Ebola: Responses to a public health emergency Contents

2DFID’s response to the crisis

DFID’s initial response

8.Most of the responses to our inquiry agreed that the initial international response to the outbreak (including the UK’s) was too slow. Médecins sans Frontières (MSF) told us that, despite its own warnings, “the global alarm was sounded painfully late” and that “a real mobilization effort did not begin until September [2014], resulting in the loss of a critical time window to prevent the epidemic’s spread.”9 Dr David Nabarro told us, with reference to WHO’s approach to the epidemic:

[…] there were certainly problems because eyes were not focused on the Ebola outbreak, particularly in June/July. There were announcements made, but they were not pushed hard enough by the organisation and, in retrospect, all of us feel, if only there had been a louder shouting three months early, the situation would have been much better.10

The Wellcome Trust echoed this, noting:

The slow international response was partly the result of a significant delay in the declaration of a ‘Public Health Emergency of International Concern’ (PHEIC) by the [World Health Organization (WHO)], which was not made until 8 August 2014. However, national governments could have done more to call on the WHO to make such a declaration.11

9.In light of MSF’s early warnings when it was almost a lone voice, and for which we commend it, we asked Andre Heller Perache of MSF UK when the international community should have mobilised:

[…] even in the early days of the outbreak we had explained that it was the largest outbreak of Ebola that we had ever faced. […] In July, there should have been a massive mobilisation, but, as it stands, it was not really until mid-September that there was an effective mass mobilisation from powerful western Governments, as well as eastern Governments.12

10.Rt Hon Justine Greening MP, Secretary of State for International Development since September 2012, defended the speed of DFID’s response:

[…] we did react quickly to the Ebola outbreak. Our initial funding, working with people like MSF, was going on in July, and we were already looking at action on the ground in June, so we did respond quickly. It was right for us, initially, to really push the international system to respond.13

11.As evidence to the Committee indicated, “The trigger to UK rapid response activities was the WHO announcement [of a PHEIC]”.14 This announcement politically escalated the crisis, as Dr David Nabarro told us:

At the beginning, there was a sense in DFID that we would do what we could do, where we had capacity to do it, but we would not bend over further, because that would be exposing us and the British to the possibility of things that might not be helpful, and we do not want to make big mistakes. That was the correct response of public servants.

Then the politicians got engaged. It got above the civil servants. It was when Justine Greening and then Philip Hammond and then the Prime Minister, obviously together with others in the upper level of the apparatus, got engaged. It happened very quickly at the beginning of September, stimulated often by bilateral dialogue between, for example, the Prime Minister and the President of the US, or trilateral dialogue involving the Secretary-General of the UN, who spoke to both separately and, on some occasions, jointly. It was then that the position shifted; we will put in a much bigger response, because we appreciate the need to get massively scaled up to get ahead of this geometrical increase in the outbreak. That occurred in the first two weeks of September.15

Dr Nabarro went on to say:

Justine Greening took it to the Foreign Secretary. The Foreign Secretary took it to the Prime Minister, and then a different kind of stance was taken. I am massively grateful for this. It is absolutely impossible to find the words to express it. […] This was good political leadership.16

12.When we asked the Secretary of State about what DFID had done to ensure that it could respond more quickly in future, in addition to talking about improved capacity and teams of emergency response staff, she said:

Alongside that, in the region, we are part of an overall WHO effort that is putting in place much better early-warning surveillance and response, and of course that sits alongside broader World Health Organization reform, which is looking at how that organisation can get better than it was at its own emergency response.17

13.Surveillance systems play an important part in catching outbreaks at an early stage in order to respond quickly. The Medical Research Council told us that “improved global surveillance for infections and better shared access to surveillance data would enable stronger more rapid research outputs to be delivered promptly.”18 The Malaria Consortium also emphasised the importance of improving surveillance systems, especially through using communities “in the collection and use of surveillance data”.19 In March 2015, as part of the Budget, the Government announced the Fleming Fund, a £195 million fund to build laboratory capacity, surveillance networks and response capacity in low- and middle-income countries.20 While the fund’s main focus is on antimicrobial resistance, any building of wider surveillance-capacity is encouraging.

