Peer Reviewed Papers on the African Ebola Outbreak Patients Perspective

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Critiquing the response to the Ebola epidemic through a Primary Health Care Approach

BMC Public Health volume 16, Article number:410 (2016) Cite this article

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Abstract

Background

The 2014/2015 West Africa Ebola epidemic has caused the global public wellness customs to appoint in difficult self-reflection. First, it must consider the part it played in relation to an of import public health question: why did this epidemic take hold and spread in this unprecedented style? 2d, information technology must use the lessons learnt to reply the subsequent question: what can be washed now to forbid farther such outbreaks in the future? These questions remain relevant, even as scientists announce that the Guinea Phase III efficacy vaccine trial shows that rVSV-EBOV (Merck, Precipitous & Dohme) is highly efficacious in individuals. This is a major breakthrough in the fight against Ebola virus disease (EVD). Information technology does not replace but may be a powerful adjunct to electric current strategies of EVD management and control.

Discussion

Nosotros contribute to the current self-reflection by presenting an analysis using a Primary Wellness Care (PHC) approach. This arroyo is appropriate as African countries in the region affected by EVD have recommitted themselves to PHC as a framework for organising health systems and the delivery of health services. The approach suggests that, in an epidemic made complex by weak pre-existing health systems, lack of trust in regime and mobile populations, a broader approach is required to appoint affected communities. In the medium-term health organisation development with attention to primary level services and customs-based programmes to accost the major illness burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local direction and an investment in human resource for wellness. Crucially this has to be adult alee of, and not in parallel with, future outbreaks. In the longer-term a delivery is required to address the underlying social determinants which make these countries so vulnerable, and limit their capacity to respond effectively to, epidemics such as EVD.

Determination

The PHC approach offers an insightful critique of the global and regional factors which have compromised the response of wellness systems in Guinea, Republic of liberia and Sierra Leone also equally suggesting what a strengthened EVD response might involve in the short, medium and long-term.

Peer Review reports

Background

The 2014/2015 EVD epidemic evolved into a major humanitarian crisis and, for a period of a few months in late 2014, seemed to be out of control [1]. The global response has been criticised for being "likewise little, too late" [two, 3] and even irresponsible [4]. Now, as the epidemic ends, various analyses are existence offered as to what went wrong in organising an effective response and how a similar situation can exist avoided in the time to come [v–ix]. This has been an unusual epidemic in that information technology occurred in a region of Africa that Ebola Virus Disease (EVD) had not been seen in earlier [10]. Furthermore, for an EVD outbreak, it was unprecedented in calibration, around 65 times larger than the largest previous outbreak: in 2000/2001 in Republic of uganda 425 cases were reported in three months [11]; past xvi September 2015, 28 214 confirmed, likely and suspected cases of EVD with 11 289 deaths were reported in the iii most affected countries (Guinea, Liberia and Sierra Leone) [12]. Some argue that EVD is not an ideal candidate for a major epidemic [13] as information technology has a very high example fatality rate, a low level of infectivity (requiring close contact and exposure to actual fluid), little evidence of major air-borne spread [fourteen] and, dissimilar viral flu for example, those who are infectious evidence symptoms of major illness. The 2014/2015 West Africa Ebola epidemic has caused the global public health customs to appoint in difficult self-reflection. First it must consider the part information technology played in relation to an important public wellness question: why did this epidemic take hold and spread in this unprecedented manner? Second it must use the lessons learnt to answer the subsequent question: what can be washed at present to preclude farther such outbreaks in the future? These questions remains relevant, fifty-fifty as scientists announce that the Guinea Stage III efficacy vaccine trial shows that rVSV-EBOV is highly efficacious in individuals [xv]. This vaccination will now be tested at calibration and, if effective, represents a major breakthrough in the fight against EVD. However it should exist seen as an adjunct to current strategies of EVD management and control and requires an constructive organization of commitment to ensure it reaches the populations who need it. A concern emerging in the literature is the role of emergency preparedness in relation to a broader public health response [16–19]. This concern acknowledges that the 2014/2015 epidemic posed unique challenges because of very delicate pre-existing health systems [7, twenty, 21]. We contribute to the electric current cocky-reflection by presenting an analysis which responds to the key public wellness questions from the perspective of a Primary Health Care (PHC) approach. We believe that this approach is advisable equally the WHO itself, besides equally African countries in the region affected by EVD, have recommitted themselves to PHC equally a framework for organising wellness systems and the delivery of health services in a serial of declarations betwixt 2000 and 2008 [22]. The PHC approach offers an insightful critique of the global and regional factors which have led to current delicate health systems in Guinea, Republic of liberia and Sierra Leone also every bit suggesting what a strengthened Ebola response might involve in the curt, medium and long-term. In this commodity nosotros describe the manual and pathogenesis of EVD, the WHO intervention package and its underlying philosophy. We then provide an overview of some of the main factors which, in the electric current debate, have been argued to contribute to the failure of the traditional approach of outbreak command. Next we present the comprehensive primary health intendance arroyo as an alternative philosophical approach, which we employ every bit an analytical framework to generate a further fix of insights regarding the importance of acknowledging and addressing the socio-political context of the EVD, and to map out principles of action in wellness arrangement strengthening.

