Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338Tuesday 10 November 2015
Oral evidence, 10 November 2015.
Witnesses
Dr Oliver Johnson, Former Programme Director, King’s Sierra Leone Partnership, and Professor John Edmunds, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, gave evidence.
Chair
Professor Edmunds and Dr Johnson, welcome. Thank you for joining us. We will follow the same procedure that we did with the first panel. We have a number of questions. Perhaps when you have the first opportunity to answer a question, just say a little bit about yourself.
Wendy Morton
With cases reaching zero, which is excellent news—so this inquiry is even more timely—what is the situation like on the ground and in communities? In particular, what has the toll of this crisis been on those who have been left behind?
Dr Johnson
My name is Oliver. My background is as a medical doctor, although I mainly worked in health policy and global health since graduating. I was out in Sierra Leone for about a year and a half before the outbreak, working in the main hospital and medical school. When the outbreak started, I became involved mainly in the clinical side of running a number of holding units, helping set up the command centres and advising a bit the Sierra Leone and British Governments. I left in August; I know a bit about what has happened in the last couple of months from people back there. It is timely to have this meeting after Saturday’s announcement of the end of the outbreak. A lot of people are prepared that one or two more cases could crop up, like in Liberia. Largely, people feel confident that at least this outbreak has come to an end. There is some good planning going on at the moment for what happens with possible resurgence of cases. I feel pretty confident that we are on track to get there and there are some good structures being put in place for anything in the future. The impact is big, though, and it has come in a number of ways. The health system has been hit very hard. The hospital where I worked had about 10 consultant‑level doctors at the start of the outbreak, of whom three died. 11 out of the 12 doctors who were infected died. Most of those were senior doctors. They were some of the only teachers at the medical school, so the medical school has been hit very hard. The nursing profession was hit very hard indeed. In a country with a weak health workforce, this is huge and anyway, before this, the lack of senior health workers seemed like an unbridgeable gap to get over. That is something that will need sustained and significant investment to try to help the country to overcome. There have also been impacts on the economy and this double hit they have had, as was mentioned earlier: the collapse of the economy from the mining sector coupled with the impacts of Ebola. The impact that will have on tourism, flights and things is pretty crippling. The education sector has been hit very hard, with the potential for a lot of lost schooling. Everyone is trying hard to catch up now so they do not lose a whole year group of doctors, of graduates, but that is difficult. Those are some of the significant effects. That said, this is potentially one of those moments of renewal in terms of political priorities and international support, so maybe there is optimism now that we can learn from some of the mistakes before, and that is up to us.
Wendy Morton
Professor, would you like to add anything?
Professor Edmunds
Yes, I will introduce myself. I am a professor of infectious disease modelling at the London School of Hygiene and Tropical Medicine. My role during the epidemic was mainly analysing the data, giving an idea of situational awareness, projections of what might happen over the coming weeks or months and the potential impact of different control programmes and so on. I am also dean of the Faculty of Epidemiology and Population Health at the school, and I was involved in facilitating our staff to volunteer to go out to West Africa and organising that. This was an unprecedented emergency and we felt we had staff who could make a difference, so I was involved in doing that as well. In terms of the situation on the ground at the moment, let us not get carried away too much, because there are still cases occurring in Guinea—okay, at a very low level, but they are still occurring. There was, I think, one last week. It is at a very low level, but it is not eliminated from all three countries yet. I agree that there may be a few subsequent late‑transmission events; that certainly cannot be ruled out. I suspect that, if that occurs, it will be only one or two. I do not expect large numbers of these late‑transmission events now. I have tried to estimate the risk of that, and I do not think it is very large. In terms of rebuilding, there is an enormous task left to do. It seems bizarre, but there are some good things to have come out of this in some senses. If you go to Sierra Leone now and talk to people, then you have people who have had the mother of all crash courses in epidemiology and public health responses, and they really do know what they are doing. With a bit of basic background training to give them the broader training, you have the building blocks of a responding force that could respond for the region in the future over the coming few years, because epidemics will strike. There are things like that that are there, so it is not all doom and gloom. Yes, there is a huge rebuilding task and the UK, I hope, would be very involved in that. They must be. But there is some good news as well, if you like.
Wendy Morton
You make a point about the lack of skills now due to the loss of skills, particularly in areas of expertise. You mentioned healthcare, and I am imagining in education and teaching it will be exactly the same. The process of rebuilding is going to be critical and at the heart of taking things forward. Alongside all of that, I just wondered if you could perhaps give us an insight into the situation with regards to orphaned children, because we have heard and we read stories of families that have basically just been wiped out, for want of a better phrase. I was reading about FGM. Cases of FGM fell dramatically during Ebola. Is there a sign, then, that that is going to increase, or can something be done to try to keep those at a low level? I also really sadly read a story in the newspaper about young women and girls who were turning to prostitution, to try to make a living post‑Ebola. I appreciate I have thrown a lot into my question. I suppose it is probably around not the skills now but the softer side of thing and people’s real day-to-day lives.
