Ebola and Other Viral Outbreaks: Providing Health Care to the Global Poor in Times of Crisis

February 13, 2015

Introduction

JOANNE MYERS: Good morning.

I'm Joanne Myers, and on behalf of the Carnegie Council, I would like to welcome you to the first program in our new series on global health.

Our guests today are Dr. Robert Klitzman and Dr. Unni Karunakara. I believe you have a copy of their bios, so I will just take a brief moment to introduce you to Robert, who is on my far right. He is professor of psychiatry in the College of Physicians and Surgeons and director of the Masters of the Bioethics Program at Columbia University. On my near right is Unni, who is a former international president of Médecins Sans Frontières [Doctors Without Borders/MSF] and is now senior fellow at the Jackson Institute of Public Affairs at Yale. Together, they will be discussing the challenges in providing health care to the poor and what has been learned from the recent Ebola outbreak so that the world will be better prepared for the next health crisis.

Bob and Unni will have a conversation for about 25 to 30 minutes. Then we will open the floor to questions so that you can ask anything that hasn't been addressed during their conversation.

If you are wondering why global health matters, especially to those of us who live in countries where health care is readily available, doctors are well-trained, and most diseases are under control, just consider what the recent Ebola epidemic demonstrated, which is to say, health care is not always attainable, there are not always enough doctors, and diseases do not respect borders.

This concern was in evidence last week when President Obama, as part of his national security strategy plan, included global health as one of America's national security interests. By doing so he was acknowledging what others have known for a long time, which is to say, health is one subject that raises issues of human rights, equality, and equity, and if left unattended, can create global security challenges.

In this new series, we will examine some of the more important global health topics and their economic and social consequences, along with the ethical issues they raise.

Let's begin. Please join me in giving a very warm welcome on this cold morning to two of our guests, Dr. Robert Klitzman and Dr. Unni Karunakara. Thank you for launching the series.

Remarks

ROBERT KLITZMAN: Thank you very much, Joanne, for that wonderful introduction. Thank you all for coming, and thank you, Unni, for being here with us.

Just to start off, why don't you tell us a little bit about how you look at the current situation with Ebola?

UNNI KARUNAKARA: We are perhaps looking at the end of the outbreak. By no means over, but we are seeing fewer and fewer cases. We have seen certain hospitals close down. But we are also seeing in some parts small satellite outbreaks which still need to be attended to and addressed. But overall, the trend is going downwards.

But that doesn't mean the job is done. We have to make sure that we wait for the three-week period that we need to wait to ensure that there are no new cases before you can start closing down Ebola response activities. The job is not done.

One of the reasons why this extraordinary outbreak happened—if you look at the history of Ebola, this is like no other outbreak that we have seen before—this is because in all of the three countries—Guinea, where it started, Liberia, Sierra Leone—the health systems are in such abysmal shape that they were not able to control an outbreak. In fact, they didn't even recognize the outbreak. They thought it was something else for the first couple of months.

As the outbreak sort of comes to an end, I think it's time to start addressing deeper health-systems issues, because if we don't, in the future we will be in the same situation if another outbreak happens. So I think this is something where the international community needs to see how we can assist these countries in getting their system to a shape where they can respond to future outbreaks.

ROBERT KLITZMAN: Just to follow up on that, what would that entail? What should be done to help their health systems?

UNNI KARUNAKARA: During the outbreak of Ebola, a lot of hospitals were closed down and were just limited to Ebola patients. Who was treating the other diseases? We shouldn't forget that in all of these countries there are people who die from malaria, HIV, TB [tuberculosis], and other diseases every single day. If you look at the overall numbers, perhaps more people die from these diseases in the span of a year than Ebola. Ebola, of course, is a powerful sort of—it's a virus that evokes fear. We are, of course, worried about the havoc it has created. But people are dying every day.

So there is a very, very strong case to be made that systems need to be built up so that they can take on the task of attending to health, the regular services that need to be provided.

But then again, in outbreaks you need to be able to bring in extra capacity to bear. I hear that there is a move to set up an African CDC [Centers for Disease Control and Prevention]. The African Union in Addis Ababa apparently has approved or they are seriously considering setting up an African CDC. That, I think, is not a bad move, where epidemiologists and response capacities in the continent are built up to respond to such emergencies in the future.

ROBERT KLITZMAN: Another key component, of course, is the world response. I'm wondering if you could tell us your thoughts about the world response. Obviously it has been lacking. But if you could drill down, maybe from a year ago, when the first cases happened, how do you look at what the world response has been?

