>> Welcome to the final session of our course on Ebola virus disease.

Today, we're gonna be talking about lessons learned for global health.

At the beginning of this course, we talked about the state of global health pre-Ebola

and we discussed how it's important for us to understand local history in context.

We also talked about how the fact that Ebola is a relatively new virus.

And so we have a steep learning curve in terms of transmission,

treatment and prevention.

Do you wanna talk about how important the emergence of other tropical

forest zoonoses might be to the Ebola virus disease?

>> Yeah, absolutely.

I mean, as we discuss in the course, you can see that this disease emerged this

time around in West Africa where it had never been before,

probably related to some important changes in the environment.

Deforestation, movement of animal populations,

primarily bats being now closer to humans.

And I think it all really emphasizes the need for us to understand that climate

change, deforestation and changes in impinging of humans into the animal

environment is gonna bring not only future outbreaks of Ebola, but future

outbreaks of other diseases that we have seen before or we have never seen before.

And I think as a global public health community,

we need to be aware that there's a need to strengthen surveillance to

strengthen capacity to respond to this epidemic.

Because it is not just responding to Ebola, it's really responding

to a serious or emerging diseases that we almost are sure are gonna be happening.

>> Absolutely.

So we will certainly have other emerging infectious diseases, possibly zoonoses and

this is gonna be important as we think about disaster risk reduction,

emergency planning and climate change adaptation in the future.

We also talked about patient care of persons with Ebola virus disease, so

what were the important lessons there, Carlos?

>> Well, a lot of important lessons.

Number one is that the countries where this occur will woefully unprepared.

They are countries that have very weak healthcare facilities,

almost no healthcare providers and when the barrage of patients started coming in,

it was like a war zone.

It was like something that has never been seen before.

So again, emphasizes that when the diseases happen,

we need to be able to respond as a global community.

And the respond by some organizations on the ground like Doctors Without Borders,

et cetera was initially considered appropriate.

But the reality is that they were rapidly overwhelmed and

the response of the global community was too slow to really do something, so

it took us many months to actually be able to respond appropriately.

Here in the United States, we were not immune from this epidemic.

While the great majority of cases happened in West Africa,

Americans who got infected by this disease or others who traveled to this country or

traveled to Europe brought the illness closer to home.

And I think that was very important for a variety of reasons.

Number one, I think an increasing awareness of the community

in this country and in Europe that we are a global community

that something that happened in Africa has relevance here.

But number two, it proved to us that we need to be ready for

this kind of situations and I think the important lesson is that here at

Emory University Hospital, we had had, under the leadership of Dr. Bruce Ribner,

we've had a serious communicable disease unit that has been prepared.

Just like there's public health preparedness,

there's been clinical preparedness.

They have been prepared to dealing with a serious communicable disease.

I don't think when they founded that unit,

they thought it was gonna be an Ebola unit.

It was to respond to any emergency,

any public health emergency of significance of communicable disease.

And over the last decade, that unit has been used only once.

In fact, it had not been really used.

And all of a sudden, it had to be activated, it had to be used by Ebola.

But the fact that they were prepared, really proved to be an insurance policy.

It was at that point in time that the SCDU physicians, healthcare providers,

the unit, the personnel that worked there really responded appropriately and

were able to do what I would say was a just magnificent care for those patients.

We had the opportunity to see in our course, Ian Crozier.

Ian is a physician who has worked for many years in HIV in Uganda and

he was deployed to Sierra Leone to take care of patients with Ebola.

So we have the perspective of Ian being a provider, but

we also have the perspective of Ian being a provider that got infected and

that's something we want to emphasize in Ebola.

That one of the people at highest risk are actually healthcare providers and

Ian is an example of that and then Ian got air lifted here to Emory.

And Ian is one of the sickest patients ever taken care of with Ebola.

He literally was dead at some point in time and the care provider here

at Emory has brought him back to life in a way that is quite remarkable.

And I think hearing Ian talk about his experience of being a physician or

being a Ebola patient and now being an Ebola survivor,

I think we're incredibly useful and important lessons occur out of that.

>> So I think from my perspective, these clinical lessons are also really important

for public health, we can think about that serious communicable diseases unit at

Emory as an insurance policy as Dr. Ribner described it, but

also what that meant was a serious investment in serious planning.

As you mentioned, that unit has only been used once and

what this says to me is much like public health.

We need to invest in these systems, so that we are ready and that

includes training of healthcare personnel and end clinical service as well.

But also just in infrastructure, so that's an important lesson for public health.

I think the other thing that's important for us to think about from a public health

perspective is the lesson that we learn form Ian, which is about the care.

So many people thought that the kind of care that he received was not possible.

And while it was very technical, the things like intubation and hemodialysis.

What we actually have learned is that it is possible to treat these very

serious diseases and actually have positive outcomes.

We may not have the resources in all settings to be able to do that, but

I think we need to challenge the status quo in terms of what we can do and

what we should do.

>> And that to me is an important lesson from Global Health Perspective.

If we think about the year 2000 and what happened in HIV,

we had antiretroviral therapy in the US, we had no therapy in developing countries.

People said, you can't do this.

You can't provide antiretroviral therapy.

There's not the infrastructure and people did not accept that.

There was a challenge to the status quo.

There was a challenge to do that.

