In late August, health ministers from across Africa held a meeting in Togo in which they adopted a common strategy to confront health emergencies.
The so called “Regional Strategy for Health Security and Emergencies” commits African countries to concrete steps to strengthen disease surveillance, response and preparedness.
There are over 100 health emergencies in Africa each year — including outbreaks of infectious and deadly diseases like Yellow Fever, meningitis, and ebola. And it is sometimes the case that diseases endemic only in parts of Africa, like MonkeyPox, can spread globally precisely because of limited local capacity to contain an outbreak. This new strategy seeks to change that dynamic.
In this episode, we speak with Dr. Abdou Salam Gueye, WHO Regional Emergency Director for Africa, to discuss this new African health security plan and Africa’s role in global pandemic preparedness and response.
We kick off by discussing what COVID revealed about African health systems’ ability to respond to a massive emergency. Dr. Salam then explains some key elements of this new regional strategy on health emergencies and how the successsful implementation of this plan will have a global impact.
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Transcript slightly edited for clarity
What Do Health Emergencies Typically Look Like in African Countries?
Dr. Abdou Salam Gueye [00:00:00] If at that time you told me that monkeypox would be such a global issue today, I would not believe it. And I think there are hundreds of other issues that may be global issues, but we don’t know it yet.
Mark L. Goldberg [00:02:44] Briefly explain what weaknesses in the health emergency preparedness and response, COVID 19 revealed in African countries.
Dr. Abdou Salam Gueye [00:02:54] When COVID 19 arrived in Africa outbreak was not something they didn’t know. We have over 100 health emergencies in Africa every year, on average two health emergencies per week, so the countries were used to it. But what happened is that it arrived at the same time. The biggest weakness was in terms of supply chain. What we needed was needed by everyone at the same time, and given the weakness of our economy, we were not able to get the masks when they were needed, we were not able to get the respirators when we needed, and it was not a surprise that Africa was the last continent to receive the vaccine that we needed. There are also some other issues that we encountered during the COVID 19 emergency that were mostly related to the health system. ICU is something that was not on the normal primary healthcare. In most African countries, they had less than ten beds in ICU in the country. So, you understand that when they have an outbreak or when it became a pandemic, that needing 10 additional ICU beds every week was quickly over the capacity of the health system in those countries. Some countries have more human resources and have workforce like DR Congo or Nigeria because of the experience, but also because of the size of the population. Other countries, I know had really very limited number of epidemiologists that were able to design the country’s response. So, in order to really conclude on that, I think the first and most important issue we faced was in terms of supply of what we needed. The second was related to the case management, and the third is the health workforce in general that was different based on the country where you were.
Mark L. Goldberg [00:04:55] So you mentioned that Africa experiences about 100 health emergencies each year, which breaks down to two per week. COVID was seemingly extraordinary. What are these more routine health emergencies like? Can you just kind of walk me through what some of these health emergencies entail?
Dr. Abdou Salam Gueye [00:05:18] The health emergencies mostly are outbreaks: outbreaks of vaccine preventable diseases that still exist like cholera, meningitis, yellow fever. For example, as we are speaking over 11 African countries have reported yellow fever outbreaks that are currently going on. There are also some other diseases like Ebola that do not happen often, but when it happens, it has a big impact on the zone that it happened in, but also on the country and the region where it happened because it’s related with a lot of issues on traffic and people may have some reaction that are over exaggerated. Also, a lot of environment and climate related emergencies that are happening more and more and each year we have some countries that are having floods. We have also some that are related to violence that are manmade or not manmade violence, that have health emergencies. So overall, on the emergencies that we are having in Africa, over 70% are related to outbreaks and 30% are related to humanitarian emergencies that may be manmade or not manmade.
Why did African health ministers meet in Togo recently?
Mark L. Goldberg [00:06:38] So recently, health ministers from across Africa met in Togo and agreed to the adoption of a regional strategy on health security and emergency response. Can you walk me through what some of the key elements are of that strategy?
