leadership, the CDC engaged in several productive collaborations in China, Latin America and Africa. He was the CDC’s Strategic Lead for the pediatric response to the 2009 H1N1 flu pandemic, and was a senior investigator for epidemic investigations of Nodding Syndrome in Uganda. Dr. Trevathan was previously Professor and Director of the Division of Pediatric and Developmental Neurology at Washington University in St. Louis, and Neurologist-in-Chief at St. Louis Children’s Hospital. He has published widely in public health, epidemiology, neurological and developmental disabilities, multi-center clinical trials, and child health. His new research interest, working under experts at King’s College London, focuses on Global Health Diplomacy in conflict-affected countries. You can follow Edwin Trevathan at @edwintrevathan.
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Dr. Trevathan: There have been more deaths from other ‘expected’ causes (malaria, malnutrition, childhood diarrheal diseases) than from Ebola in theses poor countries of West Africa over the past several months. However, Ebola poses a risk of becoming more widespread, disrupting the life of a city, closing borders, and provoking unrest. Ebola uncovers the weakness of public health systems, which will need to be addressed; a disease-specific approach to control will not be sufficient.
In your view, have global health bodies like the WHO been able to coordinate with affected countries in an adequate fashion?
The coordination of epidemic responses is often most difficult in epidemics that cross borders of resource poor countries, or poor countries that simultaneously are involved in armed conflict. One of the great challenges in these responses is the often poor coordination between the local health authorities and the national Ministry of Health of these developing countries. Poor in-country coordination delays requests by the national Ministry of Health (MOH) for assistance from the World Health Organization (WHO) and organizations like the U.S. Centre for Disease Control and Prevention (CDC). These problems of coordination within countries are further exacerbated when disease outbreaks occur in rural areas in border regions, as occurred in this Ebola outbreak, and then extend into densely populated cities.
Why has the international response been so seemingly slow?
It is always difficult to analyze a response to an epidemic in the middle of a response. After control of this outbreak, there will certainly be investigations that will lead to recommendations for future action. These are some preliminary thoughts.
Although some of the initial response may have been somewhat delayed by poor in-country coordination, I do not perceive that the response has been significantly slower than previous outbreaks (i.e., Uganda, South Sudan, Eastern DR Congo). However, the efforts to control spread of Ebola have been less effective for a variety of reasons, primarily related to the local efforts of health workers. These reasons include:
- The local authorities and health systems have been less well-equipped to prevent disease spread. For example, some local healthcare providers to not even have access to basic hygiene measures such as rubber gloves.
- The local tradition of handling the bodies during funerals (large numbers of people embracing the body and kissing the bodies) has amplified the spread of Ebola in some areas.
International NGO responses seem to have been relatively rapid. Yet by the time they set up their response teams the disease has spread further for reasons more related to inadequate local initial responses.
Can you comment on the health system responses from the countries most affected by Ebola?
A few thoughts:
- The outbreak has occurred in an area of relatively high population density close to borders, but with low density of physicians and other healthcare workers trained in how to recognize Ebola and use basic methods (gloves, gowns) to prevent disease spread when in contact with patients who may potentially have Ebola.
- People with the initial symptoms of Ebola look much like the other people in the community with malaria or other diseases. Traditional management of these other infectious diseases in communities do not include measures to prevent transmission of Ebola.
- Local health officials and public health officials have not implemented infectious disease precautions (“universal precautions”) in routine care before the diagnosis has been confirmed.
- The prior Ebola outbreaks were easier to control because of remote and rural nature of the communities that were impacted, and by the local health authorities more coordinated response while working within a single country.
Have we seen previous Ebola outbreaks of this scale before?
Is the US worried about the potential threat posed to its security by Ebola?
Ebola should not be a threat to the health of residents in the U.S. Universal disease precautions in hospitals and clinics should be effective in preventing disease spread. The security of the U.S. and of Europe is indirectly threatened by Ebola-exacerbated threats to security in West Africa.
Do you think Obama’s initiative to set up an African Centre for Disease Control is useful in responding to diseases such as Ebola?
Yes. The establishment of the China CDC has been very helpful in responding to epidemics in Asia. Most importantly, the nations of Africa will need to focus on epidemic and pandemic preparedness in order to best equip their countries to deal with Ebola and other emerging infectious disease threats.
Thank you very much.
* The recent Ebola epidemic has thus far caused a recorded 1,069 deaths and infected 1,975 others around the world, with victims largely from West Africa, but these numbers are stated to ‘vastly underestimate the magnitude of the outbreak’. Ebola has a fatality rate of up to 90% and though Canada has now sent 1,500 doses of a new, experimental vaccine, there remains no proven cure.