U.S. and International Health Responses to the Ebola Outbreak in West Africa

Congressional research reportOct 29, 2014

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U.S. and International Health Responses to

the Ebola Outbreak in West Africa

/name redacted/

Specialist in Global Health

October 29, 2014

Congressional Research Service

7-....

www.crs.gov

R43697

U.S. and International Health Responses to the Ebola Outbreak in West Africa

Summary

In March 2014, an Ebola Virus Disease (EVD) outbreak was reported in Guinea, West Africa. The

outbreak is the first in West Africa and has caused an unprecedented number of cases and deaths.

The outbreak is continuing to spread in Guinea, Sierra Leone, and Liberia (the “affected

countries”); it has been contained in Nigeria and Senegal, and has been detected in Mali. As of

October 22, 2014, more than 10,000 people have contracted EVD, more than half of whom have

died.

Until October 2014, no secondary EVD cases had occurred outside of Africa. That month, health

workers in Spain and the United States contracted EVD cases while providing care for Ebola

patients. Other factors make this outbreak unique, including

•

its introduction into West Africa;

•

multi-country outbreaks occurring simultaneously;

•

disease transmission within urban areas; and

•

an unprecedented scale and pace of transmission.

In the aggregate, between 1976, when Ebola was first identified, through 2012, there were 2,387

cases, including 1,590 deaths, all in Central and East Africa. The number of Ebola cases in this

outbreak is four times higher than the combined total of all prior outbreaks, and the number of

cases is doubling monthly. The U.S. Centers for Disease Control and Prevention (CDC) and the

World Health Organization (WHO) have projected an exponential increase in cases. WHO

estimated that by the end of November, some 20,000 people may contract Ebola; CDC estimated

that “without additional interventions or changes in community behavior,” up to 1.4 million could

contract EVD in Liberia and Sierra Leone by January 2015. CDC indicates, however, that the

outbreak may not reach such proportions since responses are intensifying. In Liberia, for

example, improvements in burial practices have resulted in roughly 85% of all bodies being

collected within 24 hours of being reported to national officials.

In an August 2014 report, WHO estimated that it would cost roughly $500 million to contain the

outbreak by January. In September, international responses accelerated. The United Nations

(U.N.) established the United Nations Mission for Ebola Emergency Response (UNMEER) “to

utilize the assets of all relevant U.N. agencies” to address the health and broader social impacts of

the outbreak. A proposed U.N. response would cost roughly $1 billion, about half of which would

be aimed at addressing health impacts.

The United States is the leading funder of the international Ebola response, and its financial

support is growing. As of October 25, almost 900 U.S. government personnel had deployed to the

region, and some 4,000 military personnel will be deployed to the region. The U.S. Agency for

International Development (USAID) reports that as of October 22, U.S. funding for EVD

responses totaled $344.6 million. In addition, the Department of Defense (DOD) is planning to

spend more than $1 billion on EVD activities in West Africa. On October 17, President Obama

established an Ebola Czar to coordinate U.S. domestic and global responses to the Ebola

outbreak.

Some global health experts have criticized the U.S. and international response to the Ebola

outbreak, decrying the pace and scale of assistance. The limited impact of U.S. and international

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

responses to the Ebola outbreak has raised several questions regarding global health governance

structures, international commitment to bolstering pandemic preparedness and response capacity

in poor countries, and global support for strengthening health systems. The international

community lacks a rapid response team of health professionals prepared to address health

emergencies like the ongoing West African Ebola outbreak. Debates about whether WHO should

have such capacity have been at the heart of recent WHO reform debates.

While deliberating the appropriate response to ongoing Ebola outbreak, Congress is likely to

discuss the breadth of health, social, economic, development, and security challenges that this

outbreak is causing, as well as how U.S. global health aid is apportioned. This report focuses on

the health impacts of the outbreak and discusses U.S. and international responses to those health

challenges.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Contents

Background ...................................................................................................................................... 1

Ebola Care and Treatment ......................................................................................................... 2

Distinguishing Factors ............................................................................................................... 2

Unrelated, Ongoing Ebola Outbreak ......................................................................................... 4

Congressional Actions ............................................................................................................... 4

Health System Constraints in Affected Countries ........................................................................... 4

Governance and Leadership ...................................................................................................... 5

Financing ................................................................................................................................... 5

Human Resources ...................................................................................................................... 6

Service Delivery ........................................................................................................................ 9

Commodities/Supply Chain Networks .................................................................................... 10

Information .............................................................................................................................. 10

International Health Responses ..................................................................................................... 11

WHO Ebola Response Roadmap ............................................................................................. 13

WHO Community Care Campaign.......................................................................................... 14

U.S. Responses to Pandemic Threats and Ebola............................................................................ 15

USAID Pandemic Preparedness Efforts .................................................................................. 15

USAID Ebola Responses .................................................................................................. 16

CDC Pandemic Preparedness Efforts ...................................................................................... 17

CDC Ebola Responses ...................................................................................................... 17

Department of Defense Ebola Responses ................................................................................ 17

Possible Issues for Congress .......................................................................................................... 18

Human Resource Constraints .................................................................................................. 19

Leadership of the International Outbreak Response................................................................ 20

U.S. Support for Ebola Responses and Health Systems .......................................................... 21

Evaluating U.S. Responses ...................................................................................................... 22

Addressing the Long-Term and Broader Effects of the Outbreak ........................................... 23

Considering Research and Development Needs ...................................................................... 24

Conclusion ..................................................................................................................................... 25

Figures

Figure 1. Ebola Outbreaks: 1976-2014, as Reported on October 22, 2014 ..................................... 1

Figure 2. Map of Current and Past Ebola Outbreaks ....................................................................... 3

Figure 3. Health Statistics: Affected Countries, Africa, High-Income Countries, World ................ 7

Figure 4. Health Personnel Ratios and EVD Deaths Among Health Workers................................. 8

Figure 5. Bed Capacity in Ebola Treatment Units by Country ........................................................ 9

Figure 6. Laboratory Confirmed EVD Cases by Country ............................................................. 11

Figure 7. Timeline of International EVD Funding Requests ......................................................... 11

Figure 8. Pledges, Commitments, and Disbursements for UN Ebola Plan .................................... 13

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Tables

Table 1. Impact of Health System Deficiencies on Ebola Outbreak Containment .......................... 5

Table 2. Selected Health System Financing Statistics, 2011............................................................ 6

Table 3. United Nations Ebola Response Plan............................................................................... 12

Table 4. Similarities and Differences Between ETUs and CCCs .................................................. 14

Table 5. USAID Pandemic Preparedness Funding ........................................................................ 16

Table 6. CDC Global Disease Detection Funding ......................................................................... 17

Contacts

Author Contact Information........................................................................................................... 25

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Background

Ebola virus disease (Ebola, or EVD) is a severe, often fatal disease that was first detected in the

Democratic Republic of the Congo (DRC) in 1976.1 Originating in animals, EVD is spread to and

among humans through contact with the blood, other bodily fluids, organs, and corpses of those

infected. It is not transmitted through the air, and the World Health Organization (WHO)

maintains that there is minimal risk of contracting EVD on a plane,2 though most airlines have

suspended flights to and from the affected countries.3

In March 2014, an EVD outbreak was reported in Guinea, West Africa. The outbreak is the first in

West Africa and has become the largest, most persistent ever documented. The outbreak is

continuing to spread in Guinea, Sierra Leone, and Liberia (“affected countries”) and has ended in

Nigeria and Senegal, after having infected 20 people in Nigeria and one in Senegal. As of late

October, nearly 10,000 people have contracted EVD, of whom almost 5,000 have died (Figure

1). WHO regularly updates EVD cases at http://www.who.int/ebola.

Figure 1. Ebola Outbreaks: 1976-2014, as Reported on October 22, 2014

Source: Created by CRS Global Health Specialist (name redacted) from WHO data.

Due to inadequate disease surveillance capacities in the region, WHO estimates that actual cases

may be two to four times higher than reported.4 Some health experts are concerned that the weak

surveillance systems in neighboring countries may miss EVD cases. On October 23, Mali

reported its first EVD case and some suspect that Cote d’Ivoire may have undetected cases.5

WHO is reportedly sending a team to Mali to help with clinical management, epidemiology,

contact tracing and social mobilization.

This section was summarized from WHO, Ebola, fact sheet, number 103, April 2014.

WHO, “WHO: Air travel is low-risk for Ebola transmission,” Note for the Media, August 14, 2014 and WHO,

“Statement on travel and transport in relation to Ebola virus disease (EVD) outbreak, August 18, 2014.