UNNI KARUNAKARA: The first case of Ebola, we know now, happened in December 2013. It was not until the third week of March that Ebola was confirmed and the government of Guinea declared an Ebola outbreak. It took until August 8 for WHO [World Health Organization] to declare a public health emergency of international concern—eight months later. It took another month for the Security Council in New York to put an Ebola task force together. So we are talking about a delay of almost nine months before the international community came together and mounted a response. Even then, it was sporadic, and not all of the resources came together at the right time.

This is a big delay. There are many reasons. I think WHO, as the preeminent international agency that we all look towards to give us guidance on these issues—I think there were serious dysfunctions in the way it works. There are turf issues. There is WHO in Geneva. There is WHO/AFRO, headquartered in Brazzaville.

And it's not the first time. We saw that a few years ago when the cholera outbreak happened in Haiti, where the Pan-American Health Organization, which is WHO in this part of the world, was not able to respond to the extent that they should have. They were late in calling in reinforcements from Geneva.

These turf issues are also something that we need to recognize, and at some point, they need to be addressed if we are to detect and respond to such emergencies in a much more timely fashion in the future.

ROBERT KLITZMAN: Just to drill down on that a little bit, WHO was delayed. There were some dysfunctions. I wonder if you could fill that in a little bit, what needs to happen or why it's not happening.

UNNI KARUNAKARA: We have been talking about a reform of WHO for quite some time now. It's not clear what the elements of those reforms are. Different people have talked about it.

But we also have to realize that our international governments are reducing their commitments to WHO. So there is a real funding issue as well, where they are also having to make choices. If you talk to WHO, they feel that they are an organization that sets standards and brings science to bear, and they don't necessarily see themselves as an organization that is on the ground sending doctors, like Doctors Without Borders, for example. They don't see themselves as an agency of doctors fighting and the response in the field. They set standards. They are the ones who set protocols and guidelines. So there is also a mismatch between what we expect WHO to do and what they themselves think they should be doing.

These are important dysfunctions or misunderstandings that we need to resolve as well when we consider the reform of WHO. And that has to be backed by funds as well. I think right now the nature of funding has changed. Before, there was a lot of—I don't know what the term is—there was a lot of money and WHO then decided the priorities. Right now a lot of the funding is for projects. Gates Foundation is perhaps one of the largest funders of WHO, and not Member States of the UN.

So we have to really look at how WHO is funded, but we also have to then be tough and hold them accountable to the dysfunctions and the job that they are not doing.

ROBERT KLITZMAN: Let's come back to MSF. You were the international president. MSF is an extraordinary organization. Tell us a little bit about what you think made MSF so able to get in there with Ebola and help in ways that other organizations weren't.

UNNI KARUNAKARA: Let me go back to my personal experience, and I think that will inform. The last time I was directly on the ground, face to face with an Ebola response, was in 2002 and 2003 in Congo, Brazzaville. On the border with Gabon there is a big forest reserve, and there was an outbreak there. Even in that outbreak, our teams reached the small village where Ebola was raging towards the end of February. Later, we determined that the first transmission actually occurred in October. Even there, you see a delay of months.

That also highlights, in some ways, the dysfunctions of health systems. First of all, it happens in remote places. Then it takes a while for the news to reach the outside world—one person dies. No one thinks this could be Ebola. Then another person dies. But when health systems start putting two and two together, then the capacities don't exist in the capital to know what's going on. By the time it works up the chain, it takes some time, and a lot of people are killed.

In the past, with most of the outbreaks, they happened in very remote places, and the numbers were actually small. Compared to what we are facing in West Africa today, the numbers were very small. There was sort of a division of labor. The ministry of health normally was responsible for working with the community, passing on messages, enforcing small movement-restriction policies. You need to restrict people from moving from one village to another to prevent transmission, spread of infection, etc. The government did that.

CDC would come in, they would have a lab-in-a-box, and they would confirm cases. WHO would do the epidemiology. They would do the contact tracing. It's important to trace contacts, because that's how you follow and make sure that further spread doesn't happen. Then an organization like Doctors Without Borders would do the case management.

This worked reasonably well when the outbreaks were small. But what we saw in West Africa was almost like a perfect storm. First of all, the first known transmission was in Gueckedou, which is a town in northern Guinea on the border with Liberia and Sierra Leone. Unlike in the previous outbreaks, this happened in a periurban area, a densely populated part of the world, and with very mobile people. A friend was telling me that even the dead travel, because they carry dead bodies to other villages for burials. So the disease spreads. So periurban, very mobile population.

None of these three countries had prior experience of Ebola. First they thought it was Lassa fever, which is another hemorrhagic fever. A lot of the measures that initially they put in place either didn't work or were not appropriate for this disease.