Professor Edmunds
It is true of not just Ebola but any of these major humanitarian crises that it is not just the health impact; it is the wider impact on people’s lives. We forget that sometimes or very often. I hope that there is a concerted effort to rebuild the economy, to rebuild education systems in Sierra Leone and elsewhere in West Africa. But they are not the only countries suffering because of these sorts of humanitarian emergencies. There are many others.
Dr Johnson
I would just add that, unfortunately, some of the things you outlined are worse because of Ebola, but a lot of them existed. I know a lot of young Sierra Leoneans are orphans, and that was before Ebola. In a sense, there are some community systems and extended families. People are used to helping each other out in those situations. There are organisations that have been there, trying to support orphans from the war and others, which will just need more support. Unfortunately, this is going to fall into a wider group of people who are incredibly vulnerable in Sierra Leone and were before Ebola.
Fabian Hamilton
I wondered if you could tell us a bit about how well you think local communities were engaged in the efforts to bring Ebola under control. I wonder whether the engagement of communities had developed at all during the course of the epidemic. Do you think that those communities should have been engaged in a greater capacity at an earlier stage, because they are critical to bringing the whole outbreak under control?
Professor Edmunds
You are right: they are critical to bringing the whole outbreak under control. The other aspect of the response—the building of the hospital beds and other facilities—was very important, but the real key was changing communities’ behaviour and acceptance of different policies to reduce their risk. That was the real key to bringing this epidemic under control; I am sure of it. It is very difficult to put a finger on it accurately to quantify the impact of that. We tried, and that will be a subsequent research question for the next few years, so I cannot give you accurate estimates, but, unquestionably in my mind, that played a really key role. At the beginning, many mistakes were made, partly out of good will. A lot of different agents and actors came in, perhaps too many, so getting a consistent and accurate message across was very difficult. There were plenty of problems and mistakes that were made, without a shadow of a doubt. What happened subsequently is that people learnt to work with the communities rather than trying to take a slightly more authoritarian response. That is probably a lesson for the future: that we should take a little more time to work with the communities and build our response around them, rather than trying to impose it. I think that is something: take a little more time. I know that, in an epidemic when things are moving very fast, there is huge pressure to act quickly, but under these circumstances that pressure to act quickly perhaps was counterproductive, in some senses.
Fabian Hamilton
Was there ever a sense that the communities were a blockage to stemming the tide of the outbreak?
Professor Edmunds
I do not think that is a very helpful way to think about it.
Fabian Hamilton
I agree, but I wonder whether there was.
Professor Edmunds
That is how we were thinking about it in the early part of the epidemic, and it is the wrong way to think about it. It is their lives, so work with them to help them see the best way to protect themselves.
Dr Johnson
I would agree with a lot of that. At the beginning, the community engagement was not strong and there was a slight tendency, where there was community engagement, just to try to tell communities what they should be saying and thinking. If I think of the early days, there were meetings quite early on where, for example, all the traditional healers in the country and the traditional healers union were brought in by the Government to try to engage them on the issue. My impression was that those meetings would have been quite a lot of telling traditional healers how they should act, but there were efforts. One of the challenges is that I am not sure community engagement had been very strong in the delivery of Government services in Sierra Leone prior the outbreak. In the hospital where I worked, there was not always a great relationship between patients and staff, in the way we would expect in terms of doctor‑patient relationships or, for example, having patients on the board of the hospital or doing feedback surveys from patients. The sort of structures we are used to did not really exist in any way, so I am not sure there was a strong baseline to work from, from the Sierra Leone Government’s point of view. There was a lot of progress, though, when the President personally became involved and started engaging with some of the traditional structures, and the British Foreign Office was encouraging of this. He really started to engage with paramount chiefs, going out to the different districts and using those chieftain‑level structures better. That had an important impact. Within the response, the shift from safe burials to safe and dignified burials was a very significant shift. You could see all of us very quickly catching up. It was a catch‑up and we should have been there at the beginning. Similarly, the NERC briefings as to what was going on in the cases started to engage much better with communities in the later stage of the final outbreaks and, where there were traditional beliefs, engaged in those traditional beliefs. Where there was a patient gone missing who had turned into a snake, they did not aggressively try to disavow the idea that a patient could turn into a snake. They would engage more with the idea of the community on that, and try to work with them on their belief systems in a way that was much more effective. But it was catch‑up, and part of that is because a lot of the people involved were not the normal players. I am not a humanitarian. I am not an infectious disease doctor, neither were the British Army. A lot of us were catching up. By the end it was good. If we had had that from the beginning, it would have been much better. 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.
