An orchestra is an army. Chilly Gonzales

Hard Lessons

The sluggish response to the Ebola epidemic in West Africa shows the same fundamental flaws as the global response to HIV in the 1980s.

Infectious disease experts have warned for years that the extreme poverty, political instability, habitat degradation, overcrowding of urban centers, and poor medical infrastructure that exist in much of the developing world are a toxic brew that could spawn dangerous epidemics. Couple that with the interconnectedness of the modern world, and we have the potential for explosive global outbreaks. The current Ebola epidemic is a case in point, and a good wake-up call. The other major infectious disease epidemic in recent history, HIV/AIDS, has also provided valuable insights that continue to inform global health policy. To date Ebola has killed about 8,000 people, a relatively modest number compared to HIV’s 40 million, and its economic toll has been estimated at $1.3 billion. HIV’s economic impact over thirty years is estimated to be in the trillions of dollars.

The global response to Ebola has been widely criticized as too slow and disorganized. The crisis focused a spotlight on the World Health Organization (WHO), the premier worldwide health agency, which failed to lead a global fight against Ebola although this is exactly the kind of crisis it was founded to handle. A recent report from the Chatham House, a prominent British think tank, concluded that the WHO is too politicized and bureaucratic, and also suffers from a significant loss of funding (>$1 billion) due to the current global financial recession. They say that if the world wants the WHO to be a strong leader on the global stage, it needs to contribute more funding, and to support its transformation into a more mission-oriented and efficient organization.

The crux of the problem

The response of individual countries to the Ebola epidemic has also been slow and fragmented. Due to the extreme lethality of the virus and need for highly trained and well-equipped medical personnel, small international NGO’s such as Doctors without Borders were left to heroically handle the crisis on their own for several months. Cuba, a small developing country, was among the first to send a large medical team to the Ebola stricken region.

The crux of the problem is that the global response to the Ebola crisis has been reactive rather than proactive. Ebola was first characterized as a dangerous human pathogen nearly 40 years ago. Why are there no vaccines or drugs? Was the global response to the HIV epidemic, which began in the 1980’s, any different? HIV also started out as an epidemic of fear and stigma, and the response of the medical community was slow. Now after more than 30 years there are effective antiretroviral drugs that suppress HIV infection, improving and extending the lives of infected individuals and slowing transmission of the virus. But there is still no cure, nor are there vaccines or topical microbicides which would be the most effective weapons to eradicate HIV/AIDS. The United States, which has led the world in AIDS research, dedicates less than 3% of its $3.8 trillion discretionary budget to medical research, while defense-related appropriations in recent years have risen to claim 57% of expenditures.

A better World Health Organization

Insufficient funding from the US National Institutes of Health for AIDS prevention research (<$700 million/yr), has enabled private pharmaceutical companies to outcompete in the HIV arena. Over 30 HIV drugs have been developed to date, with an average cost to market of $1.3 billion each. But their investment has paid off. Whereas an HIV vaccine, if it existed, would cost approximately $100/person for lifelong protection, HIV drugs currently incur annuals costs of $10,000 – $15,000/person in developed countries (less for those in developing countries with access to generic drugs), and must be taken over the course of a lifetime. In 2011, the pharmaceutical industry made a profit of $9.7 billion on AIDS drugs. US taxpayers are paying billions for HIV drugs through the international PEPFAR and domestic Medicaid programs. Some say that HIV vaccines and topical microbicides are no longer needed because we now have an arsenal of effective drugs. I disagree, but without improved funding and better oversight for HIV research, this will become a self-fulfilling prophecy.

With two epidemics underway and other dangerous pathogens waiting in the wings, it’s time to recalibrate the global response to infectious diseases. It’s time to learn from our mistakes, and to mount a coordinated international effort to proactively and intelligently build better medical infrastructure and design strategies to confront pathogens before they gain the upper hand. I support the Chatham House recommendations: We need a reconstituted and better-funded World Health Organization to provide strong international leadership in global health.

Read more in this debate: Kadryn Kadasia, Abdoulaye Mar Dieye.


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