14.As a result of WHO announcing a declaration of a Public Health Emergency of International Concern too late, DFID reacted slowly to early warnings, albeit from a limited number of actors, notably Médecins sans Frontières, that this outbreak of Ebola was on an unprecedented scale. Its initial delay was due to an over-reliance on the existing international public health system to sound the alarm at a political level. Improvements to global surveillance networks are needed and welcome. The fact remains that, in the case of the Ebola epidemic, warnings were given but were not heeded. Had they been heeded, DFID would have been able to respond much faster, as evidence shows from DFID’s response after the PHEIC was announced when the UK demonstrated strong and swift political leadership, which we commend. We note that improvements are being made to the international early-warning surveillance and response systems. We are concerned however that DFID is still relying too much on improvements to the international system, without improving its own ability to independently assess international public health risks. DFID must ensure that it has the ability to listen and react to information and warnings from a range of sources, not just the World Health Organization, in order to assess the severity of public health and humanitarian emergencies.

The response capacity of DFID and the UK

15.DFID told us that it “drew on its standing humanitarian capacity as well as surging in capability of over 200 surge staff, to respond to the Ebola outbreak”, alongside “1,300 military personnel, […] over 150 staff from the National Health Service (NHS) and other agencies co-ordinated by Public Health England (PHE), and over 100 specialists from PHE.”21 Health Poverty Action expressed some uncertainty about the expertise of these surge staff,22 and the Wellcome Trust similarly had “concerns regarding the lack of expertise of Public Health England to act in affected countries”.23

16.Despite these concerns, we heard many positive things about the UK response after full mobilisation, including that involvement and coordination of Ministry of Defence, Public Health England and NHS staff was an example of good practice. Dr David Nabarro stated that “It was a superb operation. In particular, it recognised that you need good quality co-ordination at district level.”24 World Vision, from its experience of being actively engaged on the ground teaching safe burial practices, “noted that using the British military has worked well.”25 The Wellcome Trust said, “Collaboration in affected countries between DFID, MoD, Department of Health and clinical researchers worked well.”26

17.We asked the Secretary of State about DFID’s response capacity, and how it was building on its experience of the epidemic. She told us that the UK Government “have developed three cadres of emergency response staff, who now can respond.”27 DFID told us that it “is now working with the Department of Health (DH) to build on the Ebola experience to enable the UK to provide further global leadership on health emergencies”,28 and that the experience has “helped [it] put in place much stronger processes between UK military and DFID”.29 The Secretary of State also assured us that the use of surge staff did not impact on DFID’s ordinary operations.30

18.The UK Government should be commended for the way it responded after the declaration of a Public Health Emergency of International Concern. In particular, we applaud all of the staff who worked in Sierra Leone and the region to bring the epidemic under control. The UK’s response to the Ebola crisis represents a very good example of cross-Government working, in terms of displaying the advantages of a co-ordinated effort as well as showing how such an effort can be well co-ordinated. We welcome DFID’s work with other departments to improve the UK’s readiness and capacity for future outbreaks and humanitarian emergencies; this work should continue and the lessons and best practice on cross-Government working learned from this response should be disseminated across Government.

19.Notwithstanding this praise, we have been told of a small number of issues which arose in DFID’s handling of the crisis, relating to the importance of resources being deployed in the right ways and at the right time. An evaluation by the Institute of Development Studies (IDS) of community care centres, which “were set up with beds for the purpose of allowing local people to voluntarily be isolated if they suspected that they had the disease”, found that “by the time DFID and its partners had implemented the [community care centres] the outbreak had reached a level whereby the need was greater than beds.”31 While communities “appreciated the care for non-Ebola related health problems that [the community care centres] provided”, DFID had ended up dedicating resources in an area where they were no longer best placed.