Dr. Abdou Salam Gueye [00:06:57] We need to learn from COVID, and we also have a lot of assessments that happened in Africa, like the joint external evaluation had been done in all the 47 countries of the WHO region in Africa. Also, a lot of other assessments were done. In addition to that, there is some global recommendation that happened because of COVID: over 300 recommendations coming from G7, G20 or WHO Organized Committee was to help us improve the way we are preparing for, we are detecting, and responding to emergency. Based on all those, there is a strategy that was drafted, and the consultation was done with our international partners with over 30 ministers in Africa. And we came up with a final draft that was submitted to the Minister of Health. That draft was concerned with four elements. The first element is to respond to the emergencies that are happening. As I said two emergencies are happening on average per week. And also, we need to have funding available. We need to have resources and operations that are already set when those emergencies arrive. The second is related to preparedness. The preparedness is promoting resilience of health systems to be ready when there is an emergency, and it needs the assessment of the country where they are in terms of the international health regulation capacity and also where the country is in terms of response capacity. Also, it helps countries to develop national action plans for health security and to go through the implementation of those plans, notably to help with them on the monitoring, evaluation, accountability, and learning. The third part of this strategy is related to the detection. We want to support countries to put in place effective surveillance systems where it is at the community, where it is event based, and also it is indicator based that can be collected and analyzed and reported too. And finally, the fourth one we see is not the least important, we see is the surge related point for helping the African country have 3000 responders that are ready to respond 24 to 48 hours after an emergency. Each country would have on average 50 people that are multidisciplinary, multi-sectoral, and some countries would have more than that because of their size. But also, those teams, we want them to be interoperable so some countries may be able to help others. So, it is four parts in the plan. The first to respond to emergency. Second, to prepare. Third, to detect. And fourth, to respond.
Why do African health ministers want to have a reserve emergency health force?
Mark L. Goldberg [00:09:48] That’s fascinating. So, on this fourth issue, you’re basically creating like a reserve emergency health force that is transnational across African countries in which a responder in Ghana could be deployed to Mali or something like that.
Dr. Abdou Salam Gueye [00:10:05] Exactly. And let’s just start saying it is first for the country themselves. They should be able to respond to their own emergency, but in their own emergency also, sometimes they may be overwhelmed, or they may have a specific need that they don’t have help for. And some neighboring country can help them to respond to it. I think it is a win win because the country that is receiving the support will be able to control the emergency and get back to normal life. And the country that is helping is also one way to prevent the emergency to arrive to the border because if it arrived there, they are going to need a lot more effort. So currently the African countries are really looking forward to it and each of them when they are thinking about developing their team, they are also thinking about how they would be able to help their neighbor or even beyond when it is needed.
How will African countries implement their new health emergency plan?
Mark L. Goldberg [00:10:57] So it sounds like this is potentially, if implemented, a really transformational strategy but I guess my key question is how will this be implemented? It’s one thing to have a good strategy on paper, it’s another thing for countries and health ministers and the broader international community to actually embrace the strategy and put it into action. What will it take next for this strategy that you say revolves around four key issues, including preparedness, detection, response, how will these issues be actually implemented in practice?
Dr. Abdou Salam Gueye [00:11:38] We did some early implementation, and you can call it pilot in five countries just before the regional committee meeting: Mauritania, Niger, Nigeria, Botswana, and Togo. And each of those countries, when we arrived, we expected the government to support our idea. That’s why we went to them. But we were surprised about how high-level people was looking forward to discussing with us and to find out a way to prevent what happened with COVID happening again in their country. In some countries, I was really surprised to get a call that the Prime Minister wanted to see us. In other countries, they asked us to go to the State House where we went and to see the level of commitment. We were able to support Member States, create over 200 multi-discipline and multi-sectorial people. We tried to push for having more women, a gender balance, and in some countries we successfully did it, like Botswana, and then those people were trained. The training was in four phases. Each phase was representing one of the core competencies that emergency responders needed. Actually, in those five countries already there are four countries that have the team that are ready to be deployed. The rest now is to implement and to maintain those people in the team in a condition to respond, to provide supplies to those teams, but also the most important is to make sure that when somebody is leaving, they would be able to be replaced by other competent people, so the team will still be sustainable. We have now 42 countries to go and we have started to go for scoping mission on those 42 countries. As I’m talking there is a team in Namibia and there is a team that is going next week to Congo and all 17 countries will be visited by the end of this year and in 2023 the rest of the 42 countries will be visited. We have the capacity to support the country for the first year, the second and the third, the countries have to show some commitment to participate to the ongoing operation. Some countries will be able to fund it all or the country will not be able to do it. And we are expecting global collaboration in order to make sure that everywhere is safe because the world will be safe only when everywhere is safe.