And what has happened as a result of PEPFAR, the Global Fund is that we

now have several million people in therapy in developing countries.

There are more people in therapy in lower income countries,

which is where the epidemic is than there are in developed countries and

that I think has been an incredible public health, global health success and

I think there are important lessons there for what we do in patients with Ebola.

Taking care of patients of with Ebola in even the poorest setting is not rocket

science.

It requires support of care,

it requires the availability of oral rehydration therapy, it requires

the availability of IV fluids, it requires the availability of good nursing care.

And as Ian said and I think the important lesson is those are very simple things,

but incredibly difficult to implement, because we have a lack of staff and

a lack of stuff.

And if you don't have staff and stuff, you can't do the very simple things.

So I really think that those are really critical lessons as a global community.

We have to improve the training of staff and the availability of the staff and

we also have to make stuff available for people.

>> Absolutely and those kinds of resources the staff and stuff.

We're not talking about high level technology,

as we have in the serious chemical diseases unit.

I think that yes, we do need to challenge the status quo, but

also things like the oral rehydration solution.

Those are our materials which are simple and can be implemented simply, but

we have to have the capacity to do it.

We do have to have the staff, so we need capacity building for

training in public health medicine and nursing.

In resource-poor settings as well, we really need to be able to invest in that

public health infrastructure and clinical infrastructure.

>> I think it's really important, but we also need as a global community to figure

out how do we develop a emergency preparedness teams.

There's clearly Doctors Without Borders, but we need more organizations like

Doctors Without Borders that are able to mobilize itself and

respond rapidly to this epidemic.

Partners in Health has moved in there and is doing an excellent job, but

what else can we do?

What other organizations like that can exist, where maybe there's volunteers,

maybe there's people that have been trained technically, but

also are culturally competent and maybe speak the local languages and

that could be rapidly mobilize a search capacity with facilities and incentive for

those volunteers, almost like the reserve.

A way that we can mobilize healthcare providers to respond to the situations

anywhere in the world.

I think that's a challenge that we really need to think about as a global community,

how do we in front?

>> And I think incentives for that are incredibly important.

We see people that volunteer with organizations like

Doctors Without Borders and it's to be commended that work.

But how do we incentivize more physicians, more nurses,

more public health professionals to get involved with this kind of work, so

that we do have that ready reserve available.

>> Absolutely.

>> Now we have had a reemergence of some cases and Liberia went for

a period of time without a recent case and

we also had an uptick of some cases among partners and health workers.

And so let's talk about that rapid response a little more quickly,

there are some resources within the USAID,

the dart teams and CDC is also preparing rapid deployment teams.

But how are we going to think more seriously about how to meet

the international health regulations, any thoughts?

>> I think states really need to meet

the international health regulations commitments.

I think that WHO needs to be more nimble and more willing to declare public

health emergency of international concern, much faster than they did last time.

I think WHO was reluctant, I think WHO took more time than they should have to

really do what was necessary in order to respond.

So we need in one word global leadership and

global leadership right now is, it's open.

It's vacant and WHO should take it.

It's their role, but somebody else may, because if WHO doesn't wake up and

take that global leadership another organization, another group will do.

I think Dr. Margaret Chan realizes this and WHO is really looking at how can they,

we assume that global leadership that is so much necessary and

s much needed in a situation like this.

>> And we have to talk about the issue of funding.

I mean, that's the elephant in the room.

WHO has been underfunded.

And therefore, the capacity to respond

was really limited as well as the leadership gap that you mentioned.

>> Oh, absolutely.

Absolutely.

I think that I'm not blaming WHO, the organization.

I'm blaming the way the international community has over the years,

weakened WHO to the point that it becomes incapable of responding to

something like this and we're now seeing the consequences.

So the years of underfunding of global health and WHO and

other organizations, we're paying the consequences for

that now by realizing that we haven't been doing that.

So, I think there's an important lesson there in governance.

There's an important lesson there in funding and

there's an important lesson there in what we need to do going forward to prevent

something like this from happening again.

>> And of course, politics always plays a part.

So, it only became a really important issue when these cases left Africa and

came to Europe and to United States.

That's when the global community was really catalyzed for actions.

And I think personally, I believe that that was political.

>> Well absolutely,

but also you don't care about something until it's close to home.

But unfortunately, it wasn't necessarily initially the response that we expected.

The response initially was well, let's not have flights.

Let's not have people from Africa come here.

Let's prevent people from getting here.

Let's try to keep it over there,

instead of what can we do to respond to this epidemic.

And the reality is that trying to separate us from a global community is

impossible in this day and age, there's commerce.

There's people traveling all over the place.

So the nice thing is we can be tomorrow in Paris or

in Africa, the bad thing is that can happen.

These diseases travel, they're going places and you can not avoid that, but

the initial response was that of rejection was that of discrimination

was that of stigmatization.

And unfortunately, that has consequences that are very unfortunate.

The response needed to be what can we do and do it fast.

>> Absolutely.

So we need a global institution that has authority, that has funding,

that can be nimble and make fast and timely decisions and to also incorporate

preparedness into the ways in which the response could be improved.

In the future, we really need to learn a lesson from this.

>> Absolutely.

Lessons Learned for Global Health, Part 1

Ebola Virus Disease: An Evolving Epidemic

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