Three things an Ebola vaccine won’t fix

Good news from the WHO this week: trials on three promising Ebola vaccines are being accelerated and we may just have one of them in the field as early as the first quarter of 2015.

A vaccine with even limited efficacy would be welcome news indeed, particularly for the beleaguered healthcare workers, who continue to suffer shockingly high rates of infection as they care for the thousands of sick and dying.

At least one of these vaccines was discovered 10 years ago and then shelved, presumably due to limited commercial interest.

But while we have good reason to be excited, we should not lose sight of the fact that an effective vaccine will not mean the end of the Ebola crisis.

Broken systems

As multiple experts have pointed out: the devastating impact of the current Ebola crisis is directly related to the dire state of the health systems in the three most heavily impacted countries. Liberia has 1.4 doctors per 100,000 people, Sierra Leone 2.2, Guinea 10. By comparison, the United States has 245.2. As mentioned, the outbreak has had a devastating impact on healthcare workers, even killing Sierra Leone’s one specialist in the disease. A definite step in the wrong direction.

It’s not just Ebola that’s robbing West Africa of its medical personnel. Doctors, nurses, and technicians from developing countries are emigrating to richer countries in hopes of earning a better wage.

In many African countries, government spending in health is well below the 15% Abuja Declaration. In 2013, Guinea spent 7%. Sierra Leone did slightly better at 12%. Only Liberia kept good on its promise.

But Liberia’s admirable level of government spending still only translates into an average total health care expenditure of $35 per capita, well below $60– the minimum amount the WHO considers necessary to meet essential health needs. Total government revenue is simply too small to finance the country’s health needs. Overseas development assistance (ODA) is essential to build effective health systems in these and other developing countries. And with the havoc wreaked by the Ebola outbreak, the health systems in Guinea, Liberia and Sierra Leone are going to need much more help for many more years to come.  In fact, deaths due to malaria and other treatable conditions have spiked across all three countries and are killing many more people than Ebola, simply because there’s no one left to deal with them. A vaccine will help us slow the spread of Ebola, but it won’t stop the dying.

Food insecurity

Then there’s hunger. The Famine Early Warning Network expects the three hardest hit countries to face “moderate to extreme” food shortages by January if the crisis continues to grow unabated. Cruelly, this is happening in a year when the region had better-than-normal rains and was expecting bumper crops.

The most fertile and productive parts of Liberia and Sierra Leone are some of the most heavily affected by the Ebola outbreak.  Farmers have abandoned their fields due to fear and sickness leaving up to 40% of the farms in the worst affected areas of Sierra Leone empty.

Compounding the problem are the quarantines restricting movement across the region. Travel restrictions are having a double whammy affect: preventing farm labourers from getting to the fields, and preventing food from getting from the farms to the market. The resulting (feared) food shortages are causing panic buying and enormous price jumps – up to 150% already in August.

When normal supplies of food are disrupted many people in remote areas of these three countries have traditionally turned to hunting for bush meat. Bush meat staples include primates and fruit bats, which are thought to serve as Ebola reservoirs and the primary source of transmission to humans. Thus a cruel and deadly cycle threatens to continue.

While the food chain will rebound more quickly than the health system, it will clearly take time and sustained support from the international community. The World Food Programme (WFP) recently announced that it was doubling the size of its operations in Sierra Leone to be able to feed 600,000 people due to the Ebola outbreak. The situation is similar in neighbouring Guinea and Liberia. In total, WFP has requested $180 million to feed 1.3 million people up in the affected countries up to February 2015.

It’s the economy, stupid

Finally, there’s the economy. The outbreak has had a severe impact on the economies of the three most heavily impacted countries and the region as a whole. The World Bank’s “High Ebola” scenario estimates that the Ebola crisis could cost these three countries almost $33 billion over the next two years. For Liberia that translates into a 12% drop in GDP – by comparison, during the Great Recession Greece’s worst annual decline in GDP was 6.9% in 2011. The IMF has already reduced its growth forecast for the sub-Saharan Africa region by half a percent, mainly due to the outbreak.

The staggering mortality rates will have a direct impact on the economic prospects of the three countries. The Lancet’s recent Global Health 2035 report indicated that 24% of the economic growth of low and middle-income countries during the period 2000-2011 could be attributed to health improvements. Any such gains for Guinea, Liberia and Sierra Leone have now been wiped out.

The problems start with the decline in food production, the main economic activity for people in Guinea, Liberia and Sierra Leone. Less food being produced means less income for many farmers and farm labourers.

Foreign multinationals, important sources of job and export revenue have also shuttered operations in the three countries. And, like the disease itself, that fear has spread to neighbouring countries. Ivory Coast and Ghana are seeing cocoa exports plummet, The Gambia’s tourist industry has been devastated. In fact, a World Bank analysis shows that these indirect behavioural factors that are likely to inflict the most economic damage.

At this stage it is impossible to predict the extent of the economic (or human) cost of the crisis. The World Bank is clearly planning for a long-term engagement, and its President Jim Kim says: “It won’t be just the health care sector that we have to look at. We are going to have to make inputs in agriculture [and] in many aspects of the economy.”

A ray of hope?

A successful Ebola vaccine will help. It will help a lot. It will give valiant healthcare workers confidence to do their job without the real fear of having to pay “the ultimate price” as thanks for their efforts. It will also allow them to gradually stop the spread of the disease and, hopefully, to finally get the outbreak under control. The testing and deployment of the trial vaccines should be given our full support.

But a vaccine will not fix broken health systems, nor feed hungry people, nor rebuild a ruined economy. We need only look to the HIV pandemic for evidence of the limits of pharmacological quick fixes. Thanks to the introduction (and continual improvement) of antiretroviral drugs HIV is no longer a death sentence. In 2013, UNAIDS reported a 35% decrease in deaths due to HIV and the lowest level of new infections this century. More people than ever are living normal productive lives thanks to this “miracle treatment”, sometimes called the Lazarus Effect, as recovering patients compare their experience to the biblical character brought back from the dead. And yet many of the countries that have seen the biggest gains in getting HIV under control still have some of the world’s weakest health systems, highest levels of hunger and weakest economies.

If there is a ray of hope in the current Ebola crisis it is that African governments and the international community will finally understand the importance of increasing investment to help low and middle-income countries build effective health systems. In a recent Humanosphere interview, global health expert Laurie Garrett talked about the need for world leaders to rethink the post-2015 development agenda: “It’s not a coincidence that Ebola goes out of control in three countries that basically have no healthcare system… I just don’t think we can go into this next stage of negotiations in the UN system talking about our noble targets for the future without recognising that viruses will continue to emerge and they will exploit weaknesses in your health safety net.”

An Ebola vaccine will undoubtedly bring some much-needed short-term relief to a battered West Africa region. But what the region and other low-income countries really need is a sustained injection of resources – national and international – to build up strong national health systems.

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