Understanding the transmission and pathogenesis of EVD

An understanding of the manual of EVD is central to informing a health system response. EVD is a zoonosis with animals acting as the reservoir. Humans are infected when they come up into contact with the claret, secretions and organs of infected animals such equally chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines [21]. All before major epidemics have been in Central Africa, in the natural geographic distribution of fruit bats. EVD was showtime identified in 1976 with two epidemics in Zaire and Sudan; since then there have been more than more than 20 outbreaks in Central Africa which are described by del Rio et al. [23]. With the emergence of EVD in West Africa, it is hypothesized that there has been a major change in the habitat of fruit bats to include this region [10]. Human to homo transmission can take identify through direct contact (through broken skin or mucous membranes) with the claret, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. Humans are simply infectious once they become symptomatic, and the infectivity is low during the first 3 days of disease [24]. Infectivity increases with fourth dimension every bit the person becomes sicker and is especially high around death. Importantly, traditional burial practices are a source of infection [25]. Health workers are specially at risk when they piece of work in unhygienic and unprotected conditions. Basic protective clothing and gloves to forbid direct contact and maintaining a altitude of 1–ii m from infected patients is recommended for infection control [26].

There are no canonical drugs to treat the disease. Every bit the disease progresses, the only care possible is supportive; the quality of such care is crucial in determining the outcome. EVD is a gastrointestinal infection which starts as a febrile illness, ofttimes with fatigue and myalgia [2]. The predominant symptoms are vomiting and diarrhoea (each is experienced in approximately ii-thirds of those infected [20]. The master treatment required is replacement of the lost fluids and management of the electrolyte and acrid imbalances that this causes [2]. Haemorrhage occurs later in the course of the illness, is mainly from the gastrointestinal tract and is present in less than twenty % of those infected [20] and is mostly late in the course of disease.

The WHO intervention package

The Globe Wellness Organization (WHO) led the Ebola response from 1 August 2014, including steering the United Nations Mission for Ebola Emergency Response (UNMEER) which was established on 19 September 2014 to coordinate a system-wide United Nation's response beyond agencies. The strategy adopted a regional approach merely sought to remain specific to the needs of each country. The strategic framework, represented by the acronym STEPP, was to stop the outbreak, care for the infected, ensure essential services, preserve stability and forestall further outbreaks. The Ebola Response Roadmap [27] gear up out the proposed intervention package, subject to available resources. This included instance management of infected patients in Ebola handling centres (ETCs) which offered isolation, and infection prevention and command activities. Provision was made for referral processes from primary health care facilities to the ETCs and for laboratory-based case diagnosis. Further provision was fabricated for surveillance, contact tracing and monitoring, supervised burials with dedicated skilful burying teams and a process of social mobilization to brainwash on chance reduction and to create back up for contact tracing. In intense transmission areas the Roadmap recognised the need for complementary community-based care and community burying teams supported by intensified infection prevention and control with advisable personal protective equipment. In add-on the Roadmap identified the demand to ensure essential services in the short-term (such equally health services, food, instruction, water, sanitation and hygiene) recognising that national governments required back up in this from not-governmental organisations, United nations agencies, and humanitarian organizations, and a medium-term investment program to strengthen health services.

What philosophy informed the Ebola response roadmap and how successful was it?

The Ebola Response Roadmap was a archetype "outbreak command" effort [1]. An outbreak command effort typically involves rapid deployment of technical, medical interventions, and isolation of infectious cases to break the manual chain. The assumption underlying this approach is that by acting quickly and effectively the outbreak tin be brought nether command and an epidemic avoided. This end justifies a procedure in which medical experts accept command for the greater skillful. Information technology is a strategy that has worked in previous outbreaks of EVD in central Africa [20, 21]. These outbreaks were limited in size and geographic spread and the interventions were channelled through the local health care organisation, with back up from international partners. Notwithstanding the rapid growth and complexity of this recent epidemic took organisations like WHO by surprise [28] equally it spiralled out of control.

Some believe that the Ebola response contributed to the disintegration of the local wellness system [ane] with uninfected people dying from treatable illnesses such equally malaria, respiratory infections and diarrhoea [7]. Chief care facilities were converted to 'holding centres' and Ebola Treatment Centres (ETC.); the former were places where patients suspected of having EVD were kept while awaiting ship to accept them to the latter. Routine wellness care services were suspended as the already fragile health systems were overwhelmed by the Ebola response [29]. There is trivial bear witness that hospitalisation during the commencement few months of the epidemic made a divergence to mortality rates in the current epidemic (WHO Ebola Response Squad, 2014a). Cure was non the master objective in managing EVD in Treatment Centres; rather these functioned every bit role of an elaborate isolation strategy to break transmission. The centres also become function of the problem with nosocomial infection in unhygienic conditions, amplifying the transmission [30]. Health intendance staff worked in conditions that placed them at risk too, without minimum protective gear such as gloves and many fled [two, 3]. Tragically, a large number of wellness care staff became infected and died. Some question the value of the model of quarantining patients in treatment centres based on iatrogenic harm [17]. Critically important, the pre-existing health infrastructure was too limited and shortages of health care staff were too astringent for the national health systems to answer effectively. Even when massively bolstered by an international donor support-base and resource, treatment beds in Sierra Leone only met 60 % of the demand at the peak of the epidemic in November 2014.

