Ebola
Dollars - An Efficient Use of Funds? by Paul Conton
Donald
Brown, the outgoing head of the UK Ebola
response team in Sierra Leone, revealed on the popular 98.1 morning
show on Monday, Feb 9, that total British spending on Ebola operations
has thus far
amounted to
three hundred and twenty five million pounds (£325m). This staggering
sum is
only a fraction of the total amount spent in Sierra Leone on Ebola.
When one
considers spending by WHO, the lead global health agency, other
spending by international
organisations and governments (in November, 2014, the US government
asked Congress to approve USD6 billion for the fight against Ebola in
West Africa), and spending by the Sierra Leone
government, the
amount spent on this outbreak in Sierra Leone could easily exceed one
billion pounds (approx
USD1.4
billion). This does not include income lost through reduction of
economic
activity within the country. By contrast with these huge sums, the
entire Sierra Leone Government budget for FY 2015 is of the order of
USD600 million (
Read 2015
Budget Speech). How on earth would we have been able to fight Ebola if we had NOT received outside assistance?
Now the international effort
and the generosity of foreign donors is highly commendable, but it's
fair to
ask whether these huge resources could have been better spent.
Officially, the
total number of Ebola patients to date is around 11,000, of whom most
cases have resolved to a final outcome. Using the 1.4
billion
USD figure above, the amount spent per patient is in excess of100,000 USD. This is not so very
far away from published figures for cost of Ebola treatment in the
West, where of course sophistication and cost of treatment is
very much higher.
Could the Ebola money have been
better spent? Might there have been a more cost effective way to seek
out and
treat these 11,000 Ebola patients? Might the funds, better applied,
indeed have
prevented some of these 11,000 infections?
As many have pointed out,
Ebola outbreaks are stopped by breaking the chain of transmission. This
requires identifying and isolating existing Ebola patients to stop them
causing
new infections. Identifying existing patients however has proved
extremely
challenging in Sierra Leone and indeed in the other worst affected
countries, Liberia and Guinea. The Sierra Leone Government has launched
various campaigns to identify Ebola sufferers and break the chain of
transmission, with
limited success. A three day national shutdown was declared in
September with house to house inspections. Operation Surge in December,
2014, placed restrictions on trading and movement and was also
accompanied by house to house inspections. It was originally slated to
last two weeks, but is ongoing as I write in the second week of
February, 2015. It has been
accompanied by widespread enforcement of temperature checks and hand
washing. The approach has been to find, perhaps even root out,
all those suspected of infection. Success has been limited in part
because the
'suspects' have not been willing to come forward in many cases. Might
this
attitude not change ifthey were
provided incentives to come forward? Is it possible this could actually
lead to
a quicker end to the outbreak at lower cost?
The measures to date have been somewhat coercive: districts, communities
and households have been quarantined. Under the state of emergency
public gatherings are prohibited and offenders have been taken to
court. Ad hoc community checkpoints have sprung up in addition to
official ones, with passers-by subjected to temperature checks. Through
all this Ebola has continued, and it is unclear how much these coercive
measures have helped the situation. What HAS
become clearer as the outbreak has progressed is that the experts were
right in their initial assessment of tranmissibility: Ebola does NOT
spread very easily in casual situations. One is yet to see a report of
Ebola transmission in public transport or at a church, shop, restaurant
or bar. A large number of new infections have been directly traced to
two or three very specific situations involving close contact with
symptomatic Ebola patients or Ebola corpses. This is not to rule out
completely the possibility that Ebola could be transmitted in everyday
casual settings, but the evidence indicates that if at all this
happens, this is a small, or very small, part of the problem. Given
this, one
could surmise that the restrictive measures being employed among the
general population are doing little to solve the Ebola problem. The
crucial task is to find the very small number of current Ebola
patients, who may not, for diverse reasons, wish to be found. This is
very much like the proverbial needle in the haystack. Projecting, for
arguments sake, 200 Ebola infected out in communities, perhaps hiding
in their homes, this would represent 1 in 30,000 Sierra Leoneans. Even
if these Ebola sufferers were not hiding their sickness, even if they
were mingling freely with the general population, one would need to
temperature-check on average 30,000 people in order to find one sick
person. A tall order indeed!
Far easier to have the sick people come to the health center than to
have the health centers search the general population for sick people!
What if we were to shift the odds in our favour? What if, instead
of
giving those Ebola sufferers and their families reasons to hide (fear
of the disease, fear of the medical treatment, fear of stigmatization),
we gave them instead a reason to come forward. What if we paid them to
come forward? What if we paid 100 USD, say, or 200 USD, for every
confirmed Ebola case that voluntarily reported at a health center. How
much would it cost? For 200 patients at 200 USD, the total would be
40,000 USD. Peanuts compared to the hundreds of millions of dollars
that have already been spent! Yes, there would be administrative costs,
still peanuts compared to current spending. Yes, there would be many
non-Ebola patients reporting at health centers in hopes of
collecting 200 USD, but if they are genuinely sick with malaria,
typhoid or some other fever-producing disease, they should be reporting
to a health center anyway, so this could hardly be counted as an
additional cost. If they are not sick, clear case definitions and
protocols should quickly dispose of them.
Perhaps, it needs a radical, non-traditional solution such as this to
finally defeat Ebola.