By David Bishai, Johns Hopkins Bloomberg School of Public Health
Someday soon there will be a week with zero new cases of Ebola. Prior to this, the question has to be, “What would it take to make the health systems in Africa ready to snuff out the next Ebola outbreak at the first next case?”
Now that we can glimpse a post-Ebola landscape sometime in 2015 it’s time to move from crisis management to crisis prevention. Having implicated the cacophony of African poverty as causing Ebola, once Ebola is gone it is important not to go back to the same failed health systems strategies that let us down in 2014.
We seem to have forgotten that the world already pioneered a technology that stops epidemics in their tracks and works extremely well in poor populations beset with urbanization, migration, and distrust. Many countries conquered epidemics despite poverty, without using vials and syringes or gleaming shiny hospitals and in complete ignorance of DNA and the human genome. Between 1880 and 1930 the human experience of roughly quadrennial population death spasms of typhoid, cholera, smallpox, and diphtheria vanished from Paris, London, New York, Stockholm and the surrounding populations. This was before penicillin and sulfa.
Functional local public health departments are a 150-year-old technology that makes it possible to be poor, but not prey to epidemics. Local health departments must constantly assess the local burden of disease and health threats, engage the local community to understand local health problems, devise collaborative solutions, and ensure they are implemented. Yes, global issues matter, but local conditions matter more. Ebola was both global and local. Our bodies are small—what makes us sick is people, viruses, or chemicals a few feet or miles away. Furthermore, our ability to trust is local, and the solutions to many of our health problems require us to trust each other face to face. Community engagement is the bedrock of public health practice, and health officials need to communicate health threats to community stakeholders in a manner that can be understood and acted on.
Checklists can be used to assess a local health department’s performance of essential public health functions. All the missteps that allowed the Ebola epidemic to grow would have been addressed had the essential functions of public health departments been strong enough. The containment of Ebola in some fortunate West African countries wasn’t all luck; sound public health practices played a role, too. Critical public health functions include regular monitoring of the population’s health and maintaining contact with all members of the treatment community; investigating outbreaks immediately at their source; and regular communication of health issues to the community—after building its trust. Public health practice requires ongoing partnerships with the community’s schools, mosques, churches, and civic groups to identify and solve health problems. Around the world, in some of the most challenging environments, local health officers have drawn on the common interest of communities in avoiding illness combined with the most rudimentary methods of epidemiological surveillance to stop epidemics before they happen. This technique also builds political will for the basic environmental modifications that move communities towards better sanitation and hygiene. Unfortunately local public health departments only succeed if they actually perform their duties. In too many places, everywhere, health officers have lost sight of what their duties are.
Public health’s expensive glamorous cousin—medical care—dominates the health systems of Africa, like all health systems. When the full-blown Ebola outbreak exploded, it absolutely required investments in medical care. However, a conversation about prevention means getting health systems to move beyond taking care of the pressing burden of disease. There is never a respite. The local public health officers of Africa typically are asked to manage both the public health service and the clinical service network. Faced with throngs of people in daily pain and suffering at the clinics and the need to maintain epidemiological surveillance and health education, clinics will always come first. When Westerners arrive and decry a weak health system, they are anxious for it to be strengthened enough to deliver more medical commodities like antibiotics, vaccines, and cures for dreaded diseases. This exacerbates the problem. The performance measures of health systems in Africa are heavily weighted towards clinical service delivery—children treated in the clinic, attended deliveries, vaccinations given.
There is an alternative. In the early 1990s the WHO began to build a measurement strategy for local health departments to assess and strengthen their ability to conduct essential public health functions. WHO headquarters abandoned this approach to focus on measuring global disease burden and global performance. However, PAHO, WHO’s Latin American branch, continued to emphasize measurement and currently maintains an extensive set of instruments and knowledge about public health practice. The US also developed this technology into a system of voluntary accreditation of local health departments, and many European countries also regularly assess and improve their local public health practice.
The approach is simple. Give health officers a checklist to determine their strengths and weaknesses in public health practice and coach them in strategies that they co-plan with experienced and committed supervisors. Checklists remind health officers about the need to reach out to the people they serve and to build partnerships with other sectors of society and government. Effective health officers convene and coordinate with law enforcement, schools, private industry, hospitals, as well as their own staff. They share the results of their own monitoring and outbreak investigations and collaboratively develop policy. With a checklist insisting on good public health practice and the expectation that they will be held accountable for improving their performance, health officers can steadily improve their ability to protect their communities.
This blog previously appeared on the Global Health Now website