“WHO urges calm as Kenya bans contact with Ebola-affected countries,” The Guardian, August 17, 2014.

WHO, Situation Report Update, September 8, 2014.

Abby Ohlheiser, “WHO sending experts to Mali after first Ebola diagnosis in the West African country,” Washington

Post, October 24, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Ebola Care and Treatment

There are no drugs proven to prevent or treat EVD, though efforts are underway to develop them.

In October, press reports indicated that WHO planned to begin testing two Ebola vaccines in

January on some 20,000 health workers and other volunteers. The organization also indicated that

a treatment might be available for use in Liberia by early November.6 In the absence of specific

treatments, health practitioners treat EVD symptoms with supportive care, which can reduce the

fatality rate. Spread of the disease can be limited through the use of disease surveillance and

containment measures. WHO has released manuals that outline appropriate patient care,

management of contaminated objects, safe burial practices, and diagnostic protocol.7 These

measures successfully contained all the previous Ebola outbreaks.

Distinguishing Factors

The Ebola virus that is circulating in West Africa is not new. Health experts are familiar with

methods to treat and contain it. The disease is spreading quickly, however, because the health

systems in the affected countries are ill-equipped to implement requisite disease containment and

surveillance measures. Key factors that distinguish this outbreak from previous EVD outbreaks

include the following:

Emergence in West Africa. Prior to the current outbreak in Guinea, Liberia, and Sierra Leone

(affected countries), EVD outbreaks were concentrated in the DRC, Gabon, Sudan South Sudan,

and Uganda (Figure 3).

Simultaneous multi-country outbreaks. Disease transmission along the shared borders of

Guinea, Liberia, and Sierra Leone has been intense and despite efforts to detect the disease at the

borders, people infected with Ebola have imported the disease into other countries. Contact

tracing and disease containment have halted the spread in Senegal and Nigeria where the outbreak

ended on October 17 and 19, respectively. In Nigeria, an imported case resulted in an outbreak

that infected 20 people and killed eight. A single imported case in Senegal was contained to the

index case. WHO is investigating a new EVD case in Mali.

Until October, no EVD cases outside of Africa resulted in secondary cases. In that month, health

workers in the United States and Spain contracted EVD while caring for EVD patients. No

additional cases have been reported from the health workers. No other reports have emerged of

EVD spreading in other countries where EVD patients have been evacuated.

Cases in urban areas. Previous outbreaks were confined to rural and forested areas, whereas the

current outbreak is spreading in rural and urban settings alike. Responders are struggling to

isolate cases and contain the outbreak in densely populated urban areas that lack sufficient access

to clean water and sanitation and face severe shortages of health workers and clinics.

Scale and pace of transmission. Ebola is spreading at an unprecedented rate in the affected

countries. In Liberia, reported cases are doubling every 15-20 days and in Sierra Leone, reported

The Guardian, “WHO aims for Ebola serum in weeks and vaccine tests in Africa by January,” September 22, 2014.

WHO, Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed

Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola, August 2014.

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cases are doubling every 30-40 days.8 Health experts link the unabated spread of EVD in the

affected countries to weak health systems.

Figure 2. Map of Current and Past Ebola Outbreaks

Source: Created by CRS Visual Information Specialist Amber Wilheim from WHO data.

Martin Meltzer et al., “Estimating the Future Number of Cases in the Ebola Epidemic—Liberia and Sierra Leone,

2014-2015,” MMWR, (September 23, 2014), volume 63.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Unrelated, Ongoing Ebola Outbreak

A separate Ebola outbreak that is unrelated to the ongoing West Africa outbreak was detected in

the DRC on August 24, 2014.9 It reportedly began in late July or early August, when a woman

contracted an EVD-like hemorrhagic fever after butchering a wild animal. She later died and

infected several others. As of October 20, there have been 66 cases and 49 deaths in the DRC,

including eight deaths among health workers. All but five of the 1,121 contacts have completed

the 21-day follow-up period.10 This is the seventh outbreak of EVD in the DRC since 1976.

Congressional Actions

Congressional actions to address the outbreak have been accelerating. Several committees have

convened hearings on the Ebola outbreak and in July and September 2014, U.S. Representative

Karen Bass and Senator Christopher Coons introduced legislation recognizing the severe impacts

and threats of the outbreak.11 Also in September, Congress enacted legislation (P.L. 113-164,

Continuing Appropriations Resolution, 2015) that provided $88 million for the Ebola response:

$30 million for CDC Ebola response activities in West Africa and $58 million for research and

development of specific treatments and vaccines for Ebola. Congress has also permitted the

Department of Defense (DOD) to reprogram roughly $750 million of FY2014 Overseas

Humanitarian Disaster and Civic Aid (OHDACA) funds to build 17 Ebola treatment units (ETUs)

in Liberia and to support ongoing U.S. efforts in the region (see “Department of Defense”). For

more information on DOD responses to the Ebola outbreak, see CRS Report IN10152, Increased

Department of Defense Role in U.S. Ebola Response, by (name redacted).

Health System Constraints in Affected Countries

The health systems in the affected countries were already weak before the Ebola outbreak, and

have become overwhelmed by the crisis. According to WHO, there are six components of a

health system: (1) human resources; (2) governance and leadership; (3) financing; (4)

commodities and supply chain networkers; (5) service delivery; and (6) information.12 The

affected countries face severe deficiencies in each of these areas and the outbreak is exacerbating

these challenges. This section describes how constraints in each component of the affected

countries’ health systems enable the virus to continue to spread. Table 1 summarizes these issues.

This section was summarized by CRS from WHO, Ebola virus disease – Democratic Republic of Congo, Disease

Outbreak News, August 27, 2014 and September 10, 2014.

WHO, Ebola Response Roadmap Situation Report, October 22, 2014.

H.Res. 701, Expressing the sense of the House of Representatives that the current outbreak of Ebola in Guinea,

Sierra Leone, and Liberia is an international health crisis and is the largest and most widespread outbreak of the disease

ever recorded and S.Res. 541, Recognizing the severe threat that the Ebola outbreak in West Africa poses to

populations, governments, and economies across Africa and, if not properly contained, to regions across the globe, and

expressing support for those affected by this epidemic.

For more information on health systems, see http://www.who.int/topics/health_systems/en/.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Table 1. Impact of Health System Deficiencies on Ebola Outbreak Containment

Governance

Financing

Human

Resources

Description

Policies, strategies, and

plans that inform the

course of action a country

will take to meet the

health needs of its people.

Mechanisms

used to fund

health efforts

and allocate

resources.

The people who

provide

healthcare and

support health

delivery.

Goods that are

used to provide

healthcare.

The

management and

delivery of

healthcare.

The collection,

analysis, and

dissemination of

health statistics

for planning and

allocating health

resources.

Impact of

Health

System

Component

Deficiency in

Ebola

Context

Slow initial government

response to the Ebola

outbreak and incapacity

to implement national

Ebola plans has diminished

public confidence in

political authorities and

limited efforts to dispel

rumors and fears about

Ebola.

Insufficient

financial

resources to

fund local

responses and

pay health

personnel

contribute to

human resource

and commodity

shortages.

Shortages of not

only health

personnel, but

also support

staff like grave

diggers and

statisticians limit

the ability to

detect, prevent,

and treat EVD

cases.

Insufficient supply

of protective

equipment

threatens the safety

of healthcare

workers (including

community

volunteers) and is

associated with

hospital- and clinicbased infections.

Many health

facilities in

Liberia and

Sierra Leone

remain closed

due to staff

shortages and

other factors.

Limited capacity

to conduct

contact tracing

and diagnosis calls

into question the

actual EVD cases

and impedes

efforts to detect,

treat, and control

the virus.

Commodities

Service

Delivery

Information

Source: Created by CRS Global Health Specialist (name redacted) from WHO webpage on health systems, http://www.who.int/topics/

health_systems, and research on the Ebola outbreak.

Governance and Leadership

The unabated spread of the outbreak in the affected countries has contributed to perceptions of

government ineptitude. Mistrust of public officials has prompted many civilians to ignore or resist

government responses. Reports of attacks on health workers and health facilities (run by nongovernmental organization and national health ministries alike) persist. The affected governments

have used armed forces to enforce disease control measures and to quarantine neighborhoods,

further deepening public resentment. Some have questioned the effectiveness of quarantines and

criticized the measures, citing concerns about human rights, food scarcity, and possible unrest.