The response to the epidemic wrought wider social disruption that threatened local and national economies, food security and social structures. To prevent international spread The Ebola Response Roadmap [27] prohibited travel of all cases and contacts, with exit screening for symptoms at international airports, seaports and borders. Affected countries further limited motility between regions using travellers checkpoints and imposed quarantines which varied from stay-at-home days to guarded dwelling house confinement [30]. Ten thousand schools were closed, interrupting the schooling of 2 one thousand thousand children [31] and prompting experts to warn that the longer schools remained closed, the greater the gamble that children, especially girls, would drop out. This has raised concern that literacy may drib in countries which already accept low literacy rates [32] and could have a long-term impact on maternal mortality and child health. In the wake of EVD at that place has been an increment in household food insecurity due to changes in nutrient product, restricted travel to markets and reduced income potential, with 2.iii to iii million people estimated to be affected [33].

Why has the traditional approach of outbreak command failed in this epidemic?

While some postulate a change in the distribution of animate being vectors for the emergence of this electric current EVD epidemic [10], the escalation is driven by other factors. There is an emerging consensus that the boggling magnitude of the current epidemic is not related to a modify in the virus, merely due to population density and mobility and other factors [twenty]. Bausch and Schwarz [10] debate that such large outbreaks most invariably occur where there is severe poverty and health systems are compromised. In this epidemic, not only was the local, national, and international response likewise slow but it was complicated by a dysfunctional local health service, unable to human activity as a conduit for intensified international efforts [ane]. All three countries had pre-existing challenges in their wellness systems with inadequate infrastructure, severe shortages of trained health workers, shortages of basic medicines and very weak wellness data and disease surveillance systems [9]. In Liberia, Sierra Leone and Republic of guinea in 2013 at that place were 88 496, 79 365 and 24 096 people per health-middle respectively, compared to x 320 people per health-centre in nearby Ghana. Instead of the recommended i trained health intendance worker for every 439 people, there was one health worker for iii 472, five 319 and 1597people respectively for these three countries. Applying system thinking Agyepong [34] has shown how the EVD outbreak stressed the already compromised wellness systems, weakening them further in a reinforcing negative cycle. The epidemic was fabricated more circuitous by occurring in urban, highly-mobile communities moving across the political boundaries of three countries. The ability of the weak national health systems to respond was farther compromised past this complexity, and by weak national governance in the 3 affected countries making the coordination of the health system response more hard.

In mail service-disharmonize Liberia and Sierra Leone, attempts to involve communities were threatened by a lack of trust in authorities [1] which means that peak-downward implementation models were doomed to failure. Poor treatment outcomes further threatened trust in the newly introduced, alternative wellness intendance system, thereby undermining quarantine efforts. The difficulty of involving communities in negotiating appropriate and acceptable treatment and interventions to break transmission bondage meant that many infected patients and their families chose to side-pace the alienating handling centres; in Liberia they began to coffin their dead secretly to avert the mandated cremation [35]. Contact tracing suggests that in this epidemic unsafe burial practices accounted for upwards to twenty % of transmission. The grossly inadequate route infrastructure meant that transporting those infected or suspected of existence infected with EVD required long and chancy journeys consuming deficient resources and increasing the exposure of other patients and health staff to the virus.

The Comprehensive Primary Health Care approach

Changing theories about the relationship between health and development in the 1970s coupled with concerns about the effectiveness of transplanting medical models of service delivery into developing country settings and interest in culling community-based models led to the concept of Primary Health Intendance (PHC) [36, 37] which was ratified in the Alma Ata Proclamation [38]. The following definition was put forward:

"…essential wellness intendance based on practical, scientifically audio and socially acceptable methods and applied science made universally attainable to individuals and families in the community through their full participation and at a cost that the customs and state can afford to maintain… Information technology forms an integral part of the country'south health system of which it is the primal function and master focus, and of the social and economical development of the community. It is the first level of contact for individuals, the family and customs…bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care procedure".

The definition has led to a number of divergent interpretations of PHC [22]. PHC has been interpreted as the first point of contact with the health organization or the chief level of care on the one mitt, and a broad philosophy or approach to health care on the other. In the latter view, sometimes referred to as the comprehensive PHC approach, information technology is seen as a strategy for organising health care systems and social club to promote health. This perspective has strong socio-political implications, addressing the underlying social determinants of sick-wellness through intersectoral activeness, seeking to empower communities, to meet the needs of the most marginalised and to provide comprehensive intendance with the accent on affliction prevention and wellness promotion [39]. It is to this latter perspective that the African Region has re-committed itself [xl].

