Correspondence
Containment in Sierra Leone: the inability of a state to confront Ebola? The present Ebola virus disease outbreak is spreading across west African nations with alarming rapidity.1,2 As of Sept 21, the total number of recorded cases has soared to 6263, with 2917 deaths. 1 The situation is very likely to continue to worsen when the affected countries witness the exhaustion of their capacities to respond to a threat of this magnitude, and because massive international assistance is still sorely lacking on the ground.2–5 With the objective to put newly infected people into quarantine and to limit the virus’ spread, the government authorities of Sierra Leone decided to impose an unprecedented containment, ordering the nation’s 6·2 million inhabitants to stay at home for three full days, from Sept 19 to 21, with a patrol force of 7000 teams making door-to-door visits to detect possible Ebola victims. Although containment would at first appear to be an easily enacted and economical strategy, its implementation has proven to be more complex, for several reasons. First, how can the entire population of a country, the territory of which extends over more than 70 000 km², be confined while many services must be maintained? Decreeing such an obligation within even a smaller area can be difficult. Attempts to place the West Point slum in Morovia, Liberia into quarantine, at the end of August, exemplified this difficulty. Communication has a crucial role among the challenges presented by the size of the country. How could information be conveyed to the entire population, including the most remote rural areas, which haven’t been taken into account since the beginning of the outbreak?4 In order for the people to accept containment, www.thelancet.com Vol 384 October 4, 2014
it is necessary that they understand and accept the reasoning behind such measures. Moreover, containment efforts are difficult to implement. Homes and shelters are of paramount importance. Consequently, in a country where access to basic infrastructure is far from widespread, can people truly be expected to remain confined in their homes for three days without needing to be resupplied with basic necessities such as water? In a country where more than half of the population lives on less than US$1·25 per day, how can the government expect to contain all those for whom having food on the table at night depends on that day’s labour? How can containment be imposed on a rural population who are engaged in agricultural activities, in the middle of the crop harvest? Such practical issues transform into numerous preoccupations that make people apathetic to the authorities’ instructions. Mandating containment at such a large scale raises many questions. The purpose of these efforts could well be to send a political message to reassure the population by creating the illusion that the authorities have the ability to control a major crisis on the scale of the current Ebola outbreak. We declare no competing interests.
*Pierre Ozer, Aline Thiry, Catherine Fallon, Julia Blocher, Florence de Longueville [email protected] Department of Environmental Sciences and Management, University of Liege, Arlon, Belgium (PO); Spiral, University of Liege, Liege, Belgium (AT, CF); Center for Ethnic and Migration Studies, University of Liege, Liege, Belgium (JB, FdL) 1
2
3
WHO. Ebola Response Roadmap Situation Report 24 Sept 2014. http://apps.who.int/iris/ bitstream/10665/134771/1/ roadmapsitrep_24Sept2014_eng.pdf?ua=1 (accessed Sept 25, 2014). Philips M, Markham A. Ebola: a failure of international collective action. Lancet 2014; published online Sept 10. http://dx.doi.org/ 10.1016/S0140-6736(14)61606-8. Chan M. Ebola virus disease in west Africa—No early end to the outbreak. N Engl J Med 2014; published online Aug 20. http://dx.doi. org/10.1056/NEJMp1409859.
4
5
Wolz A. Face to face with Ebola—An emergency care center in Sierra Leone. N Engl J Med 2014; 371: 1081–83. Ansumana R, Bonwitt J, Stenger DA, Jacobsen KH. Ebola in Sierra Leone: a call for action. Lancet 2014; 384: 303.