Following criticisms by health experts and protests, Liberia and Sierra Leone have stopped

quarantining some neighborhoods, though some quarantine zones remain. Despite concerns about

quarantine practices, Sierra Leonean officials had characterized a three-day “Stay Home House to

House” sensitization campaign a success, noting during which 92 bodies had been recovered and

56 Ebola cases were detected.13

Financing

Per capita health spending in Guinea, Liberia, and Sierra Leone has been relatively low (Table 2),

contributing to poor conditions of publicly-funded health facilities. Health workers and other

government personnel often experience delays in compensation and benefits, contributing to

absenteeism and human worker shortages. As the Ebola outbreak intensified, some health workers

abandoned their posts, citing not only safety concerns (from lack of protective equipment) but

Naina Bajekal, “Ebola Lockdown in Sierra Leone Finds 150 New Cases,” Time, September 22, 2014 and Umaru

Fofana, “Sierra Leone wraps up three-day Ebola lockdown,” Reuters, September 21, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

also frustration over not receiving salaries. Several local staff at Ebola treatment units in Liberia

had reportedly not been paid for three months.14 Donors, including the United States, have since

begun to offer financial aid to Liberia to support payment of health workers salaries and other

financial incentives.

Table 2. Selected Health System Financing Statistics, 2011

% of Population

Living on < $1 Daily

Health Personnel

per 10,000 Pop.

Per Capita Gov.

Health Spending

Gov. Health Budget as %

of Total Gov. Spending

Guinea

43.3%

not available

$15

6.8%

Liberia

83.8%

2.8

$27

19.1%

Sierra Leone

51.7%

1.9

$31

12.3%

Nigeria

68.0%

20.2

$49

6.7%

Africa

51.5%

14.6

$76

9.7%

World

21.5%

43.3

$619

15.2%

Source: Created by CRS Global Health Specialist (name redacted) from WHO,

Notes: Health personnel refers to doctors, nurses, and midwives.

World Health Statistics Report, 2014.

All of the outbreak-affected countries lack sufficient financial resources to fund their national

Ebola response plans and need financial support. Several donors have pledged to provide support

to the affected countries, though gaps persist (see “International Health Responses”). To meet the

health and secondary effects of the outbreak, the United Nations estimates that it will cost Guinea

$194 million, Liberia, $473 million, and Sierra Leone $220 million. Roughly half of these

resources will be needed for addressing health needs.15

Human Resources

Due to severe shortages of health workers and clinics, the majority of people infected with Ebola

in Liberia are without access to medical care and treatment. Inadequate access to health personnel

and facilities is also a problem in Sierra Leone and Guinea. Human resource constraints and

concerns about conditions in health centers are prompting people to care for the ill on their own,

facilitating the spread of the virus. The shortage of medics and health facilities also means that

people needing care for non-EVD related issues have nowhere to go.

Observers are troubled not only by inadequate access to Ebola care but also to the impact that

clinic closures are having on broader health issues, particularly maternal and child health. Before

the outbreak, maternal and child mortality rates in the EVD-affected countries were among the

highest in the world (Figure 3). In 2012, roughly 26% of all maternal deaths in sub-Saharan

Africa occurred in the four countries, where more than 46,000 women died from pregnancyrelated complications (an average of 126 daily deaths).16 Also in 2012, nearly 1 million children

died in the affected countries before reaching their fifth birthday, accounting for roughly 30% of

USAID, West Africa Ebola Outbreak—Update #2, August 11, 2014.

United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), Ebola Virus Disease Outbreak:

Overview of Needs and Requirements, September 2014.

UNICEF, Trends in Maternal Mortality: 1990 to 2013, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

all under-five deaths in sub-Saharan Africa.17 Most of these deaths could have been prevented

with adequate access to vaccines, clean water and sanitation, and nutrition.

Figure 3. Health Statistics: Affected Countries, Africa, High-Income Countries, World

Source: Created by CRS Global Health Specialist (name redacted) from WHO,

World Health Statistics Report, 2014.

Acronym: Tuberculosis (TB)

Notes: Maternal mortality refers to the death of a woman while pregnant or within 42 days of a terminated pregnancy

from any cause related to or aggravated by the pregnancy or its mismanagement, but not from accidental or incidental

causes. Neonatal mortality refers to the probability of dying during the first 28 days of life. Infant Mortality refers to the

probability of dying within the first year of life. Under-Five Mortality refers to the probability of dying between before five

years of age. All statistics collected in 2012, except maternal mortality rate, collected in 2013. In 2012 and 2013, the

World Bank classified high-income countries as those with gross national incomes of $12,746 or more.

Press reports indicate that some pregnant women are avoiding health facilities out of fear of

contracting EVD in health settings. At the same time, many needing assistance during labor and

delivery are unable to receive medical attention due to clinic closures and human resource

WHO, World Health Statistics Report, 2014.

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constraints. According to the United Nations, “[m]ore people are now dying in Liberia from

treatable ailments and common medical conditions than from Ebola.”18

High maternal and child mortality rates in the

affected countries are linked to the dearth of

health workers in the affected countries.

Between 2006 and 2013, Sierra Leone had

only two doctors per 100,000 people,

according to the WHO (Figure 4).19 At an

August 2014 congressional hearing, one

witness testified that prior to the Ebola

outbreak, Liberia had fewer than 200

doctors.20 After the outbreak, he estimated

that about 50 doctors remained to provide

clinical care, due in part to the evacuation of

several expatriate doctors. EVD deaths

among health workers have further

diminished these staffing levels. On October

22, WHO reported that 443 health workers

had contracted EVD, of whom 244 died.21

More than 40% of these deaths occurred in

Liberia. Sierra Leone and Liberia face

shortages that are much more severe than

Nigeria and the rest of the world.

Figure 4. Health Personnel Ratios and

EVD Deaths Among Health Workers

(health personnel per 10,000 population, 2006-2013)

Ebola control is labor- and resource-intensive,

due to requisite surveillance and containment

measures. WHO estimates, for example, that

a facility treating 70 Ebola patients needs at

least 250 healthcare workers.22 In order to

stop the spread of EVD, WHO estimated at

Source: Created by CRS Global Health Specialist (name

the end of August 2014 that the affected

redacted) from WHO,

World Health Statistics

countries would need more than 13,000 health

Report, 2014 and WHO, WHO: Ebola Response Roadmap

workers to provide health care, contact

Situation Report, October 22, 2014.

tracing, and safe burial.23 The plan estimated

Notes: Health personnel ratio data collected between

that roughly 5% of the health personnel

2006 and 2013.

would come from foreign countries and the

rest would be comprised of national health staff. The affected countries do not have enough health

personnel and countries are beginning to deploy medics to the region.

United Nations, “Secretary-General’s Remarks to the Security Council on Ebola,” Press Statement, September 18,

2014.

WHO, Unprecedented number of medical staff infected with Ebola, August 25, 2014.

U.S. Congress, House Committee on Foreign Affairs, Subcommittee on Africa, Global Health, Global Human Rights

and International Organizations, Combating the Ebola Threat, Testimony by Dr. Frank Glover, August 7, 2014.

WHO, WHO: Ebola Response Roadmap Situation Report, October 22, 2014.

WHO, “WHO Director-General briefs Geneva UN missions on the Ebola outbreak,” Briefing to United Nations

Member States, August 12, 2014.

WHO, Ebola Response Roadmap, August 28, 2014, p. 24.

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Service Delivery

The Ebola outbreak has further diminished healthcare

options in the affected countries. Many health facilities in

Liberia and Sierra Leone are closed. Even before the

outbreak, access to clinics was limited. The vast majority

of health facilities are concentrated in urban areas and

Ebola treatment centers are concentrated in high

prevalence areas, leaving large swaths of the population

without access to both general healthcare and Ebolaspecific treatment. Due to limited access to clinics, the ill

frequently travel great distances in search of healthcare,

prompting most to wait until health complications are

severe. Delayed health-seeking practices are reducing

survival prospects among those sickened by Ebola and

encumbering efforts to detect and contain the virus.

Figure 5. Bed Capacity in Ebola

Treatment Units by Country

(as of October 18-19, 2014)

A variety of health services are needed to control the

outbreak, including Ebola treatment centers, laboratories,

contact tracing, and safe burial services. All of the affected

countries face severe deficiencies in these areas. Most of

the health services are unable to meet the demands and

new ones are filled up as soon as they are opened. Patients

turned away from treatment facilities typically return to

their communities, often on public transportation, likely

infecting several more people along the way. CDC

estimates that fatality rates could be halved if people were

able to access treatment and healthcare.24

Liberia faces the most severe treatment shortage. As of

Source: Created by CRS Global Health

October 22, WHO estimated that it had only 23% of the

Specialist (name redacted) from WHO,

beds it needed to treat those sickened by EVD (Figure 5). WHO: Ebola Response Roadmap Situation

Treatment capacity is expected to improve with U.S. plans Report, October 22, 2014.

to support the construction of 27 ETUs in the country, 12

of which will be built by the Department of Defense (DOD).25 Health experts are investigating a

recent reduction in people seeking Ebola care in Liberia, reportedly leaving some beds vacant.26

Safe disposal of dead bodies is also improving in Liberia, where roughly 90% of dead bodies are

being removed within 24 hours of being reported to the National Call Center.27 EVD responders

are also working with community leaders to adapt traditional funeral practices that can facilitate

EVD transmission, such as kissing and touching corpses.

