Dr Margaret Chan
Director-General of the World Health Organization
Keynote address at the Princeton – Fung Global Forum, Dublin, Ireland
2 November 2015
Honourable Mr President, faculty, and alumnae of Princeton University, distinguished speakers and panellists, representatives of UN and humanitarian agencies, noted journalists, ladies and gentlemen,
I am honoured to speak to this audience, and thank Princeton University and the generosity of William Fung, who is with us today, for making this event possible.
You are looking at experiences during the Ebola outbreak in West Africa to explore shared features with past plagues but also to demonstrate several unique features of modern plagues.
Ebola is not a new disease. The first outbreaks, in what is now South Sudan and the Democratic Republic of Congo, date back to 1976. Prior to the current outbreak, Ebola was a rare disease, largely confined to rural areas isolated by lack of transportation by road, air, or water.
Much about the disease was poorly understood. The previous 22 outbreaks, which occurred in Ebola’s traditional geographical home in equatorial Africa, were controlled using measures, like isolation and quarantine, that date back to the Middle Ages.
We are now into the second year of the outbreak in West Africa, which is by far the largest, longest, most deadly, and most complex Ebola outbreak in history. Much research has been undertaken and knowledge of the disease, its patterns of transmission, and its clinical features, has improved considerably.
What WHO and all other responders failed to grasp quickly enough was the potential of Ebola to behave very differently in West Africa than it had in equatorial Africa.
In terms of lessons for future outbreaks, one overarching conclusion is this. Outbreaks of new and emerging diseases cannot be reliably predicted, but large, severe, and sustained outbreaks can be prevented through adequate vigilance, preparedness, and quick detection and response.
The watchword is this: be prepared for the unexpected. Constant mutation and adaptation are the survival mechanisms of the microbial world. There will always be surprises.
This was Ebola’s first appearance in West Africa. The disease was neither expected nor suspected. In Guinea, where the first case occurred in December 2013, the virus circulated undetected, off every radar screen, for three months. The earliest cases in Liberia and Sierra Leone were likewise missed.
This late detection gave the virus a momentous head-start, which further accelerated when the disease reached capital cities. National and international responders did not begin to catch up until October of last year. As studies now show, late detection and delayed intervention contributed to the outbreak’s size.
Ladies and gentlemen,
For vigilance, preparedness, and early response, the context of modern plagues is extremely important, especially in a century characterized by striking inequalities in wealth and fundamental state capacities.
This session is looking at the contribution of advances in information and communications technology. That technology played a decisive role in ending the 2003 outbreak of SARS, the first severe new disease of the 21st century.
SARS was very much a modern plague. It revolutionized our understanding of the power of real-time communications during an outbreak.
One set of statistics illustrates that power well. In mid-March 2003, WHO used the internet to alert the world to a deadly new disease, of unknown cause, that was spreading quickly in sophisticated urban hospitals. The message was widely reported by the world media, amplifying its reach.
The March alert provided a clear line of demarcation between the earliest outbreaks, in China, Hong Kong, Hanoi, Singapore, and Toronto, all of which were severe, and the 26 additional countries and territories where cases were imported by international air travellers.
Areas with outbreaks prior to the March alert accounted for 98% of the global total number of cases and 79% of total deaths. The additional sites, characterized by high levels of vigilance and preparedness, were able to prevent further transmission or limit it to just a handful of cases. WHO declared the outbreak over less than four months after the alert was issued.
The Ebola outbreak in West Africa evolved within a very different context. Whereas SARS was largely a disease of sophisticated urban settings, Ebola took its heaviest toll on three of the poorest and least prepared countries on earth. All three were recovering from years of civil war and unrest that left health services and infrastructures severely damaged or destroyed.
Deep poverty, a disruptive political history, and centuries-old cultural beliefs and traditions created immense barriers to rapid containment.
Poverty meant that there was not enough of anything: doctors and nurses, isolation wards, hospital beds, laboratories, medical supplies, ambulances, daily provisions for people held in quarantine, or even protective gloves and body bags. Transportation and communication systems were primitive. In rural areas and also in some cities, real-time reporting of suspected cases and lab results was out of the question.
Many rural areas could not be reached by any form of communication, not even by mobile phone. Every day that symptomatic patients were left in the community, waiting for test results or transportation to a treatment centre, gave the virus multiple opportunities to spread.
The political history of conflict and unrest left populations deeply mistrustful of government authorities, their policies and advice, their military, and their public health systems. People preferred to seek care from traditional healers under conditions that virtually guaranteed explosive spread.
Foreign health care workers were even more deeply mistrusted, frequently to the point of violent resistance. In some countries, competing political factions used the outbreak to promote their own agendas.
In fact, cultural beliefs and practices proved to be one of the most difficult barriers to address. Responders took too long to learn how to break this barrier down.