The alternative to the comprehensive PHC arroyo, the selective approach to PHC [41] proposed focussing on a circumscribed number of diseases with high morbidity and mortality, using largely effective therapeutic or personal preventive interventions. This became the dominant expression of PHC implemented in developing countries [36] and ushered in an area of vertical medical programmes. Baum (2007, p 36) suggests that selective PHC "…robbed primary wellness care of its community engagement, broader social change and re-distributive vision and placed it firmly back in the medical framework". The importance of investigating the impact of such upstream determinants has been reaffirmed in the last decade, with the findings of the WHO Commission on Social Determinants of Health [42]. Importantly, comprehensive PHC has been recognised as the organising philosophy and framework for African countries [22], as evident in a gear up of regional declarations such as the Health-For-All Policy for the 21st Century in the African Region: Agenda 2020 and the Ouagadougou Declaration on Master Wellness Intendance and Health Systems in Africa: Achieving Meliorate Health for Africa in the New Millennium. These declarations take an explicit health service focus besides as stiff socio-political implications, seeking to respond more than equitably, accordingly and effectively to basic health care needs and also address the underlying social, economical and political causes of poor wellness. The principles of the comprehensive PHC approach include universal accessibility and coverage on the basis of need; comprehensive care with the emphasis on disease prevention and health promotion; customs and individual involvement; intersectoral activity for health; and appropriate technology and cost-effectiveness in relation to the bachelor resources.

What does a comprehensive PHC approach offer? Understanding the importance of social determinants in the spread of EVD

A deeper analysis of this EVD outbreak exposes the pathology of the global economic and political system [13]. Despite being resource-rich countries, the populations go along to experience extreme poverty and inequity. It has been suggested that poverty and chronic food shortages in the three countries have led to communities penetrating deeper into the forests to look for food and fuel, potentially exposing them to bats and other animals which are host to the Ebola virus [10]. Further, changes in the local environmental accept altered the patterns of the distribution of Ebola'south animal hosts [10]. Deforestation has increased through the growth in the logging industry in Sierra Leone [43] and strange-owned global agribusiness in Republic of guinea [44] which brings people and wildlife into closer contact with the risk of zoonotic affliction [45]. Deforestation as well undermines local nutrient product [46]. Fifty-fifty where foreign investment and economic growth is loftier every bit in Sierra Leone, transnational corporations accept been implicated in tax evasion - see for case [47] - and there are allegations of government corruption in all iii countries [nine, 48], often serving and exacerbated by strange interests, as seen in the civil wars in Liberia and Sierra Leone. Civil state of war itself impoverishes poorer countries [34] and destroys health organisation infrastructure. For example, in Sierra Leone where the ceremonious war lasted from 1991 to 2002, only xvi % of the health centres were still functional by 1996 [49].

Probing the factors contributing to the long term fragility of health systems of Liberia, Guinea and Sierra Leone reveals bereft investment despite the fact that these are mineral rich countries. The full health expenditure per capita (USD) in 2013 was $24.80 in Guinea, $44.xl in Liberia and $95.80 in Sierra Leone while the boilerplate for Sub-Saharan Africa was $101.30 and globally was $1,047.80. Underinvestment has been linked to a history of exploitation by multinational companies, civil war and abuse [13]. The World Bank and the International Budgetary Fund also have played a role through structural aligning programmes which reduced public spending on welfare and public services [5] and aggravated health worker migration from the pool of critically-stretched trained health workers. More doctors born in Liberia and Sierra Leone work in OECD countries than in their domicile countries [50]. The international public health customs's focus on illness preparedness has likewise been implicated in weakening wellness systems in the region [51]. Fearnley (2015) describes the "emerging diseases worldview" in the 1990s which shaped the evolution of the then new field of global health, which detracted from edifice health systems and instead siphoned off resources to focus on disease surveillance and hospital preparedness to quell early epidemics. In the current epidemic EVD has been bandage as a global health security threat [7, 23, 30, 52, 53].

An agreement of the social determinants of EVD frames it in a broader socio-political context which needs to be addressed if further outbreaks of this magnitude are to be avoided. The importance of investigating and addressing these factors has been reaffirmed in the concluding decade, with the findings of the WHO Commission on Social Determinants of Health (Earth Health Organization & Committee on the Social Determinants of Wellness, 2008). The global public health customs has a responsibility to advocate for and partner with governments to invest in national health systems [13]. Further, to address the underlying poverty and inequity driving the occurrence and spread of EVD, international advocacy is needed to support pro-poor changes in economic and power relations.

What does a comprehensive PHC arroyo offer? Principles for activeness in health organization strengthening

In this section we explore the importance and relevance of the principles of comprehensive PHC to the contexts in Guinea, Sierra Leone and Republic of liberia and suggest how they might be applied in a medium and longer-term strategy to accost EVD and rebuild wellness systems in the region. Dubois et al. [9] point out that, in response the Millennium Development Goals (MDGs) and international funding, significant progress in reducing in kid and maternal mortality had been made in the region in the decade prior to the 2014/2015 Ebola epidemic. However, they fence that the target-oriented approaches promoted by the MDGs led to vertical funding and 'narrow bands of attention and progress' which overlooked the broader agenda of addressing the social determinants driving ill-health and of wellness arrangement strengthening. This view is supported by others [54] who accept noted the 'fragmented, project-oriented arroyo to health sector rehabilitation and development, which privileged certain public health bug' in Sierra Leone after the civil war. There is a call for a more comprehensive approach to health system development. This section does non offering technical recommendations but adds to the small but of import literature [9] which is seeking to look beyond the operational issues to underlying systems. We draw on the principles of comprehensive PHC to propose what such an approach might await like.