The poor quality of health care delivery is also a concern. Inconsistent adherence to infection

control protocol, for example, is contributing to EVD cases among health workers. In July, CDC

Teleconference with CDC Director Tom Frieden, September 5, 2014.

Communication with USAID, October 26, 2014.

Sheri Fink, “In Liberia, a Good or Very Bad Sign: Empty Hospital Beds,” New York Times, October 28, 2014.

U.S. Government Inter-Agency Conference Call on Ebola, October 17, 2014.

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investigated a cluster of Ebola cases among HCWs in Liberia and identified “multiple

opportunities for transmission of Ebola virus to HCWs, including exposure to patients with

undetected Ebola in the hospital, inadequate use of personal protective equipment during cleaning

and disinfection of environmental surfaces in the hospital, and potential transmission from an ill

HCW to another HCW.”28 During a September tour of Liberia, CDC Director Tom Frieden noted

inconsistent availability and use of gloves and hand washing. 29 Interruptions in water supply in

health clinics further hamper efforts to ensure necessary sanitation. Dr. Frieden noted of 29 health

centers surveyed during his tour to the affected region, only one had running water.30

The poor conditions of the health facilities also discourage attendance. Power outages and

interruptions in potable water delivery are common.31 In addition, ambulance services are

virtually non-existent in rural areas and limited in urban areas. One district in Sierra Leone with a

population of 465,000 people reportedly has only four ambulances, which are often overcrowded

with ill people, irrespective of Ebola infection status.32

Commodities/Supply Chain Networks

Shortages of protective gear are associated with EVD cases among health workers, and may

allow EVD to be spread within health facilities. The affected countries have limited supplies of

appropriate protective equipment and not all health and support personnel who interact with the

public have access to such equipment. Due to resource constraints, the protective equipment is

primarily provided to healthcare workers in Ebola treatment centers, leaving health workers who

operate among the general population at risk of contracting and spreading the disease (and other

infectious diseases) should they encounter an undiagnosed EVD case. WHO noted, however,

shortages of PPE even in ETUs.33 Health providers also lack sufficient supplies of antibiotics and

safe blood to treat Ebola. The price of disinfectants and medicine has reportedly doubled, as

people attempt to protect themselves and self-medicate in light of health system deficiencies.34

Transporting aid workers and commodities across and within the affected countries is

complicated by poor road conditions and the suspension of air service by several commercial

airlines. Efforts by the international community to develop alternative transportation routes have

improved the situation, though limited air service remains a problem.

Information

Awareness about preventing EVD infection has improved, but due to poverty, infrastructural

deficiencies (e.g., clean water and sanitation), and health system constraints, many people lack

Joseph Forrester et al., “Cluster of Ebola Cases Among Liberian and U.S. Health Care Workers in an Ebola

Treatment Unit and Adjacent Hospital – Liberia, 2014,” Morbidity and Mortality Weekly Report, (October 17, 2014),

volume 63, number 41.

Teleconference with CDC Director Tom Frieden, September 5, 2014.

Ibid.

Doctors Without Borders, “Flash Quote: WHO Declares Ebola an International Public Health Emergency,” Field

News, August 8, 2014.

The Star, “In Sierra Leone, an exhausting struggle to contain Ebola,” August 18, 2014.

WHO, “Unprecedented number of medical staff infected with Ebola,” Situation Assessment, August 25, 2014.

Newsweek, “Ebola Frontline: Flooding in Sierra Leone Exacerbates Public Health Fears,” August 12, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

means to avoid infection. Before Ebola hit, hunger was already a problem in the affected

countries, particularly in rural areas. Consumption of wild animals is common practice,

particularly in areas with high food insecurity. Health officials have been expanding efforts to

inform the public about the risks associated with eating wild animals, including fruit bats and

other animals that might carry EVD.35 Without sufficient access to food, hunger often compels

people to continue hunting and eating the animals despite the risks.

Figure 6. Laboratory Confirmed

Efforts to contain the outbreak are encumbered by weak

EVD Cases by Country

laboratory and surveillance systems. Health experts are

(as of October 22, 2014)

uncertain about how many EVD cases exist and where

they are occurring, particularly in Liberia where roughly

20% of EVD cases have been confirmed through

laboratory diagnosis (Figure 6). Limited laboratory

capacity has resulted in extensive diagnosis backlogs,

further calling into question the number of EVD cases and

hindering efforts to contain the outbreak. Uncertainty

about EVD cases endangers health workers, other patients,

and those living among people sickened by diseases of

undetermined origins.

International Health Responses

International responses are accelerating, though it remains

to be seen how much it will ultimately cost to contain the

outbreak and when this will be achieved. The financial

requirements for containing the outbreak are rising along

with the spread of the outbreak (Figure 7). In March,

WHO estimated that it would take $4.8 million to contain

the outbreak. At the end of April, more than 200 EVD

cases had been discovered in Guinea, less than a dozen in

Liberia, and none in Sierra Leone. In August, the

organization revised its Ebola response plan, estimating it

Source: Created by CRS Global Health

would cost roughly $490 million to contain the outbreak.36

Specialist (name redacted) from

By then, the outbreak had reached Sierra Leone and

WHO, WHO: Ebola Response Roadmap

Nigeria and had caused 3,685 EVD cases, including 1,841

Situation Report, October 22, 2014.

deaths. The outbreak is continuing to spread, is causing

broader social and economic disruptions, and has infected more than 10,000 people.

Figure 7. Timeline of International EVD Funding Requests

(U.S. millions)

Source: Created by CRS Global Health Specialist (name redacted) from WHO and UNOCHA funding requests.

“Ebola risk unheeded as Guinea’s villagers keep on eating fruit bats,” The Guardian, August 4, 2014.

WHO, Ebola Response Roadmap, August 28, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

In September, the United Nations (U.N.) established the U.N. Mission for Ebola Emergency

Response (UNMEER) to coordinate the international response to the outbreak. That month, the

United Nations Security Council held a special meeting on Ebola, urging member states to

expedite support for the affected countries and to contribute to a U.N. integrated Ebola response

plan. The six-month, $988 million plan calls for addressing the health and social impacts of the

outbreak (Table 3).37 Roughly half of the funds would be spent on health programs and the

balance would be spent on addressing issues such as food insecurity, economic disruptions, and

establishing and maintaining supply chain networks.

Table 3. United Nations Ebola Response Plan

(U.S. $ millions)

Common

Services

Guinea

Liberia

Sierra

Leone

Total

(1) Stop the Outbreak

Case identification and contact tracing

7.0

26.8

116.5

39.2

189.5

Safe and dignified burials

0.8

4.3

14.2

4.4

23.8

(2) Treat the Infected

Ebola care and infection control

7.0

52.5

212.6

59.2

331.2

Medical care for responders

10.0

1.0

2.0

1.0

14.0

(3) Ensure Essential Services

Food aid

2.5

28.4

36.3

40.4

107.7

Basic health care

1.0

47.1

12.9

36.1

97.1

Cash incentives for health workers

0.0

2.5

0.0

2.5

Recovery and economy

0.3

9.5

43.1

11.7

64.8

(4) Preserve Stability

Supply chain management

3.9

3.1

20.7

14.8

42.6

Transport and fuel

22.9

0.0

0.5

0.0

23.4

Social mobilization

0.6

18.6

13.2

13.3

45.8

Messaging

1.5

0.3

1.1

0.3

3.2

Regional support for Points 1-4

11.9

0.0

(5) Prevent Outbreaks in Unaffected Countries

Multi-faceted/preparedness (regional)

30.5

0.0

30.5

Total

88.0

194.1

473.1

220.4

987.8

Source: United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), Ebola Virus Disease

Outbreak: Overview of Needs and Requirements, September 2014.

Notes: The amounts in the table reflect the totals indicated in the U.N. plan. Due to rounding, the subtotals do

not always equal the amount indicated in the Total column.

