Will Africa’s future epidemic ride on forgotten lessons from the Ebola epidemic?

The index case of the current West African EVD outbreak is considered to be a 2-year-old boy infected in Meliandou, near Gueckedou, in Guinea, in December 2013 [5]. The WHO was notified late in March 2014, by which time, Guinea had recorded 49 cases and 29 deaths [6]. On August 8, 2014, with a total of 1,779 cases and 961 deaths in Guinea, Liberia, Sierra Leone, and Nigeria [1], the WHO declared the EVD outbreak a public health event of international concern, that is, an ‘extraordinary event’ and a public health risk to other States [1].

The Nigerian index case of EVD was an individual who had visited and cared for a sibling who died from the disease in Liberia [7,8]. He travelled to Lagos, Nigeria, on a commercial flight, arriving on July 20, 2014, by which time he was acutely ill, and was admitted to a private hospital with fever, vomiting, and diarrhea [7,8]. He was initially treated for malaria having denied any exposure to EVD. His failure to respond to malaria treatment and his arrival from an EVD-affected country led to a suspicion of a case of EVD. Subsequent laboratory tests confirmed the diagnosis, and local public health authorities were alerted of the case of EVD [7,8]. The patient died on July 25, 2014.

The limited spread of EVD in Nigeria was a combination of fortuitous circumstances and the institution of a rapid and aggressive public health and infection control measures. The index case, a diplomat, was sick on arrival in Lagos, at a time when doctors were on strike and government hospitals closed. He was subsequently admitted to a private hospital, where he was the source of infection for nine of the hospital workers, and who were then sources of infection for five others [7,8]. This is in addition to two of the protocol officers who attended to him at the airport. One of those EVD infected protocol officers later escaped the Lagos Emergency Operations Centre (EOC) contact tracing network and travelled to Port Harcourt, where he initiated another chain of infections, involving three cases [7,8].

On July 23, 2015, the Nigerian authorities declared an EVD emergency, and activated the EOC to rapidly respond to the outbreak. In collaboration with partner agencies, the government, using existing public health assets, was able to set up six response teams, namely i) point of entry, ii) epidemiology/surveillance, iii) case management/infection control, iv) laboratory services, v) social mobilization, and vi) management/coordination, to rapidly contain the epidemic. When WHO declared Nigeria free of EVD [9] on October 20, 2014, the EOC had identified 894 contacts in three states (Lagos, Rivers, and Enugu), making approximately 18,500 face-to-face contact visits. There were a total of 20 confirmed or probable EVD cases, of whom eight died [7].

Therefore, despite the success of Nigeria in containing the EVD outbreak, the country had committed certain errors which cannot be repeated if future epidemics are to be rapidly contained. In these instances, there was a delay in providing funds for the early and crucial activities of the EOC. Official pre-outbreak information provided to the public was incorrect, creating a false sense of confidence regarding government preparedness for controlling EVD.

Since 1976, when EVD was first discovered in Africa, there have been 24 other outbreaks, aside from the current West African outbreak, with a total of 2,900 cases and 1,583 deaths [10]. As of April 15, 2015, the current outbreaks have accounted for around ten times this number: 25,826 cases and 10,704 deaths [4]. Several reasons have been given for the current unprecedented and prolonged EVD outbreak. These factors include, among others, i) the unreliable disease surveillance system which failed to detect and notify the outbreak at onset; ii) an official national and community denial of the occurrence of the epidemic; iii) the fragile and weak heath care delivery system which was incapable of managing the cases and containing the epidemic; iv) cultural practices associated with unsafe burial ceremonies; and v) ease and rapid mass movement of people between rural areas and urban centres, as well as across largely uncontrolled international borders.

Initial international response to the outbreak was described by Médecins Sans Frontières as “slow and derisory, ..... irresponsible” [11]. When international response was eventually in place, it was uncoordinated, making the initial global effort seem like a “consortium of confusion”.

Having failed to apply standard infection control guidelines to contain the epidemic, frantic efforts were made at global level. The focus temporarily shifted to using available, but unapproved, therapies on compassionate grounds [12]. Therefore, efforts were redoubled to find the ‘magic bullet’, namely drugs and vaccines, for the treatment of cases and to stem the tide of the epidemic. It is becoming clear, with the reduction in number of cases in Liberia and Sierra Leone, that this ‘magic bullet’ to bring the epidemic under control does not consist of drugs or vaccines, but rather a combination of aggressive contact tracing, isolation, and treatment of cases, safe burial ceremonies, and provision of adequate and correct information.

Since 1976, when an EVD outbreak was first reported, Africa has battled with no less than 24 episodes of EVD outbreaks [10]. These outbreaks should have provided Africa with opportunities for developing appropriate capacity and enhancing competence needed to deal with any EVD or other disease outbreaks. However, in all the reported EVD outbreaks occurring in Africa for last 38 years, Africa has been at the receiving end of international aid and assistance.

These long years of international aid and assistance for capacity building of Africans in disease control and response, have not actually yielded the desired result on building human resource capacity. This failure to build appropriate capacity is aptly illustrated by an extract from the published diary of a WHO expert, who is assisting with the control of several EVD and other viral hemorrhagic fever outbreaks in Africa. He wrote “We received the first emails on the Guinea event on Friday 14 March. During the weekend, I was travelling in the DRC for a training course on how to take blood samples in Ebola. It was a 3-day training course” [13]. It is inconceivable to think, and inconsolable to know, that training in ‘how to take blood samples in Ebola’ is the type of external technical assistance offered to health workers in DRC, a country where 38 years ago, the first EVD case was detected, and which has brought under control at least seven other EVD outbreaks [14]. DRC nationals have provided and continue to provide technical assistance to other African countries on EVD control.

By its nature and character, international assistance or aid, be it for economic development or research collaboration, tends to benefit the donor more than the recipient. A Director of a UK funded research center in Africa, wrote this piece in an annual report of the center: “Perhaps the most important achievement of the Unit during the past five years has been the training of a group of dedicated scientists and clinicians who have gone on to establish their own highly successful groups elsewhere in the tropics and in the UK and who continue to maintain the high reputation of the UK in tropical medicine” [15].

This is not an isolated case. A cursory review of the activities of foreign funded research centres in Africa revealed that scientists of the donor countries have benefitted more than their African counterparts in areas of research publication, competition for grants, and international recognition [16]. In many international conferences where issues concerning diseases of African origin and which are endemic in Africa, most, if not all the researchers and paper presenters are non-Africans. The disease outbreaks in Africa have become opportunities for foreign researchers to fine-tune their skills, enabling them to solve African problems, doing for Africa what African scientists should be doing for Africa.

Meanwhile, African scientists remain dependent on the crumbs from the tables of external donors; reduced to mere sample collectors and impotent contributors to disease prevention and control efforts locally or globally. If the next epidemic is not to catch Africa unprepared, this character and nature of external aid and assistance for research collaboration with Africa must change. To reduce dependence on external aid, Africa must reorganize her priorities, and invest more funds in research and research capacity building. African governments must create a conducive environment for African scientists to function with relevance, effectively and productively, freed from the bondage of dependency on foreign external support. On their part, developed countries should ease off on their dominance and control of the processes of global disease surveillance and create an atmosphere for genuine collaboration based on mutual appreciation and respect [17]. Only then can developing countries truly ‘own’ the processes of establishing a sustainable and reliable disease surveillance system for the prevention and control of disease and contribute to global health.