20.We heard evidence that the reason behind resources not always being best targeted was that prediction models did not account for the effects that engaging communities ultimately had. Annie Wilkinson, one of the researchers involved in the IDS evaluation of community care centres explained:

[…] towards the end of 2014, there were models and predictions saying there would be millions of cases, far above the current capacity for safe isolation. One response to that was to put a lot of money into building medical facilities. […] But what those models did not show was how instrumental local organisation, local learning and responses and behaviour change were going to be.32

Professor John Edmunds added that, therefore, more flexibility within DFID “unquestionably needs to happen. You discussed earlier about treatment centre beds being built long after the epidemic had passed. […] It would have been better, in some instances, though not very many […] it would have been better to do something else. Some flexible funding is essential.”33

21.A similar issue involved attempts to get small amounts of funding for early efforts to bring the outbreak under control. Dr Oliver Johnson told us about difficulties he had had in June 2014, when he requested £7,500 from DFID for eight isolation units. He said, “I could not get a penny from the British Government, despite repeatedly asking. I could not get £7,500. If I had been able to do that, that would have had the impact of hundreds of thousands of pounds later on.”34

22.A recurring theme in our scrutiny of DFID is the difficulty it has in disbursing and managing small amounts of money. This issue was present at the start of the Ebola epidemic and may have hampered some early efforts to tackle the disease. Evidence suggests that small amounts of money disbursed at the start of a crisis, in order to bring that crisis under control quickly, can be very effective. In general small early interventions will deliver good value for money and can reduce the amount of money required further down the line. In contrast, a response that is playing catch-up is very likely to cost more. DFID should ensure that it can operate more flexibly to respond to rapidly changing circumstances, including developing a mechanism to allow country offices to authorise the spending of small amounts of money without fear of negative consequences. This should apply not only during crises, and should involve devising easier means for applications to DFID to be made for smaller sums.

Community engagement

23.Much of the evidence we received suggested that cultural practices in the affected countries played a large role in the spread of Ebola and the scale of the epidemic. Ritual burial practices, including of the victims of the disease, involved physical contact with the deceased when bodies were still highly contagious. This made teaching safe burial practices a vital aspect of the response.35 All three of the epicentre countries were affected by conflicts in recent history. Save the Children said, in relation to Sierra Leone, “Although the civil war ended 12 years ago, there are still high levels of post-conflict distrust in the authorities and in health services”.36 This led to a high reliance on traditional healers and drug peddlers instead of the conventional health services which response efforts focused on.37 The Royal College of Paediatrics and Child Health called the impact of these cultural practices on the spread of the disease “significant”.38

24.Levels of distrust did not only flow in one direction; in some cases responders also mistrusted local communities. The Institute of Development Studies wrote in its submission:

One of the main issues connected to cultural practices during the Ebola crisis was trust, or distrust between the medical response teams and local authority and community institutions and vice versa. Just as local populations have their

own understandings of, and don’t trust hospitals and biomedical approaches; so medical response teams have their views of, and don’t trust ‘culture’, community institutions and local authority.39

Dr Oliver Johnson said, “I agree that there was a real sense of communities being a blockage, which at times I probably shared. It was unhelpful, and that is an important little learning.”40

25.Now that the Ebola crisis is over, it is vital that every effort is made to eradicate FGM in Sierra Leone and worldwide. As the Secretary of State told us:

Having said that, there are other areas, actually, where in its own way Ebola unlocked some progress: for example on FGM, where we saw FGM largely stop during the Ebola crisis. Sierra Leone has now signed the Maputo Protocol. It is the final country in West Africa to do that, and of course we are very keen to now work with Sierra Leone to keep that progress in place.41

26.As a result of these factors, much of the evidence we received has emphasised the importance that community engagement played in eventually tackling the outbreak. The All-Party Parliamentary Group on Africa submitted written evidence to us based on its own inquiry into community-led approaches to health systems strengthening and lessons from the Ebola outbreak. It found that, “due to the complexity of coordinating international aid, especially during a crisis, the support of bottom-up capabilities is often overlooked by governments”.42 The APPG called for “DFID and the wider development and humanitarian sectors to put community ownership at the centre of response efforts during health crises, and more broadly of health systems, as a critical component of health systems strengthening.”43 Christian Aid agreed, “More involvement of communities at the beginning of the response would have reduced their fear of ambulances, protective suits and health facilities, and would have mitigated the effects of Ebola.”44