Mrs Grant
This is a question for both of you. Some of it has been covered in the last couple of questions, but can you just set out the main lessons that have been learned as a result of the outbreak and how can those lessons be applied usefully in the future?
Professor Edmunds
There are the obvious lessons about responding far, far, far more quickly and finding a way to respond. Where there may be blockages because of difficulties within a country or at country level, there must be a way round that and we must ensure that there is a way round that. In the earlier discussion about reform of the WHO, one hopes that those sorts of things would help in that in the future. That is the most obvious one. This epidemic would not have got out of control if we had acted much more quickly, so that is the first thing. There are other lessons. As we mentioned just now, the community engagement is key. Frankly, it is key to every public health measure. It does not matter where you are, whether you are in Lambeth or Liberia. To get people to engage in public health, you need to talk to people: to mothers to get their children vaccinated or whatever it might be. I think we forget that. We think that, if we provide a system, people will use it, and they will not necessarily. It is that behavioural science part of it. There needs to be far more investment in the science around that, and then also in implementation during outbreaks, but not just during outbreaks, in other preventative measures and so on. That is one major one. There are some lessons we have learnt about control of Ebola and so on, which are more specific just to Ebola. We have now got to a stage where there is a potential for vaccines to be available. We now have to think about how we might deploy those in the future and plan for that. That is going on. We are involved in that sort of work at the moment.
Dr Johnson
One would be 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. Although the British Government has talked of and is better than some donors in having a whole‑system approach, if you are just focusing on maternal and child health, HIV, TB and malaria, or if you are sitting in the Ministry of Health trying to work out how to deal with workforce issues, that is not a whole‑system approach. The hospital where I worked isolated about 800 Ebola patients but received no DFID funding before Ebola because it is an adult hospital and adult hospitals do not get funded by aid agencies because it is not considered a priority. As a consequence, this was not as functional an institution as it could have been. I do not want to criticise DFID too much, because DFID is a lot better than other donors and there was some work on cleaning up the payroll and looking at the supply chain that was whole‑system, but we could further. That would have allowed a central system within Government for a health system that could have responded much more effectively to that. It was very difficult with so few doctors and nurses to really mount an effective local response. There is some learning from the UK Government. The rapidity of how DFID responded, once it came in in September, was incredible, with blank checks in terms of financial support for people on the ground. But I remember, in June, putting in a request to DFID for £7,500 to set up about eight isolation units over the course of a month. That was for supplies and staffing—£7,500. 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. That was in late June and that was despite raising this with a number of people, and it is because DFID lacks any mechanism to get small amounts of money flexibly on the ground. The Irish Embassy gave us money. They had the capacity to write us a €2,000 check. At that moment in time, as a small organisation, that had impact.
Mrs Grant
So more flexibility within DFID is needed.
Professor Edmunds
That unquestionably needs to happen. You discussed earlier about treatment centre beds being built long after the epidemic had passed. That did happen, and that is because that was what the contract said: they had to build a treatment centre. By the time the contracts got signed and so on, the epidemic may have passed. It would have been better, in some instances, though not very many—I agree with Jeremy; I think it was right to build those beds—it would have been better to do something else. Some flexible funding is essential. The epidemic does not care what the contract says. The virus does not care. That really does need to be addressed.
Dr Johnson
As I was saying, there was a big difference post‑September, when the taskforce came out, when Donal came out, when I do not think I could have felt more supported. When my car broke down, Donal lent me his car because I had to get somewhere in a hurry. The British Government did everything they could do to be really supportive to us. In terms of the financing, they did gymnastics in terms of very big bureaucratic processes. On the ground, I felt that that was much better, than it was before then. My question is: if this were to happen again tomorrow and there was not that emergency infrastructure in place, would I be able to get £7,500 in an emergency? Maybe DFID specifically has an Ebola fund now, but, in terms of flexibility, that would be an important lesson. There is another point about to what extent Britain was ever really able to maximise its engagement with its own public health expertise. I do not think we ever had effective British public health engagement. If you compare the engagement of, say, the CDC in America and the number of infectious disease epidemiologists they had deployed in the field and the senior role they had in working on their response, we did not have an equivalent in the British Government. DFID itself does not have a big team of epidemiologists. As to the engagement from Public Health England on the ground, I can think of two who came out, but not for a long period of time, with some seniority, but there was never a very experienced epidemiologist out for six months on the very senior leadership team. There is a question around how we can really engage with public health. For the labs side of Public Health England, there were problems trying to set up a lab in a very challenging situation, but, at the end of the day, they got it together and they did a good job, by and large. But the epidemiology side was a weakness that needs to be structurally addressed in some way. There is another issue, which is what I felt was a bit of a market failure. DFID relies on NGOs to provide its services. There was a point at which no NGO wanted to do it. MSF wanted to do it but had run out of capacity and had set a very high standard. MSF had scared a lot of NGOs because it seemed like what MSF was doing was so difficult, so a lot of usual NGOs just said, “We are evacuating. We cannot be in the clinical space.” That is a problem. Britain does not have a deployable team for health emergencies. Merlin has gone. Merlin has not been effectively replaced. MSF and British Red Cross do not do deployments in the same way as some of their equivalent branches elsewhere do. Where does that leave Britain in terms of being able to deploy NGO health emergency teams in the future? But there was some really good stuff as well. The extent to which the British leadership was co‑ordinated within itself, with a clear lead, linking in with the Foreign Office, Public Health England, DFID and the army was impressive. The flexibility once that team came out is something to be preserved. The engagement with science was quite impressive and there is a lot to learn from. Then there are all the lessons about the WHO and UN that have been mentioned.