How can the international community support Africa’s new health emergencies plan?
Mark L. Goldberg [00:14:08] Well, that was going to be my next question. I mean, it sounds like you have some key political buy in, as demonstrated by the fact that all these health ministers from most African countries signed on to it. And it sounds like there is the political will in many of the countries in which you are, as you said, sort of piloting this project, but presumably, as you just said, there are certain countries, certain governments, certain regions that are unable to fully fund this themselves. Is there a specific price tag that you’re looking the international community to fill?
Dr. Abdou Salam Gueye [00:14:45] Actually, when we did the initial assessment of this strategy, it is about $4 billion a year. In five years, we need to come up with $20 billion dollars. There is a global strategy as the Director-General called for ten recommendations in order to improve health emergency in the world. And in those ten recommendations, one is sustainable financing. At the global level this varies in the process. The collaboration between World Bank and WHO create the funding that will be helping the developing countries to implement the ten recommendations of the Director General. The strategy that we have developed in Africa is completely aligned to those ten recommendations and this effort that I’ve been doing on the global level already beginning, but it will not be enough. For example, we see the funding that is being discussed between the WHO and World Bank is aiming to have $10.5 billion. And also in Africa, it’s going to have some countries that may not have what they need. It is just seed money. And I hope that it is going to be a global commitment in order to support all countries in the world.
Was it possible to stop monkeypox from spreading globally?
Mark L. Goldberg [00:16:05] Yeah, it seems like it would be an act of self-interest if the global north, or wealthier countries, or donor countries, were able to step up and provide that kind of funding and support for health emergency preparedness and response in Africa itself. I mean, you look no further than monkeypox, which was endemic in only just like a couple of African countries and now it is a health emergency around the world, and presumably, if these systems were in place earlier, something like monkeypox could have been stopped at its source.
Dr. Abdou Salam Gueye [00:16:43] You are absolutely right. And before WHO, I was working for U.S. CDC and was part of the team that was testing the smallpox vaccine into monkey pox in DR Congo. I’m from the government, so I know pretty good about what is happening but if at that time, you told me that monkeypox will be such a global issue today, I would not believe it. And I think there are hundreds of other issues that may be a global issue, but we don’t know it yet. The only way for us to be better prepared is to support the countries on the subnational level, to be ready to respond to their own emergencies before it becomes national and before it becomes international. And it is not very costly when we know that COVID 19 has cost trillions of dollars to the world. When you do investment, we are just asking for less than 1% of what it would cost, and it is really self-explanatory and a no brainer decision that should be made.
Why is disease outbreak surveillance important?
Mark L. Goldberg [00:17:43] Disease outbreaks surveillance and health systems strengthening and all that is needed to stop an infectious disease at its source, it seems like it should be the first option when it comes to international efforts to stop the next pandemic from emerging.
Dr. Abdou Salam Gueye [00:18:06] Yeah, this surveillance is one of the most important parts because it is 717 as we put it, the target. Between the starting of an outbreak and the detection, seven days is the maximum; between the detection and the notification, one day the maximum; between the notification and the time to put in place an effective response, seven days is the maximum and surveillance is where everything starts. Today in Africa, we have a lot of experience in surveillance. In Africa, before COVID, the average time is eight days between when the outbreak is starting and when it is detected. Eight days and seven are not very far away but we need to maintain it. We need also to adapt it to the real situation. The surveillance that we are doing in Africa, in many countries, it is still mostly paper based. The electronic opportunities are not fully used. The opportunity also to use smartphones and all those software that exist now are not used. And also, there is a huge source of information in the social media in the news that we are trying to use. But more and more it will become almost impossible with this level of resources that we have. Let me just give you an example: Three years ago, we were reading on average 2000 news per week in order to detect. One year later it became 3000 news. Today we are at 6000. I don’t have enough staff to do that. I need support technologically to do natural language processing, to do artificial intelligence, and we don’t have that expertise. And those who have it could help us and in that case, we are going to win, and they are going to win because honestly, we use it for our surveillance, then maybe we will not have this economic situation in the future.