The re-institution of the wellness systems and universal admission to comprehensive health care

The comprehensive primary health care arroyo advocates for access to wellness care on the ground of equity and social justice. Universal access to health intendance and prevention has been a challenge in the three most severely affected countries, with their large rural communities and express health service and transport infrastructure. Access to health intendance is further reduced by high indicate-of-treatment costs to the patient that are oftentimes unmanageable in subsistence-based agricultural village economies. To control the spread of EVD there is an imperative to ensure that each person is reached to preclude an upsurge in new cases [8]. A comprehensive primary wellness care approach calls for delivery of skills and funding to supporting the resuscitation and development of a potent primary and community care organisation - with increased numbers of lower-level and community-based health workers - which gives universal admission to prevention and treatment of the mutual conditions which behave such a high mortality in these countries. Without this at that place will be an increase in deaths during childbirth, malaria, tuberculosis, human immunovirus/acquired immune deficiency (HIV/AIDS) and acute infectious illnesses [1]. Further, this volition ensure that at that place is an efficient conduit in identify for an emergency response to contain future epidemics. However, this would require relinquishing an emergency heed-set [54]. The Free Wellness Care Initiative, a health reform introduced in 2010 in Sierra Leone, was helpful in coordinating international aid and developing a more than comprehensive arroyo to health system development pre-Ebola, including infrastructure and homo resources development [54]. Rebuilding the health system is not a project for heroic, top-down intervention – information technology is a medium-term project where priority must exist given to the process of building the planning and direction chapters of the Ministry of Wellness and commune level management to support a strong network of customs wellness workers and primary level facilities. The development of primary intendance services requires a strong community-based component to ensure acceptable coverage of hard-to-reach areas and because complementary abode- and community-based interventions are required to be effective [55–57] given the burden of disease. Such a service will be able to identify new cases of EVD and be bachelor to organise itself to evangelize new technologies, such as an efficacious EVD vaccine, when they become available.

Engagement with communities

The emphasis on breaking transmission to control EVD is an appropriate public health response in the early phase of an epidemic. Upward until now this has required early diagnosis and quarantine which, in turn, both require building a human relationship of trust between communities and health services [i]. The advent of an constructive vaccination still requires date with communities who must larn to trust the vaccination, and continues to rely on there being a functional network in the customs which tin place the symptoms of EVD and set up a local and effective response. In the current epidemic the WHO Roadmap included social mobilisation [27] but this proved hard to implement in the midst of the crisis. Fright and suspicion had tragic consequences in some instances; for instance riots erupted in Republic of guinea in August 2014 after rumours spread that health workers, who were disinfecting a marketplace, were actually contaminating people; in some other incident in Guinea in September 2014 8 members of a team trying to raise awareness about EVD were killed past villagers using machetes and clubs [58]. A key lesson of this EVD outbreak is that it is difficult to appoint communities unless there is already a well-adult relationship and a network of health workers who are already accountable to and embedded within communities. A comprehensive primary health care response further advocates for extensive community date every bit a mechanism to give phonation to marginalised communities and reduce their vulnerability. Working with existing civil and customs structures and local leadership promotes trust-building which is particularly important in settings such as Liberia and Sierra Leone where trust in the authorities has been broken and where top-down directives are counterproductive.

Intersectoral action to address the epidemic

A comprehensive main health intendance approach promotes intersectoral action for health, recognising that other sectors such as education often requite admission to key populations and themselves work towards similar health outcomes, that social determinants can confound wellness organisation responses and that social determinants usually underlie the health problems themselves. The importance of intersectoral action is starkly illustrated in relation to food security. In belatedly 2014 the Globe Nutrient Plan estimated that betwixt 2.3 to 3 million people are food-insecure in the three most affected countries [33], with 0.seven to one.5 one thousand thousand as a directly or indirect effect of EVD which acquired social disruption, affected farming and motility of crops (cassava being the staple) besides as affecting labour markets and people's livelihoods, significant that households did not have the money to buy food. In the curt-term information technology meant that there was an urgent need to distribute food to insecure households, a response which was advisedly monitored in the after phases of the epidemic [33]. Yet food distribution to outlying communities was thwarted by the poor road infrastructure. Development initiatives are now required to support economies and the re-establishment of local farming practices to reduce vulnerability to future food insecurity. National and local intersectoral activity for health therefore needs to exist office of the medium term planning involving ship, trade and evolution sectors.

Conclusion

A comprehensive primary health care approach adds novel insights into what the global health customs might larn from the failure to limit the recent EVD outbreak before it spiralled out of control. The approach suggests that, in an epidemic made complex by weak pre-existing wellness systems and lack of trust in regime and mobile populations, a broader approach was required to engage before, more actively and more directly with afflicted communities. In the medium-term health system development with attention to main level services and community-based programmes to address the major disease burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local direction and an investment in homo resource for health, including a potent core of community workers. Crucially this has to be developed ahead of, and not in parallel with, future outbreaks. In the longer-term a commitment is required to accost the underlying social determinants which make these countries so vulnerable, and limit their capacity to reply finer to, epidemics such as EVD.

Ethics approval and consent to participate

This commodity did not involve any principal research with homo subjects (including man material or human data). It did non therefore go through an ethics committee. Consent was not an issue.

Consent for publication

Not applicative.

Availability of data and materials

All the data supporting analysis is contained inside the manuscript.

Abbreviations

EVD:

Ebola virus disease

ETC.:

Ebola handling centres ETCs

HIV/AIDS:

Human immunovirus/Acquired immune deficiency

PHC:

Primary Health Intendance

STEPP:

End the outbreak, treat the infected, ensure essential services, preserve stability and foreclose further outbreaks.