By the time the international response kicked in, because of the mobility and because of the density of population, it was out of control. Nine months later, it's almost trying to stop a freight train. It takes a lot of energy and a lot of capacity to be able to pull this whole train to a halt. And that is what has happened. It has raged on for more than a year now.

ROBERT KLITZMAN: Just as a little background, do you want to say something about Ebola as a virus, why it keeps popping up in areas and how it's spread? How does it come to this village at the border of these three countries?

UNNI KARUNAKARA: No one quite knows where the natural reservoir of Ebola is. It's now thought to be bats. For example, in 2002-2003, we had also got reports from forest rangers who were working in that forest that there were large ape die-offs. Apes were dying in very large numbers—monkeys, apes, but also porcupines, deer, etc. Then humans started dying. They were worried that somehow this was perhaps connected, and they called.

I think, in this part of the world, people do rely on forests for their sustenance, whether it is for fruits or for meat. It is completely conceivable that the transmission occurred in one such encounter or one such contact and then, of course, it spread.

Satellite infections happen because people move from one place to another. There is an incubation period of 7-21 days. These are days when people move around. They are completely asymptomatic. You don't transmit the disease until you start showing symptoms. But by then, they would have moved to another area. Then another satellite cluster of infections can happen.

But the other thing is also that there is a lot of fear and misinformation that is spread. There are conspiracy theories that this is a plot by the West to somehow depopulate West Africans. In Liberia, there was a whole strike that was going on just before the outbreak. The health workers had gone on strike for better pay. There was another rumor that this virus was deliberately released so that this would force the hand of the government in the pay discussion.

This is the nature of discussions. There are a lot of rumors. And you can imagine, when people are dying, it happens.

There are also cultural beliefs that play a big role. In most of these places the communities believe that illness and health are mediated by spirits. One way of addressing that problem is by—when elders die, when they send them off, there are certain rituals that need to be done. One involves the washing of the body. This again is an important form of spread, because the body is highly infectious when the person has just died.

So there are so many different elements and factors. We are not just telling them, okay, this is a virus. You also have to negotiate and engage with communities to understand why they need to change some of their practices in order to stop the spread of Ebola.

We are not very good at communicating. That we find again and again and again. Measures like quarantine, isolation, without really engaging with the community and letting them know why these measures are necessary, don't really work. In fact, quarantine measures in Sierra Leone, for example—this was a disincentive for people to actually seek health care. They didn't quite know what that was. For an ordinary person, what they see is that a family member is taken away to an isolation ward, and the next thing they know, they get a dead body back.

So I think there has been a great failure of communication and really bringing the communities along in the fight against Ebola.

But even in this country, in the United States, there is a lot of fear. The way CDC guidelines have been employed by, let's say, Governor Christie and others, it has been not science-based; it's based on fear and politics. They want to show that they are in charge of the situation, so the policies have been implemented. CDC has very good guidelines on how people who come in contact with Ebola should be dealt with, but they haven't necessarily been followed in the way they should have been.

ROBERT KLITZMAN: A bunch of questions here we can follow up on, or thoughts I have.

Let's just come to the situation in this country. There was attention given to the nurse in Maine who went bicycle riding. The media covered that. There were people who were quarantined in ways that were not good.

What should have happened, and what happened that should not have happened?

UNNI KARUNAKARA: I think all of the doctors and nurses who had gone out with Doctors Without Borders—and I have to say, with all of the other agencies, like International Medical Corps, Samaritan's Purse, etc.—they are given very good briefings on what they should do when they come back. We know that they are not transmitting the disease when they are asymptomatic. They also know their responsibility. They also know exactly what to do if they get a fever or if they start getting some signs and symptoms of some sort of illness. They know where to go, they know who to see.

I feel it was irresponsible of the authorities in various states to force these people into isolation. What this does is, it's a disincentive for other doctors and other health professionals who might actually want to go and help. They take three weeks or a month from their work, and if they feel that when they come back they will be in isolation for another three weeks, or they are being subjected to—instead of being supportive, we are actually vilifying them. We are telling them that they were irresponsible; they went cycling; "Dr. Spencer took the metro, and he was irresponsible." Instead of being supportive, we are calling these health workers irresponsible for actually doing what they should be doing as health professionals.

We also have to look at the social implications of these policies. Otherwise, it might just backfire.

ROBERT KLITZMAN: Let's come back to policies. You spoke at President Obama's Commission on Bioethical Issues just the other day, I think. Do you want to tell us what you thought of what the commission was looking at and your response and what you said?