United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), Ebola Virus Disease Outbreak:

Overview of Needs and Requirements, September 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

As of October 29, 2014, donors have contributed $493 million towards the UN plan and pledged

to provide an additional $279 million (Figure 8).38 Donors are also providing resources for

addressing the Ebola outbreak outside of the UN response. The United Nations Office for the

Coordination of Humanitarian Affairs (UNOCHA) estimates that some $894 million has been

committed for addressing the outbreak and an additional $938 million has been pledged for the

immediate and long-term preparedness needs. WHO and UNOCHA will likely revise their

requests for funding and material support as the outbreak continues to spread.

Figure 8. Pledges, Commitments, and Disbursements for UN Ebola Plan

(as of October 27, 2014)

Source: Created by CRS from UNOCHA, Financial Tracking Service webpage on the Ebola outbreak at

http://fts.unocha.org/, accessed on October 22, 2014.

WHO Ebola Response Roadmap

As indicated above, roughly half of the U.N. request for tackling the outbreak is aimed at

addressing direct health impacts. The World Health Organization is leading that component and

has outlined measures the international community would need to take to contain the outbreak by

January 2014. In the plan, entitled the Ebola Response Roadmap, WHO requested donors provide

roughly $490 million for:

•

building 158 referring and isolation centers capable of holding over 1,500 beds;

•

increasing diagnostic capacity to process 600 samples monthly; and

•

attracting more than 13,000 health workers to provide health care, conduct

contact tracing, and institute safe burial protocols.

UNOCHA webpage on Ebola Outbreak Funding at http://fts.unocha.org, accessed on October 22, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

WHO Community Care Campaign

Since September, pledges to send health workers to the region have increased, though human

resource constraints continue to inhibit containment efforts. Since September, several countries

have pledged medical support to the region, including Cuba’s commitment to deploy 165 health

professionals;39 a U.S. commitment to deploy 65 U.S. Public Health Service Commissioned

Corps officers for providing Ebola care in an DOD-established ETU;40 Britain’s provision of 750

troops, including medical officers;41 and China’s pledge to send more than 170 health workers.42

The African Union and East African Community have respectively committed to send 100 and

600 health workers.43

In light of human resource constraints, the Liberian Government, WHO, CDC, and other partners

developed the Community Care Campaign, which will initially be targeted at “the 400,000 most

vulnerable households in Liberia” and will be subsequently expanded to cover the rest of the

country and region.44 The Community Care Campaign calls for the establishment of community

care centers (CCCs), which will be managed and staffed by non-governmental organizations

(NGOs), community health workers (CHWs, lay people with rudimentary health training) and

family members of EVD patients. The CCCs are intended to “complement” Ebola Treatment

Units that are staffed by trained health practitioners and are operating at maximum capacity. The

Sierra Leonean government and implementing partners are also establishing CCCS in the country.

Table 4 summarizes similarities and differences between the two facilities.

Table 4. Similarities and Differences Between ETUs and CCCs

Ebola Treatment Units

Community Care Centers

Bed Capacity

up to 100 beds

up to 15 beds

EVD Diagnosis

yes

depends on facility

Healthcare for EVD

patientsa

intravenous care, including hydration and blood

transfusion; maintenance of oxygen and blood

pressure levels; and treatment of other infections

oral rehydration, pain killers,

fever reducers, and

antimalarials

EVD Care

provided by trained medics

provided by NGOs, CHWs

and family members

Oversight of Ebola Care

Practices

on-site

off-site

Access to food and water

yes

Source: Created by CRS from WHO, Key Considerations for the Implementation of an Ebola Care Unit at

Community Level, September 2014.

For more on care and treatment of EVD symptoms, see http://www.cdc.gov/vhf/ebola/treatment/.

WHO, “Cuban medical team heading for Sierra Leone,” Press Release, September 2014.

HHS, “U.S. Public Health Service Commissioned Corps to help treat Ebola patients in Liberia,” September 16, 2014.

USAID, “West Africa-Ebola Outbreak,” Fact Sheet #4, October 22, 2014.

Ewan MacAskill and Rowena Mason, “British troops to be sent to help fight Ebola,” The Guardian, October 8, 2014.

USAID, “West Africa-Ebola Outbreak,” Fact Sheet #4, October 22, 2014.

White House, “Fact Sheet: U.S. Response to the Ebola Epidemic in West Africa,” September 16, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

U.S. Responses to Pandemic Threats and Ebola

The United States is the leading funder of the international Ebola response and its financial

support is continuing to rise. The U.S. Agency for International Development (USAID) reports

that as of October 22, U.S. humanitarian funding for EVD responses totaled $344.6 million.45 In

addition, the Department of Defense (DOD) is planning to spend more than $1 billion on

containing the outbreak in support of U.S. EVD activities in West Africa, as described below.46

On October 17, President Obama established an Ebola Czar to coordinate U.S. domestic and

global responses to the Ebola outbreak. The U.S. Global Ebola strategy has four key goals:

1) control the outbreak,

2) mitigate second order impacts,

3) establish coherent leadership and operations, and

4) advance global health security.

U.S. global efforts focus primarily on Liberia, where the outbreak is most widely spread, although

the United States is engaged in all three affected countries. As of October 25, nearly 900 U.S.

Government personnel are stationed in the region, more than 700 of which are among the 4,000

military personnel who will be deployed to the region.47

U.S. responses to the current Ebola outbreak are built on prior and ongoing efforts to build the

capacity of foreign nations to prepare and respond to disease outbreaks—including Ebola. These

activities are primarily implemented through USAID and CDC, though the U.S. Departments of

Agriculture, Defense, and State also contribute to such efforts. Pandemic preparedness programs

began in earnest after the 2005 avian flu outbreak and have experienced varying levels of

congressional support. The section below briefly describes U.S. pandemic preparedness efforts,

including Ebola outbreak responses, by agency.

USAID Pandemic Preparedness Efforts

Since 2005, USAID has invested roughly $1 billion on helping countries detect, prepare for, and

respond to outbreaks that originate in animals, such as Ebola, and that have the potential to cause

pandemics. 48 In FY2014, USAID spent $72.5 million on such efforts through the Emerging and

Pandemic Threats (EPT) program, which operates in 18 countries in Africa and Asia. The

program grew out of USAID’s initial response to H5N1 avian influenza in 2005.

Congress appropriates funds directly to USAID for EPT. These funds have fluctuated between

FY2005-FY2014 (Table 5). Related activities in 18 countries in East and Central Africa and

South and Southeast Asia focus on:

USAID, “West Africa-Ebola Outbreak,” Fact Sheet #4, October 22, 2014.

White House webpage on the U.S. Ebola response at http://www.whitehouse.gov/ebola-response, accessed on

October 23, 2014.

Communication with USAID, October 26, 2014.

See the USAID webpage on pandemics at http://www.usaid.gov/what-we-do/global-health/pandemic-influenza-andother-emerging-threats.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

•

viral detection—identification of viruses in wildlife, livestock, and human

populations that may be public health threats;

•

risk determination—characterization of the potential risk and method of

transmission for specific viruses of animal origin;

•

institutionalization of a “one health” approach—integration of a multi-sector

approach to public health (including animal health and environment);

•

outbreak response capacity—support for sustainable, country-level response to

include preparedness and coordination; and

•

risk reduction—promotion of actions that minimize or eliminate the potential

for the emergence and spread of new viral threats.

Table 5. USAID Pandemic Preparedness Funding

(current U.S. $ millions and percent)

Avian Flu/

Pandemic

Preparedness

FY05

Actual

FY06

Actual

FY07

Actual

FY08

Actual

FY09

Actual

FY10

Actual

FY11

Actual

FY12

Actual

FY13

FY14

FY15

FY14Actual Estimate Request FY15

162

161

115

190

106

-31.0%

Source: Created by CRS correspondence with USAID officials, August 6, 2014.

Note: Includes supplemental appropriations.

USAID Ebola Responses49

USAID has deployed a Disaster Assistance Response Team (DART) to West Africa to coordinate

the U.S. Government’s response to the Ebola outbreak. In coordination with other federal

agencies, the team is overseeing the U.S. response. Between March and October 2014, USAID

has committed to provide more than $300 million for combating Ebola in West Africa.50 This

included the provision of resources for 1,000 treatment beds, 130,000 sets of protective

equipment for healthcare staff and outbreak investigators, as well as 50,000 hygiene kits, which

include soap, bleach, gloves, masks, and other supplies to help prevent the spread of disease.51

USAID is also supporting the International Federation of Red Cross and Red Crescent Societies

(IFRC) to raise public awareness of Ebola’s mode of transmission, teach disease prevention

practices to communities, train volunteers to detect Ebola symptoms and identify contacts of

confirmed or suspected cases for further monitoring, and support safe burial and body

management activities. USAID has reprogrammed funds from the Global Heath and International

Disaster Assistance accounts to fund these efforts.