Chair
We are going to move on now to some questions relating to the health system itself, particularly in Sierra Leone.
Jeremy Lefroy
Oliver, I must declare that we know each other from two or three years ago in Sierra Leone. You have covered some of these issues, but I wanted to touch on one or two more. Just in terms of a deployable team, I remember from the Lancaster House conference that the Cubans said they were going to send a lot of people out there. Did that happen and was that effective? They seemed to have a medical brigade that was on standby.
Dr Johnson
Yes, they did deploy a team very quickly and they were out in the field with the WHO. There were challenges associated with it. They were not all very young, the team that was deployed, so they provided a certain degree of support themselves. There was a lack of clarity about exactly what they would be doing in the field. There were language issues to do with the fact that most of them spoke very limited English. But they did succeed in deploying a team very quickly. There were lessons in whether they were the right people and how they were used, but, yes, there was very rapidly a Cuban team out there.
Jeremy Lefroy
They had the ability to do that.
Dr Johnson
As did the Chinese, sending in an army team very, very quickly. They arrived in early September and were doing clinical work very quickly.
Jeremy Lefroy
So that something for us to learn in the UK.
Dr Johnson
Potentially. With both of those groups, I do not know that they were as effective as they could have been, but they did get out in the field quickly. There is an issue with force protection. I had a similar impression to colleagues from MSF. King’s called for British military involvement. We wrote to the relevant Secretary of State. I was on the media expecting, similarly to what MSF colleagues have said, there would have been a hazmat team on the ground, quickly setting up units. I have learnt now that the British military would not ever have done that. There was no group in Sierra Leone I met that had a higher level of force protection than the British Army, who were very, very cautious, understandably, about having any contact with Ebola. They would not come to my hospital for a long time, for example to my office, because it was considered an unsafe area. To an extent, it was unlikely the British were going to be able to do what the Chinese did—and they had their own force protection issues. In general, I have learnt a lot about how likely it is that state or Government individuals will be put in harm’s way in that situation.
Jeremy Lefroy
Just coming on to the broader question of health systems, you talked about certain programmes. There was a malaria bed‑net distribution programme going on in June last year right across the country, and it seemed to be relatively effective. We went into a fairly remote village and saw the bed nets in use and operational. But you said that perhaps this slightly silo‑based approach had not helped to strengthen the Sierra Leonean health system. Is that correct?
Dr Johnson
There were strong pockets and weak pockets. For example, the malaria team is much stronger in Sierra Leone because of that investment, but, if you look at the directorate of hospitals, that was one man. He is overseeing all the Government hospitals in the country personally. He has no effective aid. He was not able on his computer to immediately give me a list of the medical superintendents of the country. When we were trying to get information out to the different hospitals about how to prepare for Ebola, my team had to spent quite a lot of time helping them even to get that group together, because that directorate was so unsupported. I do not criticise the individual, because how can you possibly do that job as one man, compared to I do not know how many hundred people who would do that job in this country? You will see some parts of the Ministry that are well‑funded and effective: HIV/AIDS, maternal and child health. That is good, but there are other parts that also could do with some investment in those sorts of structures.
Jeremy Lefroy
Do you think that donors, and indeed the Sierra Leonean Government, are recognising now the importance of a much stronger health system?
Dr Johnson
I think the Government do to some extent. In comments to DFID in the past, I have said we cannot want it more than they do. The Government need to really want this and set out the plan, and only at that point can DFID fund it. DFID funding cannot go before that very clear commitment from the Sierra Leone Government in the detail of exactly what they want to do within their health system. It is getting the right balance there. The new DFID plan looks good. There are always more areas for thinking systems‑wise, so I would just encourage that journey to continue, if possible.