UNNI KARUNAKARA: I think the Bioethical Commission recognizes the problem. They, I think, are trying to do the right thing. They are trying to see how policies should be enforced in the future so that it is science-based, but at the same time, it does the job of preventing the spread of such diseases in the country.

We also have to realize that the reason Ebola spread the way it did in West Africa is because their systems are broken. Here we may have one or two cases, but there is the capacity to treat these cases, and also prevent the spread. There has not been one documented evidence of spread in the country because the system is able to contain it.

We have to make that distinction. Here we have the capacity to prevent something like this getting out of hand. It's not an airborne disease. You have to be in direct contact. So we can deal with it. West Africa is a completely different situation because the system is not developed enough to address the problem.

Going beyond that, the commission is also interested in making recommendations on what measures should be put in place in the future to perhaps address such outbreaks in countries of origin, whether it is enhanced support to WHO, whether it is the CDC themselves taking an active role. These are issues under consideration.

They are also looking at the ethical dimensions of movement restrictions, quarantine, isolation, etc.

ROBERT KLITZMAN: Let's focus on the ethics for a moment. There are a number of ethical issues here. Obviously, the largest tension is the rights of an individual to say, "I want to move around freely," versus the state saying, "No. We're going to control you. You can't move." Tell us about that tension, how that plays out or how we should think about that.

UNNI KARUNAKARA: Under the Siracusa Principles, you can restrict movements of individuals, citing public health concerns. If we feel that an individual or a group poses a particular threat from a public health standpoint, there are provisions by which we can actually restrict movement. But there are certain conditions that need to be met for an agency or the state to restrict movement.

I think in this case that wasn't the case. We didn't even keep with the guidelines that were set by the premier professional agency in the country.

It's not just individual rights of patients or potential contacts and infected people that we are worried about. It's also the social implications of it. We have experience from TB outbreaks in the past in New York City. We also know what happened 25, 30 years ago during the time of HIV. In those days, Haitians were all considered to be infected with HIV, and there were blanket—first of all, there was a stigma attached to it, and our policies and the public perception of Haitians were also colored. Today it's West Africans. If you are a West African, you are almost seen as someone who could potentially infect you with a virus.

The state has a responsibility to guard against propagation of such ideas and thoughts. That's why, if we are not able to justify publicly—be transparent about it, be aware of the social implications of any sort of isolation or social distancing measures that we put in place—then we have a big problem on our hands.

ROBERT KLITZMAN: It's interesting, of course, because that tension between one's individual rights and doing things in the name of public health for others is at the heart, I would say, of a domestic issue we are facing with vaccination for measles at the moment. That is a sort of other issue, but I think it's a similar tension. When does a state come in and say this is something that one, as an individual, has to do?

You also spoke about—there is a public perception of the heroes of Ebola. You have some thoughts about that, I think. Do you want to tell us about that?

UNNI KARUNAKARA: In the public and also in the meetings that I have been to, doctors and nurses returning from West Africa are portrayed as heroes. I have actually rejected that label, for many reasons. First of all, the notion that a doctor is a hero for providing care, which is what they should be doing—they are doctors to do just that. Of course, they are doing it in another country. If we accept the fact that there is a certain amount of risk involved—they have gone out of their way, they are putting themselves in harm's way, and they are treating patients with Ebola—fine. But we now know how to reduce risk of transmission 100 percent. If you are well-trained, if you wear all of the protection material, you will not get Ebola. You are certain of it.

When risk is minimal or nonexistent, I think doctors have, I would say, even a duty to provide care. Normally, we would consider this as an obligation of physicians to actually provide care. Let's say West Africa is a long way away. We can still make a case for it. But to say that providing care by health professionals is something extraordinary, I think we are expecting less from physicians. We should be expecting more from them actually. Provision of care should be a normal part of the work they do and not something extraordinary.

That's the problem that I have. Of course we have to be supportive when they come back, and we shouldn't in the press be calling them irresponsible or vilifying them in other ways. We should be supportive. But I don't think calling them heroes is going to help other doctors to join the cause, because a regular health professional might say, "Well, I'm not a hero." We are making it something that it is not supposed to be.

ROBERT KLITZMAN: Let me switch topics a little bit to issues of global health ethics more broadly. MSF has done, as I said, amazing work, but there are also various moral strains and dilemmas that MSF faces or has faced. I wonder if you can tell us a little bit about what some of those are, how the organization faces tensions that come up.

UNNI KARUNAKARA: Today, from an organizational perspective, there are perhaps two broad sets of challenges. One is to reach the people who need assistance. These are people affected by conflict, disasters, epidemics such as Ebola, and in many cases, people who are neglected by their health system or by their government for their politics, for their religion—so conflicts, disasters, epidemics.

