Feb 12, 2015

Ebola Dollars - An Efficient Use of Funds?
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 of  100,000 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 if  they 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.