The Ebola Endgame in West Africa

            With the Ebola Virus Disease outbreak in West Africa nearing its end, we can now begin to step back and take stock of what went well and what went wrong. Failing to analyze the response from an objective and ex ante perspective runs the risk of failing to observe a "teachable moment," in global public health. I have already published my report on the Guinea Health Surveillance System below, but I think it deserves some further context:

• Health Systems: If the West African countries of Guinea, Sierra Leone, and Liberia had sufficient health systems, with adequate facilities and healthcare workers, the disease could have been managed mush more easily. Had there been an adequate infectious disease surveillance program, with lab facilities and a system capable of rapid response the outbreak could have been stomped out in its early stages. These are issues of poverty, but also of weak systems that are at risk of collapsing once the attention and aid money begin to subside. Capacity building must be the number one priority for aid agencies and it must begin now, before public attention shifts away. 
• Traditional Practices: There remains a significant cultural barrier to formal healthcare in West Africa. As much as 80% of those who seek medical attention due so from a traditional provider. Now there is certainly an access issue due to cost and maldistribution of facilities and physicians, but there is also a significant tradition component. This presents a decision, would it be better to discourage people from seeking traditional care? Or perhaps it would be better to utilize these traditional healers by providing them training and access to the formal health network? The latter approach might enable us to simultaneously address the underground nature of informal medicine and also to increase the number of healthcare workers in the region. Traditional burials also played a dramatic role in the outbreak, but knowledge of disease transmission had lead to a massive shift in cultural practices there.
• The World Health Organization: The problem here is two-fold, the slow initial response and the lack of willingness to step up and take leadership of the problem were a dramatic failure that played out in major newspapers around the world. I'll simply say here that concerns about undermining local ministries of health must come secondary in the context of an acute emergency that transcends national boundaries. Only the WHO has the prestige and capacity to act in such a situation. It must not hesitate to use it.

            It is too easy to lay the blame at the feet of the countries who suffered the outbreak. We must acknowledge that the root cause of their inability to act effectively remains a lack of economic and political power in the global system. While we can address specific measures as I attempt to do above, the underlying factors mean that the risk of some other new crisis erupting are present anywhere that structural inequalities persist.