Summarized from USAID, “USAID and CDC Announce Additional Assistance for West Africa Ebola Response,”

press release, August 5, 2014.

USAID, “West Africa-Ebola Outbreak,” Fact Sheet #4, October 22, 2014.

U.S. Embassy, “U.S. to Help Mobilize More Health Workers for Ebola Outbreak,” September 9, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

CDC Pandemic Preparedness Efforts

CDC funds its global pandemic preparedness efforts through a variety of accounts, including the

Global Disease Detection (GDD) program, Emerging and Zoonotic Infectious Diseases, Global

Health, Immunization and Respiratory Diseases, and Public Health Preparedness and Response.

The Centers leverage resources from these and other program accounts to respond to global

disease outbreaks—including Ebola. Appropriations for GDD have grown since 2003 (Table 6).

Table 6. CDC Global Disease Detection Funding

(current U.S. $ millions)

GDD

FY04

Actual

FY05

Actual

FY06

Actual

FY07

FY08 FY09 FY10 FY11 FY12

FY13

FY14

FY15

Actual Actual Actual Actual Actual Actual Actual Estimate Estimate

Source: Created by CRS from correspondence with the Office of Management and Budget (OMB), appropriations

legislation, and budget justification documents.

CDC has requested additional support ($45 million) in FY2015 to fund activities in support of the

Global Health Security Agenda, which will accelerate activities to detect, prevent, and respond to

global infectious disease threats like Ebola.52 CDC directly or indirectly supports pandemic

influenza preparedness efforts in more than 50 countries. In some cases, CDC sends experts to

work with WHO country offices or foreign health ministries, and at other times, CDC forms

cooperative agreements with partners to support country efforts.

CDC Ebola Responses53

At the end of March 2014, CDC teams traveled to Guinea and Liberia to help those Health

Ministries characterize and control the outbreak, identify and manage EVD cases, conduct contact

tracing, and improve data management. Following an initial response, new cases flared up after

appearing to decelerate for some time. CDC returned to the region and began resumed technical

assistance efforts. In addition to the activities discussed above, CDC is also training airport

personnel and working with partners to display Ebola-specific travel messages for electronic

monitors and posters at airports in the affected countries. CDC is not providing direct care of

Ebola patients. As of October 22, 2014, CDC has committed more than $16.7 million for its

Ebola responses.54

Department of Defense Ebola Responses

Until recently, DOD responses to the outbreak were focused on researching treatments and

vaccines and providing laboratory diagnostic assistance to Sierra Leone and Liberia. On

September 8, DOD announced that it would provide $22 million to set up a 25-bed field hospital

For more on the Global Health Security Agenda, see http://www.cdc.gov/globalhealth/security/.

This section was summarized from correspondence with CDC. Also see, Meredith Dixon and Ilana Schafer, “Ebola

Viral Disease Outbreak – West Africa, 2014,” Morbidity and Mortality Weekly Report (June 27, 2014), volume 63,

issue 25, pp. 548-551; and http://www.cdc.gov/vhf/ebola/outbreaks/guinea/.

USAID, “West Africa-Ebola Outbreak,” Fact Sheet #4, October 22, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

in Liberia that would be used to treat EVD cases among healthcare workers. The Department of

Health and Human Services (HHS) U.S. Public Health Service Commissioned Corps will deploy

65 officers “to Liberia to manage and staff the hospital.”55 Military personnel will establish and

supply the facility, but not provide direct medical care.56

On September 16, President Barack Obama announced the launch of “Operation United

Assistance.”57 The operation is to be based in Monrovia, Liberia, will entail the deployment of

roughly 4,000 U.S. military forces, and be overseen and coordinated by the DOD U.S. Africa

Command. The operation will support:

•

the coordination of U.S. and international relief efforts;

•

the provision of medical personnel to train up to 200 health workers weekly; and

•

the establishment of 12 treatment centers in Liberia, each with 100-bed capacity.

Operation-related efforts are underway. The first 22-bed ETC is expected to be completed by the

end of October and three others are to be completed in November.58 More than 700 U.S. military

personnel are in the region, including personnel from the U.S. Naval Medical Research Center

who are operating three mobile medical labs for EVD testing.59 Congress has approved several

DOD reprogramming requests to fund Operation United Assistance as well as other related

activities, including those that supply personal protective equipment, laboratory inputs, and

technical advisors to the region. Total DOD funding for the global Ebola response is expected to

exceed $1 billion.60

Possible Issues for Congress

The current Ebola outbreak has overwhelmed the governments of Guinea, Sierra Leone, and

Liberia. Insufficient capacity to detect, treat, and prevent the spread of disease has enabled the

virus to spread and has further weakened health systems that were already inundated and in

dilapidated conditions. Congress has held several hearings on the outbreak and enacted legislation

that urged expanding U.S. and international responses and that provided funds for U.S. responses.

As the outbreak continues to spread, the Administration may request additional funds to contain

the outbreak. This section describes issues Congress may consider as it assesses U.S. and

international responses.

HHS, “U.S. Public Health Service Commissioned Corps to help treat Ebola patients in Liberia,” Press Release,

September 16, 2014.

Richard Sisk, “Pentagon to Set Up Ebola Field Hospital in Liberia,” Military.com, September 8, 2014; and AFP, “US

to Send Field Hospital to Ebola-Hit Liberia,” September 8, 2014.

White House, “Fact Sheet: U.S. Response to the Ebola Epidemic in West Africa,” September 16, 2014.

White House, “Fact Sheet: The U.S. Government’s Response to Ebola at Home and Abroad,” October 22, 2014.

Ibid.

White House, “Fact Sheet: U.S. Response to the Ebola Epidemic in West Africa,” October 6, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Human Resource Constraints

At the end of August, WHO estimated that it would take 13,000 health workers to contain the

Ebola outbreak.61 Although foreign governments and non-governmental organizations are

beginning to deploy medics and other health workers, their numbers are not sufficient to meet the

human resource demands. Human resource constraints are most acute in Liberia, where access to

Ebola care is the most limited. The United States has partnered with the Liberian government,

WHO, and other groups to develop a Community Care Campaign (see “WHO Community Care

Campaign”). Doctors Without Borders (known by its French acronym, MSF) has expressed

concern about the Community Care Campaign, asserting that the CCCs could turn into

“contamination centers” without strict infection control, adequate supplies, trained staff, regular

supervision, the ability to diagnose and refer patients, and proper burial methods.62 WHO

acknowledges that “any deficiencies in the quality of implementation could present major risk of

virus transmission within the CCC thus exacerbating a situation it is set out to address.”63 Key

factors that may complicate safe implementation of the Community Care Campaign include:

•

Quality control. Inconsistent adherence to infection control protocol is

reportedly contributing to EVD cases among health workers. The inability to

ensure disease infection, prevention, and control (IPC) protocols among trained

health personnel calls into question whether non-governmental organizations,

community health workers, and family members will adhere to IPC protocols.

This concern is particularly acute for lay personnel (like family members) who

may provide Ebola care in the CCCs.

•

Family care providers. To avoid the possible spread of EVD from familial

caretakers to other community members, WHO recommends that only one family

member provide care for each patient for the duration of their stay in the CCCs.

WHO specifies that the “family member providing supportive care to the patient

must not go back and forth between the CCC and the community.”64 However,

collective familial care of and close community interaction with the ill is

common in Liberia. It is unclear whether CCC supervisors will be able to curtail

this custom and ensure that only one family member provides care. Other factors,

including loss of income, separation of the caretaker from their uninfected family

members, or emotional stress from being in a CCC, might also discourage

compliance with WHO familial care guidelines.

•

Waste management and safe burial practices. IPC protocol requires that those

handling the soiled linen of EVD patients, cleaning the CCCs, or burying victims

of EVD wear personal protective equipment (PPE). Further, in order to prevent

the spread of EVD within CCCs, caretakers must follow strict protocol in using

PPE and managing waste (using only designated areas for waste disposal and

ensuring daily collection of human and PPE waste). The affected countries face

deficiencies in waste management. In 2012, less than 20% of people living in the

WHO, Ebola Response Roadmap, August 28, 2014, p. 24.

Lenny Bernstein and Lena Sun, “New effort to fight Ebola in Liberia would move infected patients out of their

homes,” Washington Post, September 22, 2014.

WHO, Key Considerations for the Implementation of an Ebola Care Unit at Community Level, September 2014.

