18-02-2020

DEVELOPMENT
TUESDAY, FEBRUARY 18, 2020
5
The coordination of global epidemics
Michael Safi
A patient presents at an emergency department
somewhere in the world. They are feverish and vomiting.
Doctors suspect it is influenza, but they are wrong.When
the outbreak of a virulent new disease such as the
coronavirus is identified, the starting gun is fired on a
vast, multimillion-dollar international effort to try to
contain it.
But nothing can start before a health professional
determines that, against the odds, they are confronting
something exceptional. "You need to work through that
process, establish that this is an out-of-the-ordinary
disease and say, let's do lab tests on it," says Jonathan
Quick, an adjunct professor of global health and author of
The End of Epidemics.
Sometimes the signs are clear: health workers becoming
infected, or patients growing sicker or dying faster than
expected.Other cases rely on a hunch. In 2003, the Italian
specialist Carlo Urbani was asked to examine a patient in
a Vietnamese hospital with symptoms of influenza.
Urbani saw a different pattern. He commissioned tests,
reinforced infection controls around the patient and
alerted the World Health Organization.
A global alert for a virus named severe acute respiratory
syndrome (Sars) was declared 12 days later. Urbani died
from it the following month.Advances in medical science
by the late 1960s led some experts to declare that
humanity had conquered infectious diseases. It was
wishful thinking. Two decades into the 21st century,
viruses are breaking out more frequently than in the past,
data shows.
One factor is that humans are spreading into territories
we have never lived in before, bringing us into contact
with animal populations carrying diseases our bodies
never learned to fight.The 2014 Ebola outbreak was
formally identified more than two and a half months after
it was first detected. The 2015-16 epidemic of Zika,the
mosquito-borne virus that led to 3,000 severe birth
defects, took 37 days. The disease always gets a head start,
and not just for biological reasons. An epidemic may be a
medical phenomenon, but it is social and political too.
In the crucible of an outbreak, sharing information is
one of the most important factors in saving lives. But
instincts often lead the other way. When Sars emerged in
China in November 2002, it raged for several months
before Beijing alerted the WHO.
"China actively hid Sars from the international
community and the WHO was really disempowered,"
says Alexandra Phelan, an adjunct professor at the
Georgetown law school.The same urgent need for
transparency applies to scientists studying the disease,
some of whom have been incentivised in the past to
withhold important findings in a crisis for fear they may
not be able to publish them in medical journals later.
The impulse for secrecy even extended to Liberian
villages afflicted with Ebola, where out of fear and
mistrust some families would hide sick or deceased
relatives from medical teams."Information sharing is
what it's all about," says Rebecca Katz, the director of the
Center for Global Health Science and Security at
Georgetown University. "If you don't know something is
happening, you can't stop it."
Once an outbreak is identified, the focus can shift to
stopping its spread, which in theory is straightforward.
"Your rate of growth needs to be less than one," says
Joshua Ginsberg, the president of the Cary Institute of
Ecosystem Studies. "If every person who gets the disease
gives it to slightly less than one person, then the disease
will go away."
That requires determining who is already sick, and who
may become so. Hospitals become vigilant for symptoms
of the disease in new patients, while teams are sent out
into communities to enlist them to report anyone showing
the telltale signs - and in some cases, to prevent those
people from making the journey to a clinic themselves.
"If a disease is highly contagious, if people are coming to
the hospital it probably means they've contaminated a lot
of people on the way," says Michel Yao, a physician who
advises the Democratic Republic of the Congo's health
ministry on its Ebola response.
Infected people take part in a process known as contact
tracing: listing everyone they have interacted with in the
past days or weeks, and for how long. Those lists can be
vast - a 2011 study found every measles case generated
sometimes hundreds of contacts that needed to be
investigated. But when Ebola hit Africa's most populous
country, Nigeria, contact tracing and surveillance
networks that were already in place to combat polio
helped to stop the outbreak in its tracks.
Medical teams managed to reach every Nigerian case
and seven deaths were reported in the country of 181
million people. "Because they had that system in place,
they were able to jump in immediately and figure out,
where did this patient go, who did he talk to? And isolate
those people," says Ashley Arabasadi, a policy adviser at
the US-based Management Sciences for Health institute.
Quarantining cities, as China has done to Wuhan in
response to the coronavirus outbreak, can often make the
epidemic worse, according to some experts."It causes
mistrust in the government and panic and concern,"
Phelan says. "People can't access healthcare because
public transport is shut down. Or they may do the
opposite and overwhelm medical facilities. And how do
you get in food and drugs for other non-coronavirus
issues? It is a very heavy-handed move that has no
evidence base behind it."
Blunting the spread of an epidemic is difficult enough in
wealthy states with strong governments and developed
health systems, but when Ebola broke out in Sierra Leone,
Liberia and Guinea in January 2014, the three countries
were quickly overwhelmed.