In the beginning, many communities refused to believe Ebola was real. Rumours spread that all this “Ebola business” was just that: a business run by government officials to secure foreign funds to pad their personal fortunes.
To counter these and other rumours, health officials communicated the message that Ebola was indeed real. In fact, this was an extremely deadly disease with no vaccine, treatment, or cure.
That message backfired. If hospitals offered no hope, communities found it logical to care for infected loved ones in their homes, where they could die surrounded by familiar faces. Traditional cultural beliefs also dictated funeral and burial practices that involved washing, cleansing, and caressing of corpses that remain extremely infectious for several days after death.
Even after safe burial teams were organized and made quickly available, secret unsafe burials continued. WHO estimates that up to a quarter of all infections in the three countries could be linked to high-risk funeral and burial practices.
As we learned, communities must be helped to understand the importance of control measures on their own terms. Simply telling them to “do this” or “don’t do that” does not work. “Listen to the people” as one of the most important lessons learned.
When communities saw for themselves that hiding patients in homes could lead to the death of entire households, they found their own way to separate the healthy from the infected. They found their own way to identify and quarantine close contacts and keep symptomatic travellers from entering the village. These changes in community behaviours helped bring some of the earliest hotspots under control.
Could digital communication systems and internet networks have been used to solve some of these problems and bring about changes earlier? I have some doubts, given the realities on the ground during this crisis.
How can communications technologies help if the messages are not trusted or the content is inappropriate? As we learned, when technical interventions go against culture, culture will always win.
In recent years, several systems for digital disease detection have been developed, also in collaboration with WHO. These systems use dedicated software applications programmed to search open web sites, news wires, discussion groups, and blogs for words and phrases, in nine languages, that signal a possible outbreak or other health emergency.
In many cases, this electronic gathering of disease intelligence operates as an effective, real-time early warning system.
In West Africa, the effectiveness of these systems is blunted for two reasons. First, these countries simply do not have a modern telecommunications system. Health-related data that might be picked up by digital systems for disease detection are sparse.
This is a reality in poor countries worldwide. Some 85 countries, representing 60% of the world’s population, do not have reliable systems for collecting, recording, and analysing even the most basic health data. They do not register births and deaths, and do not investigate or record causes of death.
Second, most poor countries in tropical areas have a heavy burden of other infectious diseases, like malaria, Lassa fever, typhoid fever, yellow fever, cholera, and dengue, that have non-specific early symptoms similar to Ebola. In the midst of so much background noise, how can surveillance systems, which are almost universally weak, pick up an unusual disease event?
Elsewhere, experiences in countries with more robust IT systems in place show some positive results, and some negative consequences.
In July 2014, an air traveller from Liberia brought Ebola to Lagos, Nigeria, one of the most densely populated cites in sub-Saharan Africa. Lagos has large numbers of people crowded together in slums with little sanitation and vast daily population movements in and out of the city. Under these circumstances, many predicted a catastrophic urban outbreak.
That never happened. Nigerian health authorities caught the first case quickly and responded forcefully, with support from CDC, MSF, WHO, and the private sector. State-of-the-art technology, developed for the country’s polio eradication programme, was re-purposed to support the search for contacts of the first Ebola patient, the tracing of chains of transmission, and the real-time reporting of results.
Nigeria had excellent laboratory support and good isolation and quarantine facilities. Remarkably, the country was able to hold the number of Ebola cases to just 20. Equally remarkable, investigators could link every one of these cases to the chain of transmission that began with the Liberian air traveller.
In wealthy countries around the world, information technology, including social media, allowed fear to spread faster than the virus. This fear could not be contained by the well-documented facts that Ebola is not airborne and spreads only under conditions involving very close contact with infected bodily fluids. In reality, the risk of onward transmission following an imported case is very low in countries with high standards of living and well-developed health systems.
Despite these facts, numerous airlines cancelled flights to all of West Africa and some countries refused to issue visas for travellers from affected countries. The cancellation of flights made it extremely difficult to move badly needed personnel and supplies into the three countries.
Apart from impeding the speed of the international response, these measures isolated and stigmatized the three countries ever further.
Ladies and gentlemen,
I will leave you with these thoughts.
In my view, the first priority must be to get well-functioning health systems in place, especially in fragile or vulnerable countries. A well-functioning health system includes surveillance and laboratory services, but also offers comprehensive care, close to people’s homes.
Surveillance functions not just to detect outbreaks early, but also to detect chronic noncommunicable diseases, like heart disease, cancer, and diabetes, early, when the chances of treatment are best and the costs are lowest. A well-functioning and inclusive health system builds trust in the government, but also contributes to social cohesion and stability.
It offers the kind of resilience needed to protect populations from sudden shocks, whether these come from a changing climate, natural disasters, or a runaway virus.
Thank you.
