Managing the West African Ebola epidemic: What do we need to do? A comment on Uganda’s malaria epidemic and his encounter with the President of the Nigerian Academy of Sciences

The Nigerian Academy of Sciences’ past president is Tomori. I had asked whether he was surprised that high-income countries were buying up monkeypox vaccine supplies and WHO was sharing its vaccines with 30 non-African countries, leaving the continent without access.

He tries not to get upset about global health inequalities as he thinks they are inevitable. African countries rely a lot on the West, which is not a good recipe for success, according to him. Western aid is always too little, too late according to Tomori. He stresses that the more important thing is that assistance is not helping us. It’s making us more dependent.”

Four weeks ago, I visited Mulago National Referral Hospital, in Kampala, where I used to work. It is home to one of Uganda’s isolation wings. During my visit, I witnessed some of the challenges that the government and health-care workers were facing to contain this terrible outbreak without the most effective tool there is: vaccines. The Sudan strain of e disease has claimed 56 lives and spread to 9 districts in Uganda, the capital city of 2 million people and regions that border other nations. If it spills into neighbouring countries, it could trigger a regional crisis.

The elephant in the room is whether achieving all this is even possible since African public health systems have long been underfunded. As one example, African Union member states pledged to spend 15% of their national budgets on health in the 2001 Abuja Declaration. Two decades later, that’s happened in only five countries: Ethiopia, Gambia, Malawi, Rwanda and South Africa.

Perhaps the most infamous example was during the West African Ebola epidemic when it took nearly three months to identify the virus in Guinea. WHO reported that the country took so long because “Clinicians had never managed cases. No laboratory had ever diagnosed a patient specimen. No government had ever witnessed the social and economic upheaval that can accompany an outbreak of this disease.” The viruses was “primed to explode” when they were finally identified.

The Likouala Prefecture is a swampy area in the north of the country and one of the least developed regions. He calls Likouala a paradise because of the number ofdisease-causingbacteria, including treponema, and the number ofviral disease. “You know something terrible is going to come out of that area,” he says. Without proper pathogen monitoring, it’s only a matter of time.

Public health agencies are still important in empowering locals with educational programs and coordinating the response. Indeed, the best early warning system might come from those living on the frontlines of novel diseases. “You can prevent an epidemic if you take care of the first case,” he says.

The Mombouli’s team visited many villages in the northern Republic ofCongo in an effort to establish a community-based surveillance system for the disease. They educated locals about the virus and how it could spread through infected wildlife carcasses, emphasizing the core message: “Do not touch, move or bury the carcass and contact the surveillance network immediately.”

COVID-19 vaccines have begun to be produced by the Biovac Institute in Africa. In other words, given all the ingredients from Pfizer-BioNTech, these manufacturers fill up vials with vaccine doses and package them for distribution. Since Africa currently imports 99% of all its vaccines, this is an important step toward domestic production, says Mombouli, but he emphasizes that this model is inherently vulnerable since it’s only the last step in the value chain.

15 spokes have been identified across low and middle income countries, including six in Africa, since last year when the WHO chose South Africa’s Afrigenetic to be the hub for messenger RNA technology transfer. Because Moderna and Pfizer-BioNTech refused to share their technology and expertise, Afrigen started training the spokes to make their own version of the vaccine, one that doesn’t require cold storage. The ultimate promise, Mombouli suggests, is for African countries to use novel vaccine technology to control diseases that are spreading on the continent.

“If the company decides to move out,” he says, “then we go back to square one.” As one concrete example, Johnson & Johnson partner Aspen Pharmacare may soon shut down its South African plant making COVID-19 vaccines because of insufficient demand due to hesitancy and difficulties distributing the vaccine (among other reasons ).

It will take time, with the clinical trial expected to be done later this year and vaccine approval coming in ten years, but there is still a lot that can be done. Beyond fill-and-finish operations, Tomori says that African countries can identify other aspects of the value chain where they can start contributing immediately. For instance, one might manufacture glass vials, another rubber stoppers, another testing swabs and so on. Every country doesn’t need to make everything at once, but Tomori says they should be starting somewhere.

But things are beginning to change. One of the four African countries has exceeded the WHO threshold, with 10.28 workers per 1,000.

This fledgling success stems from government prioritization. In a recent paper in World Health and Population, authors from Namibia’s Ministry of Health and Social Services described how they used a WHO tool to diagnose the country’s staffing shortcomings. With the data, they made evidence based decisions about expanding the scope of practice of nurses and redeploying health-care workers to areas that most need them.

The University of Global Health Equity in Rwanda, the General Electric (GE) healthcare skills and training Institute, and others are critical to the continued building of more medical institutions.