"It was actually possible that one or more [of their
governments] could have collapsed," says Beth Cameron,
Barack Obama chairs a 2014 meeting to coordinate the US government's Ebola response.
Photo: Kevin Lamarque
a health security specialist who served on the task force
established by Barack Obama to fight the disease.
Ned Price, another Obama administration official who
worked on the Ebola response, recalled a meeting in the
White House situation room that August, when those
assembled, including Obama himself, were shown the
worst possible outcome.
"It showed 1.5 million active cases by the end of January
2015," Price says. "There was shock. I forget if there were
audible gasps, but people were definitely gasping on the
inside."When Ebola cases appeared in the US, Spain and
Britain, it was clear the world was only as strong as its
weakest health system. About 2,800 US troops were
deployed to west Africa alongside soldiers and health
workers from the region and around the world, to treat
the sick, test for others who might have the disease and
prevent it from spreading.
By the end of the year, Price says, the daily reports the
White House was receiving started to show the number of
new transmissions falling. "There was a moment in late
2014 where it became apparent the intervention was
working," he says.
More than 11,000 people died in the three worstaffected
countries, but the disease continues to roil the
DRC, where more than 2,200 have died so far.One of the
keys to beating an epidemic has little to do with a
country's wealth or infrastructure. The most effective
vaccines and public-health programmes are useless if a
population does not trust those trying to fight the disease.
Sources of misinformation have proliferated. "Ebola
literally set Twitter records in terms of the number of
posts about it," says Quick. "And when we looked at what
was on there, a lot of it was false stuff, and people were
more likely to believe downright fictions on social media
than they were official sources."
Stigma is another deadly accelerant for any outbreak.
"The worst thing for an epidemic is for it to start in what
are considered the 'social evils'," says Quick, who worked
extensively on the Aids epidemic, which has killed an
estimated 32 million people since the virus was identified
in the 1980s.
He recalls the resistance among conservatives in the US
to public-health measures such a needle exchanges, and
within the gay community, the reluctance to share lists of
people they had had sexual contact with for the purposes
of tracing the disease's spread.
"They were so distrustful, with good reason, that they
wouldn't participate," Quick says. "The number-one thing
is not to politicise the disease."Leaders in the fight against
the 2014 Ebola outbreak turned to anthropologists to
explain that burial practices, including ritually washing
the dead, were helpingto spread the virus. They
recommended small changes that reduced hostility
between health workers and communities.
"The first wave of human remains were dealt with
through cremation, which is not how people in those
areas bury their dead," says Arabasadi. "It was also
discovered that if the treatment facilities had windows, or
a fence where your family could visit you and give you
food, that impacted where people would go."
Advances in machine learning are honing the science of
predicting future outbreaks. "Our goal is to have the realtime
ability to look at human traits, ecological traits and
those of animals that are reservoirs for these diseases, and
be able to say: we think there is going to be an Ebola
outbreak, in the eastern Congo, in the next six-to-eight
months," says Ginsberg. "That's the dream."
But technology will not eradicate diseases. The best that
can be done is to strengthen local health systems to
contain them as close to the source as possible, Arabasadi
says. "It is very hard to get people to fund preparedness
because the measure of success is a non-event, and that's
hard to get excited about," she says. "But investments in
health systems will have a huge rate of return, including
on things that aren't outbreak-related, like better
maternal care and less infant mortality."
Africa can be termed as
humanitarian blind spot
PetitaAlbarracín has been fighting for justice for her daughter Paola Guzmán Albarracín since 2002. Photo: CPR
Bringing perpetrators to justice:the
case of Ecuadorian schoolgirl
Kate Hodal
An international court hearing that
involves the alleged sexual abuse of an
Ecuadorian schoolgirl between the age
of 14 and 16 by her deputy head could
transform girls' rights across Latin
America.In a region where 30% of
students between 13 and 15 claim to
have experienced sexual harassment
while at school, it is hoped that the
case, heard on Tuesday at the Inter-
American Court on Human Rights
(IACHR) in Costa Rica, will establish
the first international standards to
protect girls from coercion and sexual
violence in school.
The case revolves around the 2002
death of 16-year-old Paola Guzmán
Albarracín, an Ecuadorian schoolgirl
who had allegedly been sexually
abused by her deputy head after she
had gone to him to ask for academic
help. He was 65. When, at 15, Paola
discovered she was pregnant, the
school doctor agreed to perform an
abortion on the condition that she have
sex with him, it is alleged.Paola
subsequently attempted to take her
own life, yet the school failed to get
immediate medical help. When her
mother was finally informed many
hours later, Paola was rushed to
hospital, but the doctors were not able
to save her.