Jeremy Lefroy
Professor Edmunds, I do not know if you have any comments on that.
Professor Edmunds
In relation to epidemic response, then it is probably unrealistic to expect Sierra Leone and the other countries in the region to have a very well functioning epidemic surveillance system and response—the sort of things we might have in this country. There is a role for improving health systems and surveillance of diseases, including infectious diseases, more generally, but, certainly in the short or medium term, we do not really expect that to be sufficient to be able to tackle these sorts of public health emergencies that do come up from time to time: cholera epidemics, Ebola, Lassa fever or whatever it might be. We need to strengthen not just the country’s health systems but our ability to respond as a player, as well as the WHO’s ability to respond. Do not just rely on investment in health systems in Sierra Leone and other countries, because that will not really be sufficient to be able to protect their populations, certainly in the medium term.
Jeremy Lefroy
I have one quick question, from a slightly different angle. Did you notice some engagement in terms of response from the Sierra Leonean diaspora? For instance, we had a number of organisations in the UK that seemed to be really trying to do what they could, obviously under difficult circumstances. Did you see that in the work that you were doing?
Dr Johnson
It was most noticeable where members of diaspora went back to take a role in the response. In particular at the NERC, there were a number of members of the diaspora who got involved in leadership roles, who were very important and deserve a lot of credit: people like Obi Sesay, Yvonne Aki-Sawyerr and others. In terms of the smaller diaspora groups, there was a lot of effort and there were certainly some supplies arriving, but the scale of what was happening was possibly bigger than the smaller diaspora groups could meaningfully contribute to. There was useful work in awareness‑raising, but it is very difficult for a small organisation in the UK, once the full humanitarian thing has come into swing, to provide donations, for example, that are so timely. But the people who went out and got involved were important, and some of the awareness‑raising was very important.
Professor Edmunds
They had a role, particularly, in community engagement. Going back to my earlier comments, some of that was well meaning but perhaps misplaced at times, but it improved over time.
Jeremy Lefroy
Did you feel that DFID engaged with them? I remember working with one particular diaspora group here that was supplying food and meals, and eventually DFID did engage with them, but it took a little bit of time. Do you think DFID should perhaps look more, in a case like this, at trying to engage with diaspora groups at an early stage, given that they are often likely to have some of the experience that is needed?
Professor Edmunds
In hindsight, you could say that, yes. I could see that, at the time, DFID probably had other priorities. But, yes, with hindsight, you would probably make better use of them.
Dr Johnson
Maybe, in a very targeted way. For example, if we had been able to mobilise more Sierra Leonean diaspora health workers or other people to go back and be involved as individuals, they would have had a very unique role. The challenge is that some of the diaspora groups do not always have the experience with reporting structures, financial templates and how to put together bids. It is therefore a lot of work for DFID to help guide them through the process that is needed, understandably, for accountability and sometimes on a relatively small scale. Given how much was going on at the time, it is understandable that DFID was stretched to capacity on some very large‑scale things. That is understandable, but maybe DFID could think very carefully about where the diaspora has a USP, a really unique contribution, and maximise that.
Albert Owen
Dr Johnson, as somebody who was there from before the epidemic and also during it, I just wanted to put on record my thanks to you and all the medics for the excellent frontline work you have done. But how did the control and treatment of Ebola have an effect on other, more normal illnesses? If it was negative, what can be done in the future to ensure that the health system comes up to a relatively strong state?
Dr Johnson
That is really important. We are still working out some of the data on the 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. The hospital where I was based we kept open. Because we were able early on to implement screening at the front gate, we were able to open a holding unit within the hospital, so that anyone with a fever or with compatible symptoms could immediately be isolated, and quite early on we were able to start improving infection‑prevention control. That could have been replicated elsewhere. Not as many services as I would have liked in the hospital stayed open, but emergency surgery did. The medical ward stayed open. Unfortunately, by comparison, the children’s hospital, which normally would have had up to perhaps 200 very sick children in it, closed for several months because it was not able to engage equivalent support in terms of holding units. Eventually, when it did, it reopened, but for two months there was no children’s hospital in the capital city. That could have been avoided if there had been organisations willing and able to go alongside the Government to support them to make this hospital safe. There was a big programme early on, supported by the British Government as well as other donors, at the peripheral health units to improve triage and safety. A lot of those did stay open, partly as a result, so there was a mixed success. A lot more could have been done. Very few agencies feel it is effective or safe to work inside Government institutions in an emergency. I would argue that hopefully the work the King’s group did demonstrates that it is possible. We were working in eight Government hospitals. We managed about 1,500 Ebola patients, but none of our international team became sick or infected at that time or at any time, so it is possible to do that. My learning from it would be that we should, as much as possible, try to deliver health services through existing and Government health institutions. Pre‑existing relationships are important. It was very important that I already had a relationship in those sites. Encouraging those sorts of long-term partnerships can be critical, so there is a wider lesson in engaging with Government.