How will the African health minsters’ new disease management plan work?
Mark L. Goldberg [00:20:07] So looking forward, assuming that this strategy is fully operationalized, could you walk me through an example of how it might work in a disease outbreak it might prevent? Just maybe add some color, add an example of how you see this strategy once implemented, working throughout the continent for the benefit of the entire planet.
Dr. Abdou Salam Gueye [00:20:35] Usually you don’t need to go very far away to see it. There is the Ebola case that happened in a very remote area in country X. The health workers that receive the patient are trained and are able to have a suspicion develop very early. They will report it to the district surveillance officer who will immediately report it to the international health regulator who works at the country level. When they do it, maybe that country has never had a case of Ebola like what happened in Guinea back in 2014. And then WHO is aware of it, we have reserves of testing for Ebola. In 24 hours, we are able to send it to the country to confirm the case of Ebola. And whereas the country that already has a team of responders that were trained that benefited from several simulation exercise that could be deployed 24 to 48 hours where it happened. When it happens, the first thing they’re going to do is to do an investigation and identify the contacts and those contacts will be traced for 24 days. And those contact, we can’t avoid that. When we are doing contact tracing, it is for the second level of contact that those who are trying to prevent. So, what are we going to do as soon as we identify, say, 40 contacts? We have around 180 contacts of contacts. The 180 contacts of contact we need just a 200 dose of vaccine against Ebola, and we are going to vaccinate them. And the contacts, we’re going to follow them for 24 days and taking their temperature and making a very rapid examination, and if there are any symptoms that can be related to Ebola, they would be isolated and tested. If they are being positive, they would not be transmitting it to the next contact of contact because those are already vaccinated. Usually, we are going to stop the outbreak of Ebola with two or three cases maximum. Should we not have these investments, that case will probably die without treatment and the contact of those cases, that may be 3 to 4, they’re going to have five cases that may travel and go around. In 24 hours, they can go everywhere in the world and those people will be able to close hospitals or maybe closing businesses that can cost them billions of dollars. What we are asking now is just the matter of some funding in order to complement what the African governments are really willing to put now. Because when I visited them, all of them will say, yeah, we are ready to pay for it. If they have it, they are going to put it, and what we need is just a complimentary form to make in place this strategy.
Mark L. Goldberg [00:23:32] And $4 billion is not a huge sum of money when spread across many potential donors.
Dr. Abdou Salam Gueye [00:23:40] Absolutely, and it is around $3 per person. Those people that are going to be protected by those $4 billion is close to $3 per person. The people themselves have a weight and a willingness to participate, their government also has the willingness to participate $4 billion if everybody put their contribution, it is feasible.
What can encourage global investment in African pandemic preparedness?
Mark L. Goldberg [00:24:04] So I guess lastly, we’ve known for a long time that pandemic preparedness and response around the world depends really heavily on health systems in Africa just considering the history of things from AIDS to monkeypox to a number of vaccine preventable illnesses that are still endemic in many African countries, why hasn’t this investment been made until now?
Dr. Abdou Salam Gueye [00:24:34] I do believe that there is a lot of investment that was done, but we always can say it was not enough. The biggest issue also is in terms of coordination of those investments and aligning those investments to what is needed. WHO, that is, I think the global indication that all countries decided to put in place did not have enough funding and did not have predictable funding. Only 20% of WHO budget is provided by countries in the 80% provided by donors. They are voluntary donors and most of it comes with some condition, and it comes with an orientation on where WHO should invest it. So even if globally, the funding that is arriving for the global health system, for the emergency were enough, there is some part of the health system that received more funding than they needed really and some part of the health system that needed more funding did not receive it. And I think the world should work better together and also to give more authority to WHO and more funding and predictable funding to WHO. And WHO also should adapt slightly in some parts to the real life and I’m sure it is being done with the lessons learned from COVID.
Mark L. Goldberg [00:26:06] Well, Dr. Salam, thank you so much for your time.
Dr. Abdou Salam Gueye [00:26:09] Thank you. It was a pleasure talking to you.
Mark L. Goldberg [00:26:19] Thank you for listening to Global Dispatches. Our show is produced by me, Mark Leon Goldberg, and edited and mixed by Levi Sharp.