27.One aspect of community engagement which has been highlighted to us is the opportunities presented by engaging with faith leaders in countries affected by crises. A joint submission by CAFOD, Christian Aid, Islamic Relief and Tearfund noted, “Once evidence emerged that traditional and religious beliefs and practices were a significant contributory factor to the spread of the Ebola virus, attention by responding agencies rapidly turned towards understanding faith teaching and engaging with faith leaders as mobilisers.”45 The ReBUILD Research Programme Consortium contrasted earlier Ebola outbreaks in Nigeria and DR Congo, which were more effectively controlled, with the recent epidemic, and told us, “The faith based sector has also been identified as a key resource that has enabled effective response to Ebola outbreaks in DRC.”46

28.We heard calls for the use of social scientists and anthropological expertise to inform how best to engage with communities in an outbreak. The Wellcome Trust funded the Ebola response anthropology platform with DFID, which used social scientists to help develop the response, and emphasised, “The importance of sociological and anthropological support in the epidemic cannot be underestimated.”47 The Africa APPG echoed calls for greater use of anthropological expertise in order to better understand cultural practices, how they affected the spread of the disease, and how to engage communities, “The inclusion of social science expertise was especially crucial given the breakdown of trust between communities and health systems.”48

29.Engaging communities early is vital to responding to a public health emergency. It is unhelpful just to see cultural practices as a barrier to tackling an outbreak, as this can foster distrust between medical professionals and communities. Local and faith leaders can provide a valuable avenue for spreading important public health information and good practices. In future outbreak responses, DFID must engage communities early and build community engagement into the fundamentals of its response. To assist with this, DFID should build its anthropological capacity and work with anthropologists in its work on strengthening health systems and on outbreak response. This would help it better understand the ways that people access and comprehend health services, so that it can build appropriately. To further facilitate this, DFID should also work more closely with local civil society and voluntary organisations, many of whom have long-established relationships with local communities over many years.

Health systems strengthening

30.Another major factor in the Ebola outbreak reaching an unprecedented scale, identified by most of the evidence we received, was the weak state of the health systems in the affected countries. Dr Oliver Johnson told us that, “with the structures that the Ebola response inherited in the country, it was a very bad starting place in terms of how fragmented the health system was and some of the structures around that.”49 Christian Aid said, “The system was therefore unable to cope with the enormous pressure placed upon it by the Ebola outbreak.”50 The Tropical Health & Education Trust wrote in its submission that responses to the epidemic “highlight the important task of building resilience into health systems for the longer term.”51

31.Witnesses also warned against health systems strengthening purely for health security, and argued for a more balanced approach directed at good health in local communities. The Sustainable Development Goals contain a goal focused on good health and well-being, including a target to achieve universal health coverage, showing the importance which the international community places on this. Andre Heller Perache of MSF emphasised this purpose:

Again, what I worry about sometimes, when we talk about looking forward, is health being subordinated to economic development or now to health security as well, which is more about our health than it is about their health. We should really focus on health for the sake of itself and building that infrastructure strongly.52

32.We were told that the way that countries build health systems needs to improve and be smarter, and that countries need to take ownership of and prioritise investment in health systems strengthening. The Overseas Development Institute, in its submission, focused on capacity-building as part of health systems strengthening. It criticised the current method of capacity-building as being “practiced in a narrow, technical way which ignores the capacity of systems, the human face of service delivery, and the complexities of seemingly simple change processes.” As a result it said that “the delivery of quality services demands a smarter model of capacity-building that is both people-centred and systemically aware.” This would not only include greater community engagement, which we discussed earlier, but would also require “engagement with the complexity of how the health system actually functions.”53

33.In addition to the evidence we heard on the need for health system capacity building, we were told of the dramatic impact the crisis had on existing health services. Save the Children noted, “In Sierra Leone, coverage of the measles vaccine has fallen by 20% across the country in a year. There was a surge in measles cases in affected countries–three to four times more than in the previous year.”54 Dr Oliver Johnson said, “We are still working out some of the data on excess mortality—the number of extra deaths there were—because of Ebola from things like malaria or surgical problems, but it seems to have been significant. I would not be surprised if it was greater than the burden of Ebola itself.”55