Albert Owen
Do you and your colleagues have any input into the forward planning in any way? Is there a way that you can contribute to the reopening of the children’s hospital and how it should develop?
Dr Johnson
We were quite involved at the time, talking with both Government and the hospital superintendents, but also with the WHO and the British Government, in terms of trying to direct support. The British Government did listen. It was the British Government that funded us to be doing the work we were doing. They supported Partners In Health to do somewhat similar work, working more in Government sites in Port Loko and elsewhere. Yes, we have been able to contribute to that, and we are certainly putting in mechanisms now so that there are permanent isolation facilities for any very infectious disease, including Ebola and Lassa fever, in future outbreaks, so that those will hopefully be more resilient to shocks in future. But we need to see a lot more of it.
Albert Owen
Professor Edmunds, would you like to add?
Professor Edmunds
Trying to calculate how many extra deaths may have occurred will take us some time. There have been some estimates for malaria, which suggested that about as many deaths from malaria occurred as a result of the interruption of malaria services as occurred due to Ebola. It will take us some time, and we will probably never know accurately how many extra deaths from other causes may have arisen. There are two things that really come from that. Because of the devastating impact that these kinds of epidemics have on health systems, it shows how important it is to react very, very quickly to stop that sort of thing happening, to stop it getting out of control and health systems generally shutting down. Secondly, we do now have a promising vaccine candidate, and that will be of huge importance in the future for controlling these epidemics and helping to protect healthcare workers, to enable them to stay open in these sorts of outbreaks in the future. That is one of the major benefits to have come out of this epidemic. That vaccine is not licensed yet. It will take some considerable work still to get it licensed, but at least it is a good long way along that track now. That is one positive thing that has come out of this.
Dr Johnson
One more point I would make is that the response pulled a lot of health workers out of normal health facilities as well. For example, I strongly advised that the community care centres be built attached to and as part of existing health institutions, so that the staff could, if there were no cases for a week, be in the health institution; if a case walked in, they could revert across. Where that did not happen, you saw all the resources of the primary healthcare unit sucked in. Kerry Town had over 40 community health officers. One community health officer would normally provide healthcare for a whole set of villages, and 40 of them are suddenly pulled into the centre, so robbing Peter to pay Paul. Recognising limited resources and how we use them was an important component of that opening or closure of services.
Dr Cameron
I initially wanted to pay tribute to the Aberdeen Women’s Centre in Freetown and also, on behalf of the Committee, to wish Scottish nurse Pauline Cafferkey well in her recovery in hospital. Given all the financial resources and investment that has been fed in in terms of crisis, how will we be able to ensure the resources that are there now can continue to contribute to strengthening the healthcare system? Can the new centres that have been built be adapted for use?
Professor Edmunds
I am not quite sure what you are asking. How can we ensure we do a good job in building up the new systems?
Dr Cameron
Yes, and can the facilities that are already there now or the investment that has been put in be adapted in order to ensure that they are usable?
Professor Edmunds
Oliver would know better about that, but I would imagine much of it is not particularly adaptable. Nevertheless, I will leave that to Oliver. One thing that should be brought to the Committee’s attention is that I do not think DFID have publicised their exact plans, so I do not think NGOs can bid yet. The money has been approved, as far as I know. The NGOs—Save the Children and others—still do not know what the rules are and how they can go about bidding for the next tranche of money to help the recovery phase. They need to get on with that. That is one thing you need to be aware of. There is a wider issue about building health systems so that they are resilient to these sorts of things. DFID have been very good at trying to do that. One of the strengths of UK aid has been taking a wider approach over the last 10 or 15 years, rather than focusing on individual vertical programmes, which can be dangerous. I would encourage that they carry on with the approach they have taken. A more holistic, health‑systems type approach is the right way to do this now, as it always was, and I would encourage them to carry on. Of course, there needs to be some investment in epidemic response, but let us not get too carried away and put a huge amount of investment in some kind of epidemic response mode in Sierra Leone that might sit there doing little. It needs to be a much wider response.