The other broad set of challenges is ensuring that once you reach these people, we are able to provide them with good-quality care. There are increasingly many places in the world where we are not able to reach populations in distress because of conflict. Today Somalia is one such place; Syria definitely is one such place; there are parts of Afghanistan, Pakistan, South Sudan, Central African Republic. Here it is becoming increasingly difficult to reach patients because of the conflict and because of all of the attendant problems. Geography is also sometimes a problem—very remote areas. So that's one set of challenges.

There is also a perception in some quarters—in fact, both ICRC, the International Committee of the Red Cross, and MSF started campaigns highlighting the fact that health workers are increasingly at risk for providing health care. Doctors are being targeted just for being doctors. Nurses are being targeted just because they are nurses, increasingly. Journalists are also another profession that is greatly at risk.

The other set of challenges: Today we have a situation where many lifesaving drugs which are available in the West in countries where we live are not available to people in poor parts of the world. This is not because the drugs are in short supply. It's because the way we do business—the patent regime, intellectual property rights—the costs of the drugs are so exorbitant that people in poor countries are not able to afford them.

So there are these dual challenges. As doctors and humanitarians, we deal with these issues almost every day in the field. Once we get there, what kind of care can we provide them?

Vaccines are another issue that we have to deal with.

ROBERT KLITZMAN: One last question. Many people here and others who may be listening or watching are involved in government agencies, international agencies—obviously more funding is important for WHO. But beyond that, are there kinds of policies, beyond just giving money, that can help, either around patent protections that lead to high prices of drugs or other things that government agencies could do or should consider doing?

UNNI KARUNAKARA: I think as citizens we have a responsibility to keep our government honest and to put pressure when needed for appropriate policies to be put in place. Right now trade negotiations—TPP, for example, the Trans-Pacific Partnership—talks are being held completely in secret. We don't know what is being negotiated. The people in this country don't know what the government is negotiating in these treaties.

These are things where I think we should hold the government to more transparency. We want to know what is being negotiated. We want to know what trade talks involve and what is being signed away and what kind of pressure we are putting on other countries.

We are worried, as an organization, that if the treaty is signed, it could actually be more difficult for us to provide effective care in the field, because the price of drugs is going to go up, and there are some other problems associated with it.

This is just one example where, as citizens, as individuals, we can put pressure on the government, and also be more aware of what the issues are. With Ebola, we could have pushed the government to act perhaps earlier and more forcefully. In fact, we send soldiers in before we send doctors. We need to worry about this.

Questions

QUESTION: Susan Gitelson.

Thank you for being so insightful at so many different levels. I'd like to come back to the international issue. You mentioned, on the one hand, that WHO isn't really equipped to handle a lot of the field work; on the other hand, you just mentioned maybe there could be a CDC for West Africa.

If we think of long-term solutions, how can local governments, or regions like West Africa, train doctors who know local customs and who can really reach people? Now, why should West Africa have to depend upon the Gates Foundation? Why can't there be people like Mo Ibrahim or other wealthy Africans? We didn't get to India. But in all these situations where there are poor people, there also are very wealthy ones. Why can't they receive greater prestige, whatever is necessary, because they are funding medical training, they are providing for field service?

UNNI KARUNAKARA: I think there are a lot of initiatives led by young African business leaders to do just that. But the first issue that we need to address is the dysfunctioning health systems in the country. Once you have well-functioning systems, they would be able to detect outbreaks such as these and control it before it gets out of hand. If they need extra reinforcement, then you have the CDC, or the African CDC, which hopefully will take some time to develop. They can come into play, they can assist ministries of health, and they can get the job done.

It is not going to happen overnight, because we have been talking about health system development in Africa for I don't know how many years. But these are the problems. In a way, these are countries and a continent that are really strapped for cash. Yes, there are rich people. But we are talking about a huge continent, and conflict is a big problem, and the curse of the continent. Of course it is a very rich continent, so there are a lot of issues about control for resources, and that fuels more conflict.

I can't get into why African leaders are not doing what they should. Corruption is an issue as well. But the fact remains the health system needs to be the first priority for all of us to develop so that these outbreaks can be dealt with before they get out of hand.

QUESTION: James Starkman.

I would like you to just address—and maybe Dr. Klitzman as well—the kind of hierarchy, starting with the WHO, the CDC, the International Red Cross, and Doctors Without Borders, and maybe even the Bill and Melinda Gates Foundation. Tell us a little more about the WHO. Is their budget totally a part of the United Nations' budgetary structure? Are private donations available to the WHO? How does that really work?