34.Weak health systems in the affected countries were a major factor in the rapid spread of Ebola. Robust health systems do not just allow for better control of an outbreak, but also for better treatment of more conventional illnesses, minimising the overall effect. The importance of a broad approach of building quality health systems for the sake of good health itself is recognised in the Sustainable Development Goals. Health systems strengthening should form a core part of recovery efforts in the affected countries. DFID should use its position as a world leader on health systems strengthening to ensure that this is the case and to press for affected countries themselves to invest in and take ownership of improving their health systems. It should push for an intelligent approach to implementation of Sustainable Development Goal 3 which focuses on building robust health systems, taking into account how those systems work as a whole and how people access those services, and share its expertise in this area with other countries and partners to maintain that focus.

Research and development

35.A vaccine for Ebola is currently being trialled, with early results showing it to be highly effective.56 ActionAid UK stated that “if there had been a vaccine or medicine for Ebola in 2014, it would have been possible for the affected countries to stop the epidemic in its tracks. [… Drug and vaccine trials were fast tracked only] once it was clear that an epidemic was out of control.”57 GSK echoed the criticism that Ebola was a neglected disease: “Behind many of these factors [contributing to the scale of the outbreak] is the reality that Ebola had not been identified as a disease requiring priority action by the international community, particularly in the area of vaccine research and development.”58 Regarding a vaccine, Professor John Edmunds said to us, “We should have gone through Phase I trials. […] There is no reason why we could not have done that before this epidemic.”59

36.In addition to the previously mentioned Fleming Fund, the UK Government has announced the Ross Fund, a £1 billion fund to fight malaria and infectious diseases, including £100 million support for research and development into products for infectious diseases.60 We welcome the UK’s commitment to research and development into infectious diseases through the Ross Fund. We look forward to the publication of the Science and Technology Committee’s report on Science in emergencies: UK lessons from Ebola.

Recovery and rebuilding

37.On 23 November 2015 the UK Government published a new aid strategy, alongside its Strategic Defence and Security Review, which set out “how tackling poverty and serving Britain’s interests are linked”; one aspect of this was a commitment to allocate at least 50% of DFID’s budget to fragile states and regions, such as Sierra Leone.61 DFID has committed £339.5 million to recovery efforts in the region, of which £240 million is committed to Sierra Leone over the next two years. The first phase of the recovery plan, set out by the Government of Sierra Leone, focuses on economic development and jobs, and making adequate basic services available to all (including health, education and water).62 According to ActionAid UK, the crisis has had a strong negative effect on existing development efforts in Sierra Leone, Liberia, and Guinea, “setting back development in three of the world’s poorest countries by decades, with ongoing impacts on agriculture, education and the economy.”63

38.In relation to the potential difficulty of rebuilding, the Institute of Development told us:

The term ‘reconstruction’ is slightly problematic; the very high figures (20% and upwards) for pre-Ebola economic growth in Sierra Leone were to some extent illusory, growth was not stable, and benefits were not well distributed. The hit has not just been Ebola but also the dramatic drop in global iron ore prices which has seen the economy dive, and key companies go bankrupt (e.g. London Mining). Even in recent apparent boom years for economic growth, Sierra Leone suffered from basic lack of broad-based infrastructure and functioning health systems. Rather than re-building, it is therefore more appropriate to speak of ‘building differently’, through investment and development approaches directed to inclusive health systems, education and employment opportunities.64

39.Education was one area which was particularly badly affected. DFID noted that, “Formal education for 1.8 million children was interrupted when all schools were closed in July 2014 due to Ebola.”65 Save the Children therefore argued for action on education as part of the recovery effort: “There is an education recovery plan, designed to run until July 2016 [… but] there is little visibility on longer term funding for development activities. […] Future responses must ensure plans are in place for other sectors beyond health.”66