UNMEER:

United Nations Mission for Ebola Emergency Response

WHO:

Earth Wellness Organization

References

1. Farrar JJ, Piot P. The Ebola emergency - immediate activity, ongoing strategy. N Engl J Med. 2014;37(16):1545–6.

   Article  Google Scholar

2. Fowler R, Fletcher T, Fischer West, Lamontagne F, Jacob Southward, Brett-Major D, et al. Caring for critically Ill patients with Ebola virus disease. Perspectives from West Africa. Am J Respir Crit Intendance Med. 2014;190(seven):733–7. Bachelor from: http://world wide web.atsjournals.org/doi/pdf/10.1164/rccm.201408-1514CP.

   Commodity  PubMed  Google Scholar

3. Torjesen I. World leaders are ignoring worldwide threat of Ebola, says MSF. BMJ. 2014;349(September):g5496–6. Available from: http://www.bmj.com/content/bmj/349/bmj.g5496.full.pdf.

4. Nierle T, Jochum B. Ebola : the failures of the international outbreak response [Cyberspace]. Medecins Sans Frontieres. 2014 [cited 2015 February 23]. p. 2–4. Available from: http://www.msf.org/commodity/ebola-failures-international-outbreak-response.

5. Kentikelenis A, King L, Mckee Thousand, Stuckler D. The International Monetary Fund and the Ebola outbreak. Lancet Glob Heal [Cyberspace]. Kentikelenis et al. Open access commodity published under the terms of CC By; 2014;3(2):e69–seventy. Available from: http://world wide web.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(14)70377-eight.pdf.

6. Lakoff A. Two States of Emergency : Ebola 2014. Limn. 2015;(5).

7. Piot P. Ebola'due south perfect storm. Science. 2014;345(6202):1221. Available from: http://science.sciencemag.org/content/345/6202/1221.full.

   CAS  Commodity  PubMed  Google Scholar

8. Report by the Managing director General of the Earth Health Organization, 25 Jan 2015, Geneva, Switzerland [Internet]. Geneva; 2015. Available from: http://www.who.int/dg/speeches/2015/executive-lath-ebola/en/

9. Dubois K, Wake C, Sturridge Due south, Bennett C. The Ebola response in West Africa of international aid. 2015.

   Google Scholar

10. Bausch DG, Schwarz L. Outbreak of Ebola virus disease in Guinea: where ecology meets economy. PLoS Negl Trop Dis. 2014;eight(six):8–12.

    Google Scholar

11. WHO Ebola Response Team. Ebola virus affliction in West Africa - the first 9 months of the epidemic and forwards projections. N Engl J Med. 2014;371(16):1481–95. Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411100.

    Article  PubMed Central  Google Scholar

12. Ebola Situation Report - 16 September 2015 [Cyberspace]. Geneva; 2015. Bachelor from: http://apps.who.int/ebola/current-state of affairs/ebola-situation-report-16-september-2015.

13. Sanders D, Sengupta A, Scott V. Ebola epidemic exposes the pathology of the global economic and political organization. Int J Wellness Serv (Qassim). 2015;45(4):643–56.

    Article  Google Scholar

14. Martin-Moreno JM, Llinás G, Hernández JM. Is respiratory protection appropriate in the Ebola response? Lancet. 2014;384(9946):856. Bachelor from: http://world wide web.ncbi.nlm.nih.gov/pubmed/25178253.

    Commodity  PubMed  Google Scholar

15. Henao-Restrepo AM, Longini IM, Egger M, Dean NE, Edmunds WJ, Camacho A, et al. Articles efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein : interim results from the Guinea ring vaccination cluster-randomised trial. Lancet. 2015;6736(15):1–10.

    Google Scholar

16. Lakoff A, Collier SJ, Kelty C. Introduction : Ebola' due south Ecologies. Limn. 2015;(5).

17. Redfield P. Medical vulnerability, or where there is No Kit. Limn. 2015;2013:one–8.

    Google Scholar

18. Kenny C. The Ebola Outbreak Shows Why the Global Health System Is Broken [Internet]. 2014 [cited 2014 February 18]. p. ane–11. Bachelor from: http://world wide web.bloomberg.com/bw/manufactures/2014-08-11/the-ebola-outbreak-shows-why-the-global-wellness-system-is-cleaved.

19. Fearnley Fifty. The Disease that Emerged. Limn. 2015;(5).

20. Kutzin J, Sparkes SP. Health systems strengthening , universal health coverage , health security and resilience. Bull World Heal Organ. 2016;94(9980):165050.

21. Fauci AS. Ebola--underscoring the global disparities in health care resources. N Engl J Med. 2014;371(12):1084–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25119491.

    Article  PubMed  Google Scholar

22. Schaay N, Sanders D. International perspective on primary wellness care over the by thirty years. In: Barron PR-RJ, editor. South African health review 2008. Durban: Health Organisation Trust; 2008. p. 3–xvi.

    Google Scholar

23. del Rio C, Mehta AK, Lyon Chiliad, Guarner J. Ebola hemorrhagic fever in 2014: the tale of an evolving epidemic. Ann Intern Med. 2014;161:746–nine.