And also, in communication down from the top to the local level, is anyone addressing the funding of a global communications system so that there will be better—at least a start of a better communication, which you addressed in your talk, at the local level about disease origination?

UNNI KARUNAKARA: I am not that up to speed on the details of funding. But WHO does accept private foundation funding. They also get funding from large corporations, drug companies. They work with big pharmaceutical companies to address particular health problems. But I cannot detail exactly how they all come together.

Now, when I say communications, it's not just newspapers, etc. We have to realize that we will not be able to fight outbreaks of this nature if we don't have communities on our side. They have to exactly understand what we are trying to do.

In Congo, in 2002 when I went, the community that was affected by Ebola was the pygmies. They lived in that forest. Now, they have oral history. They have heard stories about outsiders coming in and taking blood for experiments. There have been a lot of unethical studies that have been done. So they are wary of outsiders. The moment they see outsiders coming in, they run to the forest and hide. And outsiders mean not just white folks, but also other Congolese people, which are for them also outsiders. So there are many layers of mistrust, of distrust, that we need to chip away, and that means consistent engagement on some of these issues and with some of these people.

The pygmy people—one of their leaders told me, "Why are you interested in this disease? We have children dying every day from malaria and measles and there is no one here to help us."

Agencies that are charged with providing health care don't deliver every day, on a regular basis. Then, suddenly, there is an outbreak and there are people in white space suits walking around and taking their family members away to isolation wards. So of course conspiracy theories abound.

That is the importance of communication. When I say communication, I am talking about a deeper engagement with these communities so we get rid of all these conspiracy theories, we start building trust, and then get them to be part of the outbreak response. Otherwise, we have no hope in succeeding and limiting the kind of mortality that we have seen in this outbreak.

ROBERT KLITZMAN: I just want to say a few things about your question, which is a very good question. I think there is a larger ethical question that exists in this country, which is how much should we as a country be responsible for the health of people in lower-income countries and middle-income countries around the world? So there actually is quite a bit of pushback if we say that we are going to now spend money to help the health of people in other countries. There are people in Congress, you can imagine, who say, "Why are we funding studies of diseases in Africa? We have problems here in this country."

As Joanne said, Obama, I think correctly, framed this as not just a health issue, but it is a global peace issue, a global security issue; it's an economic issue, because if you have epidemics raging out of control in parts of Africa, that could lead to political instability, economic instability, etc., etc. For good or bad, I think it is important often that we frame these problems not just as, "Oh, it's five people in the forest somewhere in Africa who are getting sick," but these are important for all the rest of us.

I think that the more we can frame issues like that, I think it will help motivate people in this country to lend more support to the WHO, to CDC. The NIH [National Institutes of Health] budget, for instance, has gone down in the past 10 years in constant dollars. There is an under-funding of science. Obamacare is still under threat in this country. So, of course, emphasizing the importance of health as a funding priority is still an issue.

QUESTION: I represent the Netherlands in this town, but I am more talking now from my experience in Africa. Dr. Unni, I can say I am a great admirer of Doctors Without Borders—Artsen zonder Grenzen, as we say.

Let me say something a little bit provocative. I think something is terribly wrong, structurally wrong. You mentioned the mistrust, which is so important. I believe even if development cooperation will fade away, still we will put a lot of money from the Western world into the health sector, because it is true it may be also strategically important, but there is also this human dimension.

My minister wanted to do away with technical aid because he said, "Africa can run its own show. The only thing they need is money." And then everyone in the Netherlands said, "No, no, but not the tropical health specialists because we do need them." This is something emotional. On the other hand, we put so much money into it and we have so little to show for it.

And you are right, health systems have been on the agenda, but some way or another we can't work it out. One solution may be to look at a combination of privately owned, maybe non-profit, and government activities. Let's not forget African families pay something like 40 percent of their income out-of-pocket for health services. So there is financial capacity. That is one thing. But there is so much mistrust.

A question to both of you: Is the problem not the psychology of aid? These aid flows that are going either through multilateral or bilateral channels to Africa are not being regarded as aid. You don't like to get a present every time. You also want to give something back.

I am amazed that in the whole development cooperation business the issue of the psychology of aid is not being treated. Thank you. Thank you for your introduction.

UNNI KARUNAKARA: Ah, easy question. [Laughter]

Speaking from my past role with Doctors Without Borders—we are a humanitarian organization. We are not a development agency. In most places we are there because everything else has failed. We are there because politicians haven't been able to make true on their commitments, the international community has not been able to build peace or build the appropriate response. We are there. In fact, our presence is emblematic of a huge failure in everything. So we are there because everything else is broken.