Ibid.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

affected countries had access to improved sanitation facilities.65 It may be a

challenge ensuring strict adherence to IPC protocol among lay care takers

without medical training, particularly if they lack access to sanitation themselves.

•

Oversight. According to WHO, “monitoring and supervision is critical in

ensuring the success of the approach.”66 Most of the “low level community health

workers and members of the community” who will be tasked with providing care

in CCCs have never done so before. The Community Care Campaign calls for

once daily supervisory visits by at least one health care worker trained in IPC. It

remains to be seen whether once daily visits are enough to ensure compliance

with the IPC protocols, as well as others, including proper and consistent use of

PPE by care takers, launderers, burial team, and sanitation workers.

•

Supply chain management. Due to poor supply chain management practices,

many publicly funded health clinics in the affected countries face interruptions in

medical supplies and often lack commodities such as gloves, masks, and gowns.

A lack of protective equipment in ETUs and health clinics has been associated

with EVD infection among health workers.67 Lapses in protective gear in CCCs

can lead to unsafe practices, such as recycling or reusing existing PPE. It remains

to be seen whether WHO and its partners will be able to ensure the continuous

supply of commodities to disparate CCCs.

WHO recognizes the inherent risks of this effort and advises that Ministries of Health in the

affected countries “embark on this approach in an incremental manner starting with a few pilots

that are well monitored before taking it up to scale.”68

U.S. implementation of the Community Care Campaign is already underway. USAID is issuing

grants to non-governmental organizations to oversee the management of Community Care

Centers. The White House reports that the United States Government has already provided 9,000

community care kits in Liberia for use by individuals in their homes.69 NGOs generally have

autonomy over the implementation of USAID grants, and USAID oversees implementation to

ensure that program targets are met. Questions abound, however, about U.S. oversight and

implementation of this campaign, particularly regarding U.S. government oversight of grantees

managing CCCs and the standardization of quality control and IPC protocol.

Leadership of the International Outbreak Response

Observers have criticized WHO leadership over the global Ebola response. Some critics have

contended that budget cuts that began under WHO’s reform efforts have made the Organization

less effective and have limited its capacity to contain the outbreak.70 The 2014-2015 WHO

program budget called for a 51% reduction in outbreak and crisis response activities from 201265

World Bank database, accessed on October 1, 2014.

WHO, Key Considerations for the Implementation of an Ebola Care Unit at Community Level, September 2014.

For more on health infrastructure deficiencies, see Joseph Forrester et al., “Assessment of Ebola Virus Disease,

Health Care Infrastructure, and Preparedness-Four Counties, Southeastern Liberia, August 2014, Morbidity and

Mortality Weekly Report, October 7, 2014, volume 1, issue 3.

WHO, Key Considerations for the Implementation of an Ebola Care Unit at Community Level, September 2014.

White House, “Fact Sheet: The U.S. Government’s Response to Ebola at Home and Abroad,” October 6, 2014.

Sheri Pink, “Cuts at WHO Hurt Response to Ebola Crisis,” New York Times, September 3, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

2013 levels.71 Some observers maintain that earlier budget cuts have also crippled the agency by

reducing critical staff, causing the closure of the viral hemorrhagic fever unit, and undermining

operational capacity.72 Beyond budgetary constraints, some critics contended that WHO’s

response has been stymied by bureaucratic bloat and undue influence of underqualified staff who

attained their positions due to political relationships.73

Weak health systems in the affected countries, inadequate capacity of WHO to carry out its own

Ebola plans, as well as insufficient international responses to the outbreak have reignited debates

about whether WHO should function primarily as an advisory body or maintain some form of

operational capacity. Some analysts advocate for the establishment of a WHO-administered

“Health Systems Fund,” that could be used to both build long-term health system capacity, as

well as address short-term crises like the ongoing Ebola outbreak.74 While supporting the need for

a ready-to-deploy team of emergency health responders, others assert the “politics of

sovereignty” would preclude WHO from leading such an effort.75

U.S. Support for Ebola Responses and Health Systems

The speed at which EVD is spreading across West Africa is attributable, in large part, to weak

health systems in those countries. Donors have long grappled with how to address health

emergencies in light of dysfunctional health systems. In the early 2000s, donors turned to diseasebased funding and channeled health aid through non-governmental groups. Opponents of this

approach argued that disease-specific programs exacerbate human resource shortages in the

public sector and further weaken health systems when parallel bureaucracies are established and

government authorities are bypassed. Supporters assert that disease-based funding strengthens

oversight capacity and facilitates the monitoring and evaluation of the investments.

This debate intensified following the introduction of the President’s Emergency Plan for AIDS

Relief (PEPFAR).76 In an effort to curb the massive number of deaths that followed the

introduction of HIV/AIDS, U.S. agencies provided funding to large non-governmental

organizations and local partners who established care and treatment facilities outside of

government networks. While the effort helped save millions of lives and averted millions more

HIV infections, the United States became the sole supporter for millions of people worldwide

whose lives would be at risk should U.S. funding be discontinued. In the second phase of

PEPFAR (FY2009-FY2013), increasing portions of PEPFAR resources were used to support

WHO, Proposed Programme Budget 2014-2015, April 19, 2013, Sixty-Sixth World Health Assembly, A66/7.

Doctors Without Borders, “Ebola: the failures of the international outbreak response,” September 2, 2014. Stehpanie

Nebehay and Barbara Lewis, “WHO slashes budget, jobs in new era of austerity,” Reuters, May 19, 2011.

Jason Gale and John Lauerman, “How the World’s Top Health Body Allowed Ebola to Spiral Out of Control,”

Bloomberg, October 17, 2014; Lena Sun et al., “Out of Control: How the world’s health organization failed to stop the

Ebola disaster,” The Washington Post, October 4, 2014; and Associated Press, “World Health Organization admits

botching attempts to stop Ebola in West Africa,” October 17, 2014.

Lawrence Gostin, “West Africa’s Ebola Epidemic is Out of Control, But Never Had to Happen,” Briefing Paper

Number 9, August 20, 2014. For more on the possible structure and functions of the Global Health Fund, see Lawrence

Gostin and Eric Friedman, “Towards a Framework Convention on Global Health: A Transformative Agenda for Global

Health Justice,” Yale Journal of Health Policy, Law, and Ethics, (2013), volume 13, issue 1.

Jack Chow, “The Ultimate Ebola-Fighting Force,” Foreign Policy, September 10, 2014.

For more on PEPFAR, see CRS Report IF00042, The President’s Emergency Plan for AIDS Relief (PEPFAR):

Summary of Recent Developments (In Focus) and CRS Report R42776, The President’s Emergency Plan for AIDS

Relief (PEPFAR): Funding Issues After a Decade of Implementation, FY2004-FY2013, by (name redacted)

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

health systems in hopes of bolstering country capacity to assume ownership over HIV/AIDS

programs. Now in its third phase, debate on the use of PEPFAR funds for building health systems

has resumed. A 2013 GAO report noted that roughly 21% of PEPFAR funds were spent on

capacity building projects under the “other” budgetary category. At her confirmation hearing,

PEPFAR Country Coordinator Deborah Birx asserted that under her leadership, 50% of all

PEPFAR resources, including those funded through other accounts, would be spent on care and

treatment activities, as mandated. Health system advocates fear that budgetary reforms aimed at

adhering to the law may imperil efforts to bolster health systems.

The U.S. Congress faces a similar dilemma with the current Ebola outbreak. The affected

countries need focused support to contain and end this outbreak. If and when the outbreak is

arrested, however, the countries may not be in any better position to detect, prevent, or respond to

other potential disease outbreaks unless donors begin the arduous task of supporting the

development of strong health systems. Ken Isaacs, Vice President of International Programs and

Government Relations at Samaritan’s Purse, described this dilemma at an August 2014

congressional hearing on Ebola, stating “While it should be the goal of the developed world to

build capacity, the building of this capacity should not be the focus during times of an emergency

crisis of a deadly disease that threatens the international community.”77 USAID has reportedly

established an Ebola Health Systems Strengthening working group to support the resumption of

health care delivery and to bolster the health systems once the outbreak is contained.78

Though PEPFAR and other U.S.-funded health programs have attempted to respond to calls for

greater investment in health systems, no appropriations specifically targeting such efforts are

provided. Language in appropriations and accompanying conference reports direct the majority of

health aid to particular diseases, leaving minimal resources for broader activities to strengthen

health systems. The inability of the affected countries to respond to an unforeseen health event

may prompt Congress to review how global health funds are appropriated.