    Article  PubMed  Google Scholar

24. Kelly A. Ebola, Running Ahead. Limn. 2015;(5).

25. World Health Organization. New WHO Safe and Dignified Burial Protocol Key to Reducing Ebola Manual [Internet]. 2014 [cited 2015 Feb 18]. Bachelor from: http://www.who.int/mediacentre/news/notes/2014/ebola-burial-protocol/en/.

26. World Health Organization. Interim infection prevention and command guidance for care of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings, with focus on Ebola [Cyberspace]. Geneva: WHO; 2014. Available from: http://world wide web.who.int/csr/disease/ebola/evd-guidance-summary/en/.

    Google Scholar

27. World Wellness Organization. Ebola Response Roadmap. Geneva: World Wellness Organization; 2014.

28. Roberts L. Ebola: "Wow, that is actually tough.". Science. 2014;345(6202):1229–thirty.

    CAS  Article  PubMed  Google Scholar

29. Medecins Sans Frontieres. Sierra Leone: MSF Suspends Pediatric and Maternal Service in Gondama [Internet]. Printing release, 16 October 2014. 2014 [cited 2015 Feb 18]. p. 2–4. Bachelor from: http://www.doctorswithoutborders.org/article/sierra-leone-msf-suspends-emergency-pediatric-and-materna-services-gondama.

30. Gostin LO, Lucey D, Phelan A. The Ebola epidemic a global health emergency. J Am Med Assoc. 2014;312(xi):1095–half dozen.

    Article  Google Scholar

31. Global Partnership for Education. How the Ebola Crisis is Affecting Instruction in Due west Africa, nineteen November 2014. 2014; Available from: http://www.globalpartnership.org/blog/how-ebola-crisis-affecting-education-west-africa.

32. UNICEF. Children hardest hit [Cyberspace]. 2015. Bachelor from: http://world wide web.unicef.org/emergencies/ebola/75941_76202.html.

33. World Food Programme. Special Focus Ebola, November 2014 [Internet]. 2014. Available from: http://documents.wfp.org/stellent/groups/public/documents/ena/wfp268882.pdf.

34. Agyepong IA. A systems view and lessons from the ongoing Ebola Virus Disease (EVD) outbreak in West Africa. Ghana Med J. 2014;48(3):168–72.

    CAS  Article  PubMed  PubMed Primal  Google Scholar

35. Associated Press in Monrovia. Ebola cremation ruling prompts secret burials in Liberia. The Guardian [Internet]. 2014 October 24; Available from: http://www.theguardian.com/globe/2014/oct/24/ebola-cremation-ruling-secret-burials-republic of liberia.

36. Werner D, Sanders D. Questioning the solution: the politics of primary health intendance and child survival. Health Wrights: Palo Alto; 1997.

    Google Scholar

37. Walt G, Vaughan J. An introduction to the primary wellness care arroyo in developing countries. London: Ross Found of Tropical Hygiene; 1981. p. 1–19.

    Google Scholar

38. Earth Health Arrangement. Proclamation of alma-Ata. International conference on main health care, alma-Ata, USSR, half dozen–12 september 1978. Geneva: Globe Health Organization; 1978.

    Google Scholar

39. Baum F. Health for All Now! reviving the spirit of alma Ata in the twenty-commencement century: an introduction to the alma Ata declaration. Soc Med. 2007;2(1):34–41.

    Google Scholar

40. World Wellness Organization Regional Office for Africa. Report on the Review of Main Health Care in the African Region. Brazzaville; 2008.

41. Walsh J, Warren K. Selective PHC - an interim strategy for disease control in developing countries. North Engl J Med. 1979;30(xviii):967–74.

    Article  Google Scholar

42. Globe Wellness Organization, Committee on the Social Determinants of Health. Closing the Gap in a Generation: Wellness Equity Through Action on the Social Determinants of Health. Geneva: WHO: 1–33. [Online], Bachelor: [Internet]. 2008. Available from: http://www.who.int/social_determinants/thecommission/finalreport/en/index.html.

43. Liberian communities argument on expansion of Sime Darby and Golden Veroleum plantations. farmlandgrad.org [Net]. Monrovia; 2012 Dec three;2–iv. Available from: http://farmlandgrab.org/post/view/21381.

44. Wallace R. Neoliberal Ebola? Farming Pathogens: diseases in a world of our own making [Net]. 2014 Apr 23;1–8. Available from: http://farmingpathogens.wordpress.com/2014/04/23/neoliberal-ebola/.

45. Horton R, Lo South. Planetary wellness: a new science for exceptional action. Lancet. 2015;6736(15):one–two. Bachelor from: http://linkinghub.elsevier.com/recall/pii/S0140673615610388.

    Article  Google Scholar

46. Bello Due west. How the World Depository financial institution, IMF and WTO destroyed African agronomics. World Hunger Notes. 2008;

47. Christian Aid. Africa Rising? Inequalities and the Essential Role of Off-white Tax. London; 2014.

48. Epstein H. Ebola in Liberia : an epidemic of rumors. 2013.

    Google Scholar

49. Bertone MP, Samai Yard, Edem-Hotah J, Witter S. A window of opportunity for reform in postal service-conflict settings? the case of human resources for health policies in sierra Leone, 2002–2012. Confl Health. 2014;viii(1):11. Available from: http://www.conflictandhealth.com/content/eight/ane/11.