In 2006 the Center for
Reproductive Rights (CRR) filed a
case at the IACHR to hold the
Ecuadorian authorities accountable
for failing to investigate the
circumstances leading to Paola's
death. To date, no one has been held
responsible for what happened to
her.
"Paola Guzmán's case will allow the
Inter-American Court on Human
Rights to decide on the rights that all
women have to autonomy and how
this autonomy is the fundamental
pillar of our sexual and reproductive
rights," said Catalina Martínez Coral,
regional director for Latin America
and the Caribbean at the CRR.
"This is a symbolic case: Paola
represents many girls in the region
who are living, or have lived, through
this situation already, and by
representing this case we are trying to
get justice for Paola's family, as well as
flag to the continent that this is a
systematic and structural problem and
we need to address it.
"This is why this case is so important
for the region. It is the first case the
court has ever heard on sexual abuse
against girls in a school setting and
consequently it is the first opportunity
the court will have to create standards
around these issues, such as capacity
and consent. And what it decides will
be binding for all 23 member states of
the court," she said.
The court's jurisdiction stretches all
the way from Mexico down to Chile,
and a victory could set a precedent for
other reproductive rights cases in the
region and beyond, said Martínez,
especially those regarding access to
abortion for girls.
In Ecuador, where the age of consent
is 14, girls and adolescents are
especially vulnerable to sexual
violence: 32% of girls report
experiencing some form of sexual
violence while at school. Teachers and
administrators often take advantage of
their positions of trust and authority,
yet school authorities rarely act - a
failure that perpetuates the existing
culture of impunity, according to the
CRR.
"When a girl is facing sexual
harassment, sometimes she doesn't
even know she is a victim of
harassment, and this was the case with
Paola: she thought she was in a
relationship with the vice-principal
and that she was in love with him," said
Martínez.
Karen McVeigh
The African continent is a
"blind spot" for coverage
of the humanitarian crises
that are being fuelled by
the climate emergency,
according to a new
analysis. Madagascar's
chronic food crisis, where
2.6 million people were
affected by drought in
2019, came top of the list
of 10 of the most underreported
crises last year,
Care International's
annual survey found.
Others included Zambia,
a country on the frontline
of the climate emergency,
with 2.3 million struggling
to eat due to drought, and
Kenya, which received
only 20% of expected
rainfall in 2019, and where
1.1 million people were
hungry amid both floods
and drought.
Last year, climate
activism led by Swedish
teenager Greta Thunberg
dominated headlines in
the northern hemisphere,
but the suffering of
millions of people in food
poverty caused by global
heating in the south was
not being covered,
according to the research.
Nine of the 10 countries
in which at least one
million people were
affected by natural or
man-made disasters to
receive the least media
attention were in Africa,
where temperatures are
rising at twice the global
average, according to the
Intergovernmental Panel
on Climate Change.
"We're seeing increasing
linkages between the
effects of man-made
climate change and the
longevity and complexity
of humanitarian crises,"
said Sally Austin,
international head of
emergency operations at
Care. "From Madagascar
to Lake Chad to North
Korea, the majority of
crises ranked in our report
are partly a consequence
of declining natural
resources, increasing
extreme weather events
and global warming more
broadly."
"What the report does is
to highlight those 10
countries which received
the least amount of media
coverage. Is this because
people aren't interested in
reading about it? Should
we be thinking: 'Is this
good enough?'"
North Korea and Eritrea,
both highly secretive states
where press freedom is
limited and reporting is
restricted, were also on the
list."The increased public
attention for the global
climate crisis is
encouraging, but we must
ensure that the
conversation is not limited
to the global north and
m u c h - n e e d e d
transformations there,"
Austin said.
The countries with
most media coverage of
humanitarian crisis were
Syria and Yemen and the
Democratic Republic of
Congo, all countries with
ongoing conflict.For its
fourth annual survey,
Care used the Meltwater
group to monitor and
analyse 2.4 million online
sources, in English,
French, German,
Spanish and Arabic. A list
of 40 humanitarian crises
in which a million people
were affected was
monitored from January
2019 until 15 November.
The other countries
included the Central
African Republic, which
was ranked second after
Madagascar, due to
ongoing conflict; Burundi,
where instability is causing
displacement and 1.7
million people are hungry;
and Burkina Faso, where a
quarter of the population,
5.2 million, are affected by
escalation of violence.
Also among the areas
listed were Ethiopia, one
of the world's most
drought-prone countries,
where 7.9 million people
are suffering a cycle of
disaster, hunger and
displacement, and the
Lake Chad basin, where 10
million people are in need
due to conflict,
displacement and hunger,
partly due to the lake's
shrinking.
The report found a
correlation between media
coverage and funding
received: three of the 10
most under-reported
crises in the report are also
on the UN's 2019 list of
most underfunded
emergencies.
A Central African soldier patrols at the market in Birao, Central African
Republic.
Photo: Camille Laffont