"An epidemic is
one of the few catastrophes that could set the world back drastically in the
next few decades," Bill Gates warns in an essay he wrote for the March 18
edition of The New England Journal of Medicine.
"Because
there was so little preparation, the world lost time ... trying to answer basic
questions about containing Ebola," writes Gates (whose Bill & Melinda Gates Foundation is a supporter of NPR).
That's why, he
continues, "the world needs a global warning and response system for
outbreaks." And part of that system must be a better way to get supplies
and "trained personnel" to the scene, where they can work with local
efforts
Few people would argue with that
goal. But there's a lot of debate around how to execute his proposal.
For
example, some global health gurus
aren't so sure we need to create a response system. Maybe we already have one.
Look at the response
to the 2013 typhoon in the Philippines,
says Dr. Bruce Aylward,
assistant director general for emergencies at the World Health Organization.
"Within two weeks, we had 151 foreign medical teams on the ground."
The response
wasn't so fast when Ebola struck West Africa.
Actually, many agencies agree with Gates that it was way too slow. And the
question is why.
It wasn't
that there weren't enough volunteers, Aylward says. Rather, the volunteers
needed to know what would happen if they were to contract Ebola. And there
weren't reassuring answers early in the epidemic.
"There
was no way anyone could guarantee the right of medical evacuation for people
affected by Ebola," he says. So for any future force of emergency health
workers, it's critical to offer what Aylward calls "duty of care" —
the ability to ensure the needs of aid workers can be met if anything were to
happen, in terms of their health, security or safety.
Then there
are questions about whether flying in outsiders is the best solution.
"I'm
going to speak frankly," says Emmanuel d'Harcourt, senior health director of the
International Rescue Committee. "While there's probably some value in the
margin [of a global response system], it's not the heart of the issue, and it
has the potential to distract us from the real issues."
Which are?
"Local
preparedness and local response," d'Harcourt says. "We know that in
most disasters, not just epidemics, but all kinds of disasters, the people who
are able to respond the earliest are local. If you have local preparedness, you
don't really get a major epidemic at all."
A team on the
ground has another advantage, he says: They know the terrain. After the Pakistan
earthquake in 2005, the response from IRC didn't involve "flying people in
from all over the world." A team in Pakistan that had been serving
Afghan refugees for a couple decades was there in less than 24 hours,
d'Harcourt says. They knew how to provide health care and basic needs, such as
shelter "in a culturally appropriate way."
And it's
easier for disaster victims to trust their fellow countrymen. In the early
months of the Ebola outbreak, the citizens of West Africa
often believed that the virus was part of a conspiracy — that Western doctors
were making patients sick. Those rumors made many people reluctant to seek
treatment. To debunk that kind of thinking, d'Harcourt says, you need fellow
citizens who can say, "I know you think it's a plot, but here's why I
don't think it's a plot."
D'Harcourt
also believes that the idea of a rescue mission "infantilizes"
people, treats them like children awaiting salvation. "You know, nobody,
not even children, likes to be treated like children," he says. "I
say this as a pediatrician. Children are always asking for more responsibility,
more autonomy."
A
textbook example of how a person native to a country can help, he says, is the
story of Alpha Tamba, a Liberian physician's assistant. During
the Ebola crisis, Tamba went to villages in hard-hit Lofa County
and said to the villagers, this is what I can do — "what can you do?"
For example,
he provided the chlorine and buckets for hand washing, but the villagers set up
their own quarantines. When outsiders impose quarantines, d'Harcourt says, that
doesn't always work out.
Of
course, outsiders can, as Gates writes, play a critical role in quashing any
future outbreak. But they have to have the right mindset and even the right
garb. If workers come in with white helmets, says Dr. Joanne Liu,
international president of Doctors Without Borders, "it gives them a sort
of a militarized label. In my organization, we do not feel comfortable with the
idea that there are blurred lines of humanitarian aid and military
action."
She also
stresses that any group of emergency workers must be prepared to follow orders
from the agency they're working for. "You need people who are able to be
disciplined, to follow the rules, so you would not put yourself in
danger," she says.
Volunteers
must heed both medical and cultural instructions, she says. A volunteer who
thinks he or she knows it all could end up creating problems.
"You
just cannot improvise and be the humanitarian Ebola tourist of the day,"
she says.
So
Gates' essay is doing what it
should be doing: opening up a conversation. "Now that Gates has written
his article," Liu says,
"I need to write mine."
One point she
would make has to do with something as seemingly mundane as time away from
work. Some medical workers in the U.S.
were lined up and ready to go to West Africa,
she recalls. But when it turned out they would miss not only a month of work
when they were in the field, but another three weeks afterward for quarantine,
"some of them just could not go."