And of course, yes, development assistance is meant to build systems. But we also need to have the staying power. If you give funding to a country for three or four years and then you change your priorities—the international community and bilateral funding, very often we have attention deficit disorders where we don't stay with certain commitments, we change our priorities every too often.

These governments also respond to that. They are not willing to put in effort and money when they are not sure of the commitment of donors.

One good example is the The Global Fund to Fight AIDS, Tuberculosis and Malaria. I would say, in spite of all the criticisms that you can level against the Global Fund, what they have done is they have brought some predictability to funding flows. As a result, in the last decade we have been able to put 12 million patients on HIV treatment. This is a good example where ministries of health—initially, there was a lot of resistance to change anything in countries, but the moment they realized that the funding flows were going to be steady and they could plan on the basis of that, then you started seeing change. The ministries of health changed their structure a little bit. They were able to put more and more patients on treatment. In the year 2000, there was not a single patient on publicly funded HIV care, and today you have South Africa guaranteeing free treatment for every single HIV patient.

So change has happened. In fact, in the last decade—you can call it the golden decade for global health and that came about because of several reasons: one, there was a global commitment, money was put in; second, generic companies came together and brought the price of ARV [antiretroviral] treatment from $10,500 per person per year to less than $100 per person per year. Now it was possible for ministries of health to buy medicine and to provide it for patients. So many different elements came together to make these changes possible.

But now it is all under threat. There is a real risk that these trade policies that are being negotiated are going to go back and put a lot of pressure on companies so that the prices of drugs will go up. The financial crisis that we had a few years ago has led countries to decrease their commitments. And many of the patients who were on treatment now have to transition to second-line/third-line treatments, which are far more expensive than what it was in the past.

So there are many reasons that we should be worried that the gains that we achieved in the last decade or so are at risk of being—we are going to lose the momentum if we don't stick with it. That's why, when I talk about staying power and stamina, we have to have the will to see certain things through. Very often that is not the case when it comes to development issues.

ROBERT KLITZMAN: I would just add two things to that.

I think it is important also to take a historical perspective. Countries in Africa where we are seeing Ebola were colonies of Western countries for hundreds of years. For instance, the Congo was a colony of Belgium. The major European powers—Portugal, Great Britain—all had colonies. Often, those were not good experiences for these countries, shall we say, where the model was that the Western European country—and of course the United States essentially had colonies elsewhere as well—would take from the colony and there was really very little sense of giving back. I think that is partly what has created a sense of, at times, resentment, mistrust. I think that aid now, in the past few decades, is reversing some of that trend. But it does take time.

The other thing I would say is that there have been successes. I think MSF is a great example, the rolling-out of the HIV medication. But I would say, even with Ebola, in the beginning few months of Ebola, the epidemic was taking off like this. I think—and I was going to ask you earlier—partly by Westerners going in and saying, "Look, you need to be careful with how you bury the dead; this is transmitting the virus"—all that has decreased the number of new cases per week. It's obviously not zero yet.

So I think there have been improvements and those are important to realize. We can't wave a magic wand and cure everything all at once, but I think there has been progress.

JOANNE MYERS: For the last question, I am going to call on Ambassador John Hirsch, who was a former ambassador to Sierra Leone. I am sure he has some extra-special insight.

QUESTION: First of all, thanks to both of you very much.

On one hand, you actually, in answering Rob, pointed to some positive outcomes with regard particularly to malaria and HIV/AIDS. So it's not as if everything is a disaster. But one of the things that strikes me is that the so-called international response is always when the emergency happens.

So HIV/AIDS was denied as a significant issue for over a decade. When I was in South Africa, just shortly before you were there, there was total denial. The doctors at Baragwanath and so on were not going to come to South Africa; that was their attitude. And the black attitude was, "Anything you are going to do on this will deny us the right to have sex." So the whole thing was that way. Then Thabo Mbeki came in and said, "It's not a sexually transmitted disease." So the whole thing was a total disaster. It was only when the emergency happened or it got so bad that they responded.

That's HIV/AIDS. Then you've had malaria; you had SARS [severe acute respiratory syndrome], which has not been mentioned here; you had cholera; and now Ebola.

My underlying question has to do with your remark about dysfunctional health systems. What can be done to have functional health systems—in other words, starting with how do you have doctors and nurses who will stay in their countries and not come and work at Yale or Columbia or somewhere here and make a lot more money? This is what happens, the so-called brain drain. How do you do that? What incentive structure, in other words, can we put in place?