African countries have lost $2 billion because doctors moved to other countries, according to a study in the British Medical Journal. “So that people don’t leave the continent for other places, Africa has to look inward and start paying its citizens the proper wages,” says Happi. The Zimbabwean Nurses Association believes that nurses in the country earn a lower salary than the World Bank’s international poverty line.

This wouldn’t stop health-care workers from going to Africa, but it would help replenish their workforce. “You can’t deplete a Continent of its own resources if you aren’t honest with the people you care about,” he says.

It is not to say African-Western partnerships shouldn’t be pursued. Sikhulile Moyo is the laboratory director at the Gaborone-Harvard AIDS Institute Partnership and a research associate at the T.H. Chan School of Public Health. The Broad Institute and Happi collaborated and deployed COVID-19 tests in hospitals in Africa before they were even offered in the United States. Partners in Health also recently announced plans for the $200 million Paul E. Farmer Scholarship Fund, which will support students at the University of Global Health Equity in order to “educate future health care leaders in Africa.”

COVID-19: From universities to companies: a case study of a global collaboration after the CO VId19 Phreny in the 21st century

Simar Bajaj is an American freelance journalist who has previously written for The Atlantic, TIME, Guardian, Washington Post and more. He is a research fellow at the Massachusetts General Hospital, where he studies the history of science and chemistry. Follow him on Twitter @SimarSBajaj

According to the legend,Winston Churchill once advised to “never let a good crisis go to waste”. Scientists and institutions around the world were able to develop products, technologies and approaches to innovation through the CO VId19Phreny. “It was unique in a tragic way, and it spurred a whole new way of doing things,” says Caroline Paunov, an economist with the Organisation for Economic Co-operation and Development (OECD). It led to a different way of thinking. The crisis was so urgent and pervasive that it quickly pulled together governments, companies and research institutions for the common good. There is a question of how long that sense of cooperation can last and what kind of help was learned to cope with the next global crisis.

Ulrichsen points to another COVID-19 technology that emerged from partnerships between universities and companies. Researchers at University College London and University College Hospital worked with Mercedes High Performance Powertrains, which produces parts for Formula One cars, to create the Ventura breathing aid, a mechanical device used to open the airways of critically ill patients.

When the Pandemic struck, universities stripped down bureaucracy that limited how grants can be spent and found new ways to prioritize the most important research. The result was a more industry-like approach to speed up the research, development and eventually the commercialization of new products. An analysis1 published in January 2021 found that, in general, universities were able to bring products to market just as rapidly as private companies.

In the month of April 2020 alone, more than 2,000 papers were published on medRxiv, the health sciences preprint server. Although some concerns emerged that faster publishing could reduce scientific rigour and accuracy, the rate of retractions was not very different from research in general. By late July 2020, there were 14 preprints and many published articles that had been withdrawn or flagged for serious concerns.

Seven Years of War: What Will It Take to Catalyse Change in the 21st Century? A Critical Reflection of the Second World War

The crisis seemed to make new people move out of the woodwork. Government agencies and non-profit organizations that put out calls for new ideas or products were suddenly hearing from first-time contributors. “It shows that there is a lot of innovation potential in society,” Paunov adds.

The initiatives were both successful, but they had different paths. As Sampat explains, much of the innovation in the Second World War was generated and used by a single entity: the military. “It’s much more challenging when you need civilians and firms with diverse goals and perspectives to change their behaviours or use particular technologies,” he says.

For Sudan ebolavirus, three candidate vaccines have been identified in early testing, following research and development driven by CEPI, IAVI, the US National Institutes of Health, the US Biomedical Advanced Research and Development Authority and others. Uganda received its first vaccine shipment a week ago. Although there have been no new infections and 56 people have died, trials may be too late to determine vaccine efficacy.

I warned about this problem seven years ago in a column in Nature (S. Berkley Nature 519, 263; 2015). Yet despite the COVID-19 wake-up call, this remains one of the biggest chinks in our pandemic-preparedness armour.

A new variant must also prompt redoubled vaccination efforts in lower-income nations. Global collaborations, such as COVAX, were established to deliver vaccines equitably. But they faltered as wealthy nations prioritized vaccinating their own populations. Too often, vaccines for low income countries were delivered at a later than usual time, which made the challenge of rolling them out in places with limited health-care infrastructure worse.

I will not be writing this again 7 years from now, so what will it take to catalyse change? To be clear, we have come far, from hardly talking about this issue to living through a pandemic that daily highlights its relevance. I am optimistic that a change in mindset is in view.

It’s best for wealthy countries to take the lead. They should make sure that agencies like the Coalition for Epidemic Preparedness Innovations and the International AIDS Vaccine Initiative, which are based in Norway and New York City, are funded fully, so that they can work closely with government agencies.

