Picture of Kirsten PatrickKirsten Patrick is Deputy Editor at CMAJ


Today, World Bank HQ hosted a round table discussion on plans for ‘Ebola Recovery’ in West Africa. Heads of state of Guinea, Liberia and Sierra Leone, the three countries that still have cases of Ebola, were present and outlined their recovery plans to finance and development ministers and international partners. The event aimed to “build global support for the three Ebola-affected countries to get to and sustain zero cases, jumpstart recovery and build more resilient health systems and economies.” World Bank Group President Jim Yong Kim announced that the WB Group would be donating $650 million towards the Ebola Recovery effort; he also noted that a ‘Catastrophe, Containment and Relief’ trust fund has been set up to co-ordinate funds from other donors (fundraising continues).

Now that Ebola cases are declining, the epidemic seems to have been well-contained and the world’s media are no longer very interested in Ebola, why is so much money being pledged anew to the cause? The answer is that the scars left in West Africa by the recent Ebola epidemic have not yet even begun to be treated properly.

Yesterday, while attending the AMMI–CACMID Annual meeting in Charlottetown, I was fortunate to listen to a talk delivered by Dr Adrienne Chan of Sunnybrook Health Sciences Centre in Toronto. Dr Chan spent time working in Kono District, Sierra Leone, from December last year until February 2015. She worked with WHO teams in their response to Ebola in Sierra Leone. She co-ordinated the WHO Clinical Management Training Team at the IOM Ebola Training Academy in Freetown, after responding to a call for support from her Sunnybrook colleague, Dr Rob Fowler, who has been working with WHO since the beginning of the recent Ebola outbreak.

Dr Chan reminded us that this outbreak has been all about the structural factors that promote health. She pointed out that Guinea, Liberia and Sierra Leone are almost like one country from a geospatial perspective, and they are three very poor countries. They have been affected by heavy armed conflict in recent decades and this has weakened health systems infrastructure. While there are huge profits in mineral extraction in the countries, most people are very poor and there is high under-5y mortality. The number of physicians per 100K population in these countries is very low (<10/100K population in Guinea in 2010 compared to 210/100K population in Canada, and even fewer in the other two countries). Consider, then, that as many as 10% of the health care work force, including physicians, contracted Ebola and died in the affected countries during the recent outbreak. The health infrastructure in the affected countries was poor at the beginning of the epidemic. A highly mobile population led to the spread of the disease. The fact that most health care is paid for out of pocket meant that people did not routinely seek care when they became ill and were nursed, as is traditional, by family members, who then subsequently became ill. Add in practices around touching dead bodies as part of burial ceremony, and challenges to containment because of suspicion and the result was rapid spread that meant that there were more cases in this outbreak that in any of the other outbreaks of Ebola in Africa together since the virus was isolated in the 70s.

As outlined by the leaders of the three countries in today’s World Bank meeting, health systems were quickly overwhelmed and devastated by the outbreak. But in today’s globalized world the health does not inhabit a bubble of its own. The President of Liberia described eloquently how each of the countries faced ‘significant economic challenges’ last year that continue into this year. Exports have declined precipitously, business investment fled, trade and travel declined, and massive requirements to spend on emergency health operations meant that other services, systems and infrastructure were severely neglected. Economies contracted.

Dr Chan spoke of more individual-level consequences yesterday – whole extended families dead, Ebola orphans, a generation of children that have missed an entire year of schooling, and now Ebola survivors with health consequences ranging from uveitis to PTSD.

Dr Chan quoted figures from a Save The Children report: “The amount committed by external donors to fight Ebola in Sierra Leone, Guinea and Liberia so far has been $4.3bn. This is 15 times the annual national health budgets of the three countries combined. The 2012 gap in budgets to ensure essential healthcare for all the populations for all three countries was $1.58bn.” So…”The cost of dealing with this Ebola outbreak is nearly three times the annual cost of investing in building a universal health service in all three affected countries.“

It doesn’t take a mathematician to work out what would be most cost effective in the long run.

What I took away from Dr Chan’s inspiring presentation was her closing statement: “As important as finding the magic bullet, is finding a way to deliver it where it is needed.” By magic bullet she was referring to vaccines and specific therapeutics, currently in development, which was the subject of a previous talk by Ebola Vaccine researcher, Dr Darryl Flazarano. According to Dr Chan, it is critical to get the resources from the Ebola response leveraged to addess the collateral damage to existing health systems that happended as a result of Ebola, and to invest in training with on-site mentorship and supportive supervision.

But the World Bank and donor money is likely to be used for much wider infrastructure development. The group is all about economic recovery and development, to increase stability and lift people out of poverty. The leaders of Liberia, Guinea and Sierra-Leone asked attendees of today’s meeting to support development and implementation of their plans to work as part of a regional alliance of countries to strengthen initiatives in building health and social infrastructures.