Evaluating U.S. Responses

A variety of U.S. agencies are responding to the ongoing Ebola outbreak. The Department of

State is leading diplomatic engagements; USAID is coordinating U.S. responses, including the

provision of financial and material support; CDC is heading public health and medical response

activities; and DOD is handling support for foreign armed forces. With the exception of USAID,

the budgetary structure of each of these agencies enables them to respond to this unanticipated

event by drawing from accounts that have flexible authorities. The Department of State’s efforts

to coordinate bilateral diplomatic engagements are conducted through existing channels (e.g.,

embassy contacts) and, as such, would not require additional, dedicated funding. Outbreak

responses by the CDC can be financed through USAID disaster assistance accounts, as well as

several CDC accounts that are used for domestic and international health efforts and for which

there is not explicit congressional direction on their use. The DOD budget also supports an array

of domestic and international health activities that do not receive detailed congressional direction.

U.S. Congress, House Committee on Foreign Affairs, Subcommittee on Africa, Global Health, Global Human Rights

and International Organizations, Combating the Ebola Threat, Testimony by Ken Isaacs, Vice President of

International Programs and Government Relations, Samaritan’s Purse, August 7, 2014

USAID, Investing in Health Systems to Address the Ebola Outbreak, September 30, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Congress has established numerous directives over the years on how foreign aid funds are to be

used. As the lead U.S. development agency, USAID often receives specific direction from

Congress on how the bulk of its funds will be used through annual appropriations, leaving the

agency with limited ability to address unanticipated events, like the current Ebola outbreak,

without drawing from ongoing health efforts. According to USAID, it is currently reprogramming

funds planned for preventing future outbreaks, as well as addressing ongoing outbreaks

(including responses to H7N9 avian influenza in China and MERS-CoV in the Middle East), to

address the current Ebola outbreak.79

Supporters of the current appropriation structure see it as a tool for overseeing health programs

and ensuring that congressional priorities are met. Opponents argue that congressional directives

encumber the agility that is needed in the field and create artificial segmentation of health and

development issues, thereby limiting the impact and sustainability of such efforts.

By their nature, disease outbreaks are often unpredictable, though with appropriate disease

surveillance, detection, and response mechanisms, their impact can be minimized. At present,

USAID pandemic preparedness efforts are focused on East and Central Africa, where previous

Ebola and influenza outbreaks have occurred, as well as South and Southeast Asia. Now that

Ebola has emerged in West Africa, another EVD outbreak may occur in the region; a scenario the

affected countries may be ill-prepared to handle. The FY2015 budget request ($50 million) for

pandemic preparedness is roughly 30% less than the FY2014 funding level ($73 million). Even if

Congress funds USAID pandemic preparedness programs at the FY2014 funding level, one

USAID official contends that it will not be enough to meet current demands.80

Addressing the Long-Term and Broader Effects of the Outbreak

Under the best of circumstances, experts predict that the outbreak can be contained by the end of

January. In the meantime, the high death tolls are disrupting social structures and may cause

broad, long-term effects in the region. MSF has reported that some affected villages in Sierra

Leone have lost the majority of adult community members, leaving vulnerable populations—such

as children and the elderly—without resources to cultivate agricultural land and procure food.81

Observers are also concerned about a growing number of children who are being orphaned from

Ebola. This group is particularly vulnerable to marginalization due to overwhelming fear of the

virus. Countries in West and Central Africa already had large orphan populations due to a variety

of causes including armed conflict and HIV/AIDS. In 2012, some 28 million children were

orphaned in the region, of whom more than 4 million lost one or more parent to AIDS.82 The

outbreak is also hindering the capacity of these governments to address other health issues, such

as obstetrical complications. Experts are concerned that child and maternal mortality rates,

already high in the region, may further rise due to diminishing numbers of health personnel

(caused both by Ebola deaths and abandonment of posts), diversion of limited resources to Ebola

treatment centers, and public avoidance of health centers.

CRS correspondence with USAID, August 5, 2014.

Ibid.

USAID, West Africa Ebola Outbreak—Update # 5, August 18, 2014.

UNICEF, Towards an AIDS-Free Generation Children and AIDS: Sixth Stocktaking Report, 2013.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

The full health effects of the Ebola outbreak may not be known until it is contained. An

accounting of broader health and development needs will likely ensue and may rekindle debate

over how U.S. global health assistance funds are apportioned. Congress is likely to face

arguments from advocates from a variety of actors attempting to garner support for a bevy of

health and development issues that will have likely worsened in the wake of Ebola, including

maternal and child mortality, child vulnerability and orphanhood, poverty, food scarcity, and

water-borne infections.

Considering Research and Development Needs

Since 1976, several Ebola outbreaks have erupted in sub-Saharan Africa, yet therapeutic options

remain undeveloped. There is no specific cure, treatment, or vaccine for Ebola, nor or is there any

post-exposure prophylaxis for health workers who face regular exposure. Treatment of EVD

symptoms increases the probability of survival. Several experimental specific treatments and

vaccines are beginning clinical trials to determine their safety and efficacy. The appropriate use of

experimental drugs that have not been tested for human safety and effectiveness has become a

matter of debate, particularly around the issue of equity.

A global health lawyer described the ensuing debate. “Should [U.S.] workers receive a drug in

extremely scarce supply when Africans are affected in far greater numbers? Balanced against this

sense of injustice is the ethical concern of administering an experimental drug to African patients

that has not undergone any safety testing in humans.”83 In addition, if the experimental drugs are

ineffectual or cause serious side effects, then their use may further exacerbate mistrust in

healthcare workers and modern medical treatments. WHO held a special meeting in August on

the topic and announced that under “the particular circumstances of th[e] outbreak, and provided

certain conditions are met ... it is ethical to offer unproven interventions with as yet unknown

efficacy and adverse effects, as potential treatment or prevention.”84

In October, press reports indicated that WHO planned to begin testing two Ebola vaccines in

January on some 20,000 health workers and other volunteers. The organization also indicated that

a limited amount of an experimental treatment might be available for use in Liberia by early

November.85 At the end of October, WHO convened a meeting “with high-ranking government

representatives from Ebola-affected countries and development partners, civil society, regulatory

agencies, vaccine manufacturers and funding agencies yesterday to discuss and agree on how to

fast track testing and deployment of vaccines in sufficient numbers to impact the Ebola

epidemic.”86 Once the trials commence, debates about ethical practices will likely ensue,

particularly if trial participants die or experience other adverse reactions.

Lawrence Gostin et al., “The Ebola Epidemic: A Global Health Emergency,” JAMA, (August 11, 2014).

WHO, “Ethical considerations for use of unregistered interventions for Ebola viral disease (EVD),” WHO statement,

August 12, 2014.

The Guardian, “WHO aims for Ebola serum in weeks and vaccine tests in Africa by January,” September 22, 2014.

WHO, “WHO convenes industry leaders and key partners to discuss trials and production of Ebola vaccine,” news

release, October 24, 2014.

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U.S. and International Health Responses to the Ebola Outbreak in West Africa

Conclusion

In an August 29, 2014 report, WHO warned that bordering countries, namely Benin, Burkina

Faso, Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal, were “at risk” of seeing Ebola cases.87 On

October 23, 2014, Mali reported its first Ebola case and health officials suspect that cases may

exist in other neighboring countries. WHO is reportedly helping neighboring countries to build

EVD surveillance, preparedness and response plans. An Oxford University study concluded that

some 22 million people across Central and West Africa live in forested areas where one of the

suspected vectors (fruit bats) resides,88 raising concerns among some that future Ebola outbreaks

may occur in the region and other parts of sub-Saharan Africa. The article notes that “changes in

human mobility and connectivity will likely have profound impacts on the dispersion of Ebola cases.”

Prospects for future Ebola outbreaks in urban areas and in countries with limited pandemic

preparedness capacity raise several questions, including:

•

Is the U.S. response to the Ebola outbreak effective?

•

Does the United Stated sufficiently support pandemic preparedness efforts?

•

Does disease-specific funding encumber pandemic preparedness efforts?

•

Will the reprogramming of USAID funds to address the Ebola outbreak impact

ongoing global health and development programs?

•

Are ongoing outbreak responses by the U.S. and international improving the

capacity of the affected countries, as well as others in the region, to identify,

detect, and respond to future outbreaks?

Author Contact Information

(name redacted)

Specialist in Global Health

[redacted]@crs.loc.gov, 7-....

WHO, WHO: Ebola Response Roadmap Situation Report 1, August 29, 2014.

David Pigott et al., “Mapping the zoonotic niche of Ebola virus disease in Africa,” Elife, (September 7, 2014).

Congressional Research Service

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