Dr Johnson
We need to pick carefully, because the operating budget of the health system is very small. Therefore, we have to choose carefully. The one I think of is that there is a lot of emphasis put on building an ambulance system, with all of these ambulances. How do we make use of the ambulances? The fuel costs are very significant. To fill a tank of fuel is maybe 300,000 leones, which would provide care for a number of patients if that money was redirected. We have to be very strategic in which bits we say we want to keep and where we have to say, “Actually, this is not affordable and we might have to let some things go.” That is one thing I would say. But I agree with you: the bits we can maintain we need to be thoughtful of. I agree that a funding gap from DFID between the response and the long‑term recovery would be catastrophic, because very few agencies are able to cover the funding gap and so everything goes, and then suddenly you lose those individuals who built up relationships with local partners and those programmes get stopped. There is a real loss in that, so making sure there is not a gap is important. There are some examples of where the British do this well. The £50,000 funding we had for Ebola we used to build a 12‑bed, permanent new isolation unit that could be used for Ebola but also for tuberculosis, diarrhoeal diseases or other things and be reactivated in future. It was built within the main hospital. Somewhere like Kerry Town is more challenging, because it is a very large, very rural site. Where there were discussions at the time on those things, they have been done well. There has been a real effort to hand over into permanent sites, into universities and into medical labs some of the lab work and the equipment, and to train people to use it. There have been efforts to do this well. The British have been thoughtful of it, but we could think more now, in general with emergencies, how we could build infrastructure that is going to have a longer‑term purpose, because, where we did it, it has been really effective and useful.
Fiona Bruce
Our last Committee expressed concern about the numbers of Sierra Leone health workers working in the UK. I would like to ask how the UK’s medical recruitment practices may have affected the health systems in countries like Sierra Leone and how we could prevent this in the future, if it is a negative impact that you state.
Dr Johnson
I work for King’s, which is an NHS Trust as well as a university, and we certainly have many times more Sierra Leonean mental health nurses at King’s than there are in Sierra Leone, so I see both sides of that. It is definitely an issue. When I looked at the medical school graduate book of where the medical graduates are, the vast majority are in the US and the UK; they are not in Sierra Leone. That said, I have not come across a lot of very aggressive recruitment from the NHS in Sierra Leone. Some agencies try; certainly the NHS itself I have not seen attempt that. The issue is more how we convince Sierra Leoneans to want to stay, rather than how we stop them from coming here, because there are also legitimate human rights issues around saying to a Sierra Leonean doctor, “You are not allowed to come and want a better life, or to travel to get training overseas.” For me, the issue is how we make Sierra Leonean doctors want to stay, and a lot of them do. It is where their families are. It is where they grew up. They prefer the food. There are lots of reasons why they might stay. A lot of it is around training opportunities. A lot of people feel they have no opportunity to progress professionally, so it is enabling that. For example, we have been doing work to enable doctors to get specialist training to become surgeons or specialist physicians, by bringing in international experts for a period of time to train up a new generation of leadership, who could then take over that training programme. We are hoping that is the sort of thing DFID will support to make it a better reason for staying. There is a lot of talk about building accommodation in rural areas. There is a lot of talk about salaries and increasing the amount and quality of undergraduate training. We do know what the reasons are why people are leaving, but, if the British Government were to really look at those and to invest in those as a package, then people would hopefully want to stay. That is how I would address the issue. I could not agree more that the fact so many people are leaving is catastrophic and it is often some of the best people. Some of the best people leave, and unfortunately some of the best people died, because they were the ones who were the bravest. We often see the real leaders not on the ground where we need them most.
Chair
I have a final question. Professor Edmunds referred to the development of a vaccine for Ebola that is now being trialled. In their evidence to us, ActionAid UK suggested that the vaccine should have been developed at a much earlier stage and the crisis might therefore never have happened. Do you agree with that and, if you do agree with it, what are the barriers that meant that the vaccine was not developed?
Professor Edmunds
We should have gone through phase I trials. I do not know how familiar the Committee is with how clinical trials work. Phase I trials are the first trials that are done in humans, and they are usually done in very healthy volunteers. There is no reason why we could not have done that before this epidemic. There are other vaccine candidates now for other similar diseases and we should be looking at making sure that we get them up through at least that stage. You cannot do a vaccine trial without the cases being there to look at. It is impossible to get the phase III trials done unless there is an outbreak happening. I was involved with a couple of the vaccine trials, but in particular the one in Guinea, which was successful. One thing we did there, and the reason why that trial was successful, was that we came up with a novel way of running and doing a vaccine trial. I would hope that the kind of method we employed would be used in future to help get future vaccines through trials, but you need the cases to occur. I know that sounds a bit brutal.
Chair
No, I understand.