40.We also heard evidence highlighting the importance of economic development and governance reform as part of the redevelopment of Sierra Leone. Christian Aid recommended that work be done with the Government of Sierra Leone “to develop a broader national tax system. […] Broadening the Sierra Leonean tax base would enable more income that could be spent on health and education. It would also help to move Sierra Leone towards a future free of aid dependency.”67 Adam Smith International told us, “The issues laid bare by the Ebola outbreak are those of governance, management, human capacity and Sierra Leone’s unique political economy. […] What is needed are the same kinds of reforms that DFID has been supporting before the outbreak–on governance, institutional and public sector reform, PFM, and private sector development. These reform efforts need to be intensified.”68

41.Development after the Ebola epidemic is a complex and daunting task, and the aim should not just be to restore Sierra Leone to its pre-Ebola situation, but to take the opportunity to rebuild and develop further. DFID has made a clear commitment to development in Sierra Leone, which we welcome and commend. We judge DFID’s focus on economic development and basic services to be correctly placed to support the objective of development to a higher level, although a greater emphasis is needed on long-term support for education. In order to fully achieve this, though, DFID’s commitment must be a long-term one. In addition, and in light of the Government’s new aid strategy, we urge DFID to ensure that strengthening health and education systems remain high priorities for the Department across its portfolio.

9 Médecins sans Frontières (EBO0025) para 4

10 Q49

11 Wellcome Trust (EBO0024) para 7

12 Q2

13 Q110

14 Medical Research Council (EBO0013) page 2

15 Q60

16 Q60

17 Q109

18 Medical Research Council (EBO0013) page 2

19 Malaria Consortium (EBO0005) para 3.2

20Fleming Fund launched to tackle global problem of drug-resistant infection”, Wellcome Trust press release, 18 March 2015

21 DFID (EBO0019) paras 16 and 13

22 Health Poverty Action (EBO0015) para 2

23 Wellcome Trust (EBO0024) para 29

24 Q60

25 World Vision UK (EBO0004) para 23

26 Wellcome Trust (EBO0024) para 29

27 Q109

28 DFID (EBO0019) para 19

29 Q120

30 Q115

31 Institute of Development Studies (EBO0001) para 2

32 Q21

33 Q33 [Professor John Edmunds]

34 Q33 [Dr Oliver Johnson]

35 DFID (EBO0019) para 25

36 Save the Children (EBO0014) para 4.3

37 Overseas Development Institute (EBO0009) para 13

38 Royal College of Paediatrics and Child Health (EBO0002) page 3

39 Institute of Development Studies (EBO0001) para 3

40 Q32

41 Q112

42 Africa All-Party Parliamentary Group (EBO0022) para-4

43 Africa All-Party Parliamentary Group (EBO0022) para-5

44 Christian Aid (EBO0006) para 4.6

45 CAFOD, Christian Aid, Islamic Relief and Tearfund (EBO0011) para 3.1

46 ReBUILD Research Programme Consortium (EBO0017) para 9

47 Wellcome Trust (EBO0024) para 25

48 Africa All-Party Parliamentary Group (EBO0022) para 32

49 Q33

50 Christian Aid (EBO0006) para 4.3

51 The Tropical Health & Education Trust (EBO0012) page 1

52 Q27

53 Overseas Development Institute (EBO0009)

54 Save the Children (EBO0014) para 3.4

55 Q40

56World on the verge of an effective Ebola vaccine”, World Health Organization press release, 31 July 2015

57 ActionAid UK (EBO0010) paras 5 and 8

58 GSK (EBO0020) para 4

59 Q45

60Chancellor George Osborne and Bill Gates to join forces to end malaria”, HM Treasury press release, 22 November 2015

62The UK will stay the course in Sierra Leone until Ebola is defeated”, Transcript of a speech by Rt Hon Justine Greening MP (10 July 2015)

63 ActionAid UK (EBO0010) para 3

64 Institute of Development Studies (EBO0001) para 6.4

65 DFID (EBO0019) para 53

66 Save the Children (EBO0014) para 6.4

67 Christian Aid (EBO0006) para 7.2

68 Adam Smith International (EBO0018) para 6.1

© Parliamentary copyright 2015

Prepared 14 January 2016