How do you make the hospitals in Sierra Leone, or wherever, work? One of the things that strikes me is that the rich people in these countries always went to Europe for health care; they didn't bother with going to a hospital in Freetown, god forbid. So how do you change? How do you make the health systems in these countries functional on a sustained basis? I guess that's my main question to share with all of you.

UNNI KARUNAKARA: The solution is completely outside the area of health. It's good governance. We are talking about other conditions that need to exist for a health system to flourish. It is not going to develop and exist in a vacuum.

The reasons educated people leave—and it's not just doctors and nurses—is because they want everything that we want, they want to live in a place where there is hope of some security, they want a better future for their kids, and they have the skill set to get jobs outside in another country. So I wouldn't fault them for seeking a better life elsewhere. But how can we then create the conditions in which they can feel safe and their kids can feel safe? That is a much larger question, and political.

QUESTIONER: That is key.

UNNI KARUNAKARA: Absolutely key.

And the political systems—this is also something that we need to be aware of. Doctors Without Borders is just a small attempt to plug a hole or fix a leak. It is not going to solve any of the problems. We are there, like I said, because the systems have broken down.

But development, I think, is a contract between the citizens and the people they elect to power. They have to fight it out, figure it out, what kinds of systems that they need—whether it is health, whether it is education. We can provide some help and as the international community we can assist, but in the end the people and their governments have to figure out the kind of government they want.

It cannot be imposed from outside, but we can somehow nudge them along or support them. But they have to make the decisions on how best to develop their systems. I have ideas, but I certainly don't have the solutions for any of these countries.

ROBERT KLITZMAN: I would say two things.

I think there are potential levers in various ways. These are big problems that are multifactorial. But, for instance, I am no expert on the IMF, the International Monetary Fund, and the World Bank.

But if there are outside funders or countries giving aid to these countries, we know that one problem is corruption in various countries. So you have ministers of health who, unfortunately, siphon off a lot of the money. So even if we give aid for health to country X, the percent that actually reaches the citizens of those countries who need it is not as much as we would like.

I don't know how much the IMF or the World Bank or the U.S. government or others who provide funds under whatever terms of those countries could make it a fact that there be more transparency, that there be efforts to fight corruption, that extend to the health-care system. So that's one thing.

The other thing is I think one lesson, so to speak, of the Ebola epidemic so far, as horrible as it has been and as tragic, is I have been struck by the fact that MSF, which is a comparatively low-budget, small outfit, was so far ahead of the U.S. government, the European Union, the WHO—everybody else. The fact is, as Unni was saying, months before—I think you said it nine months or six months before—the WHO said anything, MSF was saying, "Hey, there's a problem here." So little MSF, with a little budget, has been able to do such enormous good.

What can we learn from that? What is it about the way MSF is structured—their openness, their internal processes, the fact that they can be nimble—that makes them so much more effective on the field than a big lump sum of aid from an international donor? I think we need to look at what are the lessons of that going forward that can help all of us as a global community to do the right thing, which is really the essence of ethics, in helping global health.

So I think there are areas that we can improve on.

UNNI KARUNAKARA: I wouldn't impose an MSF structure on anything. [Laughter]

ROBERT KLITZMAN: Depends what the goal is.

UNNI KARUNAKARA: Again, a note about corruption, if you allow me. I have been interactive with many ministers of health. Of course there are some exceptions. But, by and large, they are also trying. If you want to make big changes in the country and if you want to get big investments in health, you should actually be talking to ministries of finance, not ministries of health. Very often they are also fighting for budgets with ministries of finance in their own country.

But even if you take corruption out of the mix, the budgets are so small. In Central African Republic, for example, Doctors Without Borders runs four small district hospitals, and we are outspending the country's health budget.

And, as someone else remarked, every time an MSF doctor in Liberia puts on the protective gear and all of that protection materials of PPE [personal protection equipment] that they have to put on to prevent cases of infection, in that one hour they are already outspending the per capita investment in health for Liberia. This is the gap that we are talking about—for just one hour of protection for a health worker, we are outspending per capita investment in health in the country of Liberia.

So corruption is one thing, but there is just not enough money in the system for corruption to have that big an effect. So there needs to be an injection of cash. Now, how we achieve that I can't say. But there are serious issues that we need to address. And a lot of the solutions lie outside of the health system and not within the health system.

JOANNE MYERS: You both mentioned "goals." The goal of the Carnegie Council was to bring these issues to your attention, and I think you both helped us to do that in a brilliant way.

I just want to suggest to you that if you are interested, on February 24, Bob will be interviewing Glenn Cohen to talk about medical tourism, to continue the series.

Unni and Robert, thank you so much. It was a privilege having you. Thank you.

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