    Article  PubMed  PubMed Key  Google Scholar

50. Dumont J-C, Zurn P. Immigrant health workers in OECD countries in the broader context of highly skilled migration. Internal migration outlook. second ed. Paris: OECD Publishing; 2007.

    Google Scholar

51. Nguyen V-Thou. Ebola : How Nosotros Became Unprepared, and What Might Come Next. Cult Anthropol Online [Cyberspace]. 2014 [cited 2015 Feb 23]; Bachelor from: http://www.culanth.org/fieldsights/605-ebola-how-we-became-unprepared-and-what-might-come-nex.

52. Frieden T, Damon I, Bell B, Kenyon T, Nichol S. Ebola 2014 - New challenges, New global resonse and responsibility. N Engl J Med. 2014;371(13):1177–80.

    Article  PubMed  Google Scholar

53. Gomes MFC, Pastore A, Rossi L, Chao D, Longini I, Halloran ME, et al. Assessing the International Spreading Risk Associated with the 2014 Due west African Ebola Outbreak. PLOS Curr Outbreaks. 2014;i–17.

54. Denney L, Mallett R. After Ebola : why and how chapters support to Sierra Leone'due south health sector needs to alter. 2015;(June). Available from: http://securelivelihoods.org/publications_details.aspx?ResourceID=362.

55. Haines A, Sanders D, Lehmann U, Rowe AK, Lawn JE, Jan S, et al. Achieving kid survival goals: potential contribution of community health workers. Lancet. 2007;369:2121–31.

    Commodity  PubMed  Google Scholar

56. Christopher JB, Le MA, Lewin Due south, Ross DA. Xxx years after alma-Ata: a systematic review of the impact of community health workers delivering curative interventions confronting malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa. Hum Resour Health. 2011;9(1):27. Available from: http://www.human-resources-wellness.com/content/ix/1/27.

    Article  PubMed  PubMed Primal  Google Scholar

57. Winch PJ, Gilroy KE, Wolfheim C, Starbuck ES, Young MW, Walker LD, et al. Review commodity Intervention models for the management of children with signs of pneumonia or malaria by community wellness workers. Heal Policy Plan. 2005;xx(4):199–212.

    Article  Google Scholar

58. Ebola outbreak: Republic of guinea wellness team killed. BBC News [Cyberspace]. 2014 Sep 19; Available from: http://www.bbc.com/news/globe-africa-29256443.

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Acknowledgements

VS was supported past the UWC/MRC Health Services to Systems Enquiry Unit

Funding

Nil.

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Affiliations

1. Schoolhouse of Public Wellness, University of Western Greatcoat, Private Pocketbook X17, Bellville, Cape Town, 7535, South Africa

   Vera Scott & David Sanders

2. Primary Health Care Advisers, Academy of Cape Town, Individual Pocketbook, Rondebosch, Cape Boondocks, South Africa

   Sarah Crawford-Browne

Corresponding author

Correspondence to Vera Scott.

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The authors declare that they have no competing interests.

Authors' contributions

VS, SC-B and DS conceived of the article, and participated in its design. VS wrote the first typhoon which was then amended past SC-B and DS. All authors read and approved the concluding manuscript.

Authors' information

Vera Scott is a senior researcher at the School of Public Health at the University of the Western Cape, South Africa who has more than ten years' experience in teaching a module on Main Health Care to MPH students. Her inquiry interests include disinterestedness in health service commitment and innovative approaches to strengthening leadership and management development in depression-middle income settings. Sarah Crawford-Browne is a lecturer in the Primary Health Care Directorate at the University of Cape Town, S Africa. She is passionate almost preparing health professionals to serve effectively in complex environments of diversity and structural violence. Her research interests include agreement the impact of continuous traumatic stress on the lives of people living in contexts of ongoing violence. She has two decades of experience in South African and international community-based practice responding to trauma. David Sanders, Emeritus Professor and founding Director of the Schoolhouse of Public Health at the University of the Western Cape, South Africa, is a paediatrician qualified in Public Health. He has over xxx years' experience of academy teaching and health policy development in Zimbabwe and South Africa, having brash governments, NGOs and several UN agencies on primary health care, child health and nutrition, and health human resource. He has published 3 books on the political economy of health, and over 150 scientific articles in these areas. In 2012 he was awarded an Honorary Doctorate by the University of Greatcoat Boondocks in recognition of his contribution to the evolution of the global policy of Master Health Intendance, and in 2014 received the Public Health Innovation and Lifetime Achievement (PHILA) Award of the Public Health Association of S Africa. He is a founder and on the Global Steering Council of the Peoples Health Motion and has been a contributor and editor of Global Health Watch.

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Scott, 5., Crawford-Browne, S. & Sanders, D. Critiquing the response to the Ebola epidemic through a Principal Health Care Approach. BMC Public Wellness sixteen, 410 (2016). https://doi.org/10.1186/s12889-016-3071-iv

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• Received: 25 September 2015

• Accepted: 05 May 2016

• Published: 17 May 2016

• DOI : https://doi.org/10.1186/s12889-016-3071-4

Keywords

• Social Determinant
• Health System Strengthen
• Outbreak Control
• Intersectoral Action
• Efficacy Vaccine Trial

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