In many places, life took on a semblance of pre‑COVID normality in 2022, as countries shed pandemic-control measures. Government scaled back or abandoned mask-wearing mandates. Outbound travel resumed.

There were also some optimistic statements. A few months ago, the prime minister ofDenmark declared that the disease no longer posed a threat to society. In September, US President Joe Biden remarked during an interview that the pandemic was over. The director general of the World Health Organization hopes that COVID-19’s designation as a global emergency will end in the year 2023.

Elsewhere, repeated surges in infection and death are giving way to a constant thrum of loss, as well as debilitation caused by long COVID. A focus on COVID-19 has also affected the fights against AIDS, malaria and tuberculosis. Although precise counts are difficult to obtain, overall death rates in many countries are higher than before COVID-19 hit.

One thing that could shake COVID complacency is the emergence of one or more ‘variants of concern’ (VoCs). Over the next year, there will be new versions of the virus. A VoC designation has to be given if a variant is better at evading the immune system, causes more severe disease or is more transmissible than currently circulating. It’s vital that people who are fully vaccinating get booster doses because of their weakened immune systems.

The world has little more than a year to convert the draft into finished text. The current version of the commitments may be altered before an agreement is reached. It is easy to forget the need to figure out the kinds of institution and structure that are necessary to ensure agreement is delivered on as researchers prepare to publish their studies. Institutional structures are as important as the content of treaties. If an agreement includes all of the WHO’s draft, it should be looked into by the WHO and national negotiators.

The zero draft of the World Health Organization’s Plan for Pandemic Prevention, Response, and Preventing Epidemics in Developing Countries

“It has more heart and brain than I expected,” says Kelley Lee, scientific co-director at the Pacific Institute on Pathogens, Pandemics and Society in Burnaby, Canada. It doesn’t have enough teeth and spine to make a better response next time.

The first of the meetings on the terms of the document, known as the zero draft, will be held later this month. The negotiations are likely to be contentious, with some language likely to be watered down before the agreement is adopted.

It is not easy to create a new legal instrument in a short amount of time, but some researchers say it might not be enough for the next outbreak. Pathogens with pandemic potential are constantly spilling over from animals to people, and researchers are anxiously tracking a fast-spreading outbreak of H5N1 influenza in birds that has jumped to a number of mammalian species. “Time is not on our side,” says Alexandra Phelan, a global-health lawyer at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

A key focus of the zero draft is equity. Articles in the treaty include establishing a global network for the supply and distribution of ingredients used to produce drugs; strengthening research and the development of vaccines and therapeutics; and sharing that knowledge with the world.

Under the terms of the treaty, parties should also commit to allocating no less than 5% of their annual health budget for pandemic prevention and response. Developing countries have been asked to put together a percentage of their gross domestic product to prepare for the possibility of a flu epidemic. Moon thinks this would be the first instance of a government setting aside money for international aid in a treaty. “I don’t think it’s likely, but it’s a bold proposal.”

Even if countries sign up, the treaty is too weak to stop them ignoring the rules in the event of an epidemic. The document is intended to be legally binding, but in some key instances, the text avoids strong language, such as ‘shall’ and ‘must’, instead using fuzzier terms such as ‘encourage’ and ‘promote’, say researchers. Lee says it is still heavily reliant on voluntary compliance.

Negotiations around how to ensure compliance have been pushed back, to be addressed after the treaty comes into force, which is problematic, says Layth Hanbali, a health-policy analyst at Spark Street Advisors who is based in Ramallah, in the occupied Palestinian territories. “None of the promises that states will make in the treaty document itself will have any meaning, any effect, unless there is a robust mechanism in place for holding states accountable.”

Phelan says that it is important to not underestimate the value of the treaty-building process. Discussions and debates over the provisions will help to build trust between governments, change behaviour and establish international norms of solidarity.

It’s clear from the WHO’s zero draft text that the agency is determined to avoid a repeat of some of the worst of the behaviours seen during the pandemic. The text reinforces the need for companies and governments to be transparent when it comes to know-how and products that are based on publicly funded research. Had this happened before, the coronavirus would have been out of the picture.

Most important of all, a forum of 200+ countries plus tens of thousands of watchers and lobbyists isn’t the best way to enforce an agreement when there are only a small number of high-income nations. The evidence shows that legally binding agreements cannot compel nations to meet their commitments.

But COPs are expensive to run, and the creation of such a framework would mean that the WHO — which faces a constant struggle to get countries to fund it properly — would struggle even more. We know from those in charge of international action regarding the issue of climate change and biodiversity loss that COPs take a lot of time to reach decisions.