Professor Edmunds
You need an outbreak to occur. There are lessons that we probably have learnt, to ensure that that is the case. As a side issue, I should say that that trial was sponsored by the WHO. The main driving force behind that trial was the WHO. They made that trial happen from start to finish. Although the WHO have been roundly criticised for many different things, they made that happen, so they should be applauded for that. The third thing I should say about vaccines is that they are not a magic bullet. They will not solve everything. There are roles for vaccines in the future, protecting healthcare workers probably being one of the most important, but it is wrong to assume that, just because we have a vaccine, we will be able to do away with Ebola. We will not. By the time the vaccine programme comes on stream, cases will have already occurred. It is an adjunct to existing control policies, rather than a replacement for control policies. We will still be controlling Ebola in the future primarily with the methods that we used for this epidemic, which is contract tracing and so on and so forth. The vaccine will hopefully come in and help reduce cases, but it will not replace that as our primary response; I am sure of that. That is also true of the other vaccines that we may develop. It will take us many years to develop these vaccines. Even if we pick on a handful of diseases and we get these things through phase I studies, we will still have to wait for outbreaks to occur so we can test them in a real‑life setting, so they will be ready not for the next epidemic, but the one after that perhaps. It is a very long‑term thing, so we still need to keep our emergency response mode. That will still be the main focus for controlling not just Ebola but many other similar kinds of infections into the future.
Chair
Do you think there are ways in which the system can provide better incentives for research into neglected tropical diseases?
Professor Edmunds
Yes. The only reason we have these candidates at the moment is really because of the nervousness of the Americans from a bioterrorism point of view. That is why we have some candidates for several of these viral haemorrhagic fevers and so on. It is more of a health security issue as to why we have some of these vaccine candidates, rather than, as Andre mentioned earlier, for the health of people. It can be done. We can develop vaccines, even for markets we would not expect. It was done for meningitis A. That is the first vaccine that has been developed and licensed exclusively, really, for Africa, where they have had these major meningitis outbreaks across the Sahel in Africa. We can do it if we get the incentives right, and I think we should do it. We should have more focus on people’s health, rather than health security, and make sure that we do develop the appropriate vaccines. It is not just vaccines. As I said, you need these other systems in place, but also other ways of treating patients as they arise. One of the failures of this epidemic is that I am not sure we really did enough research on the best way to support patients when they were ill. It was mostly just in response mode, trying to cope with them, with very little research done on how best to treat them. Also, the opportunity has now been lost to do that research. Even looking through medical records is a very difficult thing to do. Many, many records have been lost and are being lost and destroyed as we speak. The opportunity to even look back and work out the best way to treat an Ebola patient has not been lost completely but has sadly been diminished, unfortunately.
Dr Johnson
I would just add that I agree with all Professor Edmunds’ points about the vaccine. Overall, it is very impressive that they got as far as they did in that space of time. It is a record, but I agree there are learnings to be had. I have also heard excellent things about the WHO team. There were pockets of the WHO that were really effective. It is just that, as a whole, it did not come together, but there were one or two pockets that should be commended. I also agree with the point that there was a lot of emphasis on very exciting new drugs—ZMapp and other things. The reality is that we still cannot really agree on the difference between IV fluids and oral fluids. Is that important? On certain other basic treatments, how important are they? Some of the research was quite probably pharmaceutical heavy and not enough on the ground, saying, “What are the questions you need answering?” I have another really important example of a technology we should have deployed as the British and failed to do, and it probably would be my single biggest criticism of the British Government. The Defence Science and Technology Laboratory of the MOD had developed a rapid diagnostic test for Ebola. We field tested it, in partnership with Public Health England, and found it to be very effective. It identified every single Ebola case that we put it to. It also picked up some people who did not have Ebola, but that was manageable. It played a very important role for us in the field and it is, in our opinion, superior to the other rapid diagnostic tests that are out there, because it does not need to be kept refrigerated. But we were completely unable, having done a trial, published it and found it to be very effective, to get it deployed. My understanding is that it was because of wrangling and disagreements within different parts of the British Government between the MOD, DFID and other areas linked to funding. At the end of the day, we have asked questions in Parliament about it. I have had many conversations with different people. It is an issue of leadership, and of who had paid for the research and who was going to pay for things ongoing. It was a real disappointment to me that there was a piece of science that should have gone forwards and did not.
Chair
We have the DFID Secretary of State, but with officials from other Departments, including the MOD, giving evidence later this month, so we will make sure that those questions are put directly to her and to the officials.
Jeremy Lefroy
When did you become aware of the existence of this RDT?
Dr Johnson
Late autumn 2014. We did the study in, I think, December 2014, but it was some time—I think October, November—after the Public Health England labs team first came out that they mentioned it to us.
Chair
Can I just say a big thank you to both of you? It has been enormously helpful for our inquiry. I am really grateful to you for all that you have done, but also for coming today to give evidence. Thank you. Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338 21