Elections could rekindle health debate in Brazil Michael Kepp’s World Report1 on the upcoming elections in Brazil makes some ill-conceived assertions. Compared with other countries of its size, Brazil has made the most significant progress towards universal health coverage. Spending “a mere 3·5% of the federal budget” 1 to achieve this should not be cause to criticise Brazil’s policies, but rather an opportunity to applaud them for nearly eliminating catastrophic health expenditures2 and achieving unparalleled gains in health outcomes 3–5 with small budgets. Public consternation suggests, not underfunded services, but the collective ambition to even further expand the primary care system that has already reached well over half the population in only a little over 2 decades.5 The next challenge will be to bring that same innovative approach to secondary and tertiary care. Debate of issues around health in the run-up to election periods does not, in and of itself, indicate weaknesses and fractures in Brazil’s health reforms, but instead, a healthy democratic process. Health-care reform in Brazil is a process that has entailed political struggles by a broad health movement entwined with democratisation.6 The More Doctors programme is an emergency measure to address gaps in doctor supply, but the government has also taken other bold steps to address this. They have supported the integration of curricula with primary care services in medical schools; developed new residency programmes in primary care; improved professional accreditation for family doctors; and have
Published Online September 25, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61594-4
Published Online September 29, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61637-8
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
e47
Correspondence
introduced the world’s largest pay for performance programme, which has already increased funding to primary care services by 106% since 2010. Although the Brazilian public health-care system still needs improved resourcing, Kepp’s synthesis of the current context in Brazil, based largely on the experiences of just one region, is an oversimplification that can give the impression of a health system in chaos. Instead it is a health system in rapid expansion, in pursuit of equitable, comprehensive health care for all, and it should be judged on scientific evidence. We declare no competing interests.
Fabiana C Saddi, *Matthew Harris, Raquel Abrantes Pego, Sandro Rodrigues Batista, James Macinko [email protected] Faculty of Social Sciences, Federal University of Goias, Goiânia, Brazil (FBC, SRB); New York University, NY 10003, USA (MH, JM); Imperial College London, London, UK (MH); National Network of Research in Health Policy/CNPq, Brasilia, Brazil (RAP) 1
2
3
4
5
6
e48
Kepp M. Upcoming election could rekindle health debate in Brazil. Lancet 2014; 438: 651–52. Knaul FM, Wong R, Arreola-Ornelas H, Méndez O, for the Network on Health Financing and Social Protection in Latin America and the Caribbean (LANET). Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries. Salud Publica Mex 2011; 53: s85–95. Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto M. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014; 349: g4014. Macinko J, Dourado I, Aquino RM, et al. Major expansion of primary care in Brazil linked to decline in unnecessary hospitalization. Health Aff (Millwood) 2010; 29: 2149–60. Macinko J, Lima-Costa MF. Horizontal equity in health care utilization in Brazil, 1998–2008. Int J Equity Health 2012; 11: 33. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377: 1778–97.
www.thelancet.com Vol 384 October 4, 2014
Containment in Sierra Leone: the inability of a state to confront Ebola? The present Ebola virus disease outbreak is spreading across west African nations with alarming rapidity.1,2 As of Sept 21, the total number of recorded cases has soared to 6263, with 2917 deaths. 1 The situation is very likely to continue to worsen when the affected countries witness the exhaustion of their capacities to respond to a threat of this magnitude, and because massive international assistance is still sorely lacking on the ground.2–5 With the objective to put newly infected people into quarantine and to limit the virus’ spread, the government authorities of Sierra Leone decided to impose an unprecedented containment, ordering the nation’s 6·2 million inhabitants to stay at home for three full days, from Sept 19 to 21, with a patrol force of 7000 teams making door-to-door visits to detect possible Ebola victims. Although containment would at first appear to be an easily enacted and economical strategy, its implementation has proven to be more complex, for several reasons. First, how can the entire population of a country, the territory of which extends over more than 70 000 km², be confined while many services must be maintained? Decreeing such an obligation within even a smaller area can be difficult. Attempts to place the West Point slum in Morovia, Liberia into quarantine, at the end of August, exemplified this difficulty. Communication has a crucial role among the challenges presented by the size of the country. How could information be conveyed to the entire population, including the most remote rural areas, which haven’t been taken into account since the beginning of the outbreak?4 In order for the people to accept containment, www.thelancet.com Vol 384 October 4, 2014
it is necessary that they understand and accept the reasoning behind such measures. Moreover, containment efforts are difficult to implement. Homes and shelters are of paramount importance. Consequently, in a country where access to basic infrastructure is far from widespread, can people truly be expected to remain confined in their homes for three days without needing to be resupplied with basic necessities such as water? In a country where more than half of the population lives on less than US$1·25 per day, how can the government expect to contain all those for whom having food on the table at night depends on that day’s labour? How can containment be imposed on a rural population who are engaged in agricultural activities, in the middle of the crop harvest? Such practical issues transform into numerous preoccupations that make people apathetic to the authorities’ instructions. Mandating containment at such a large scale raises many questions. The purpose of these efforts could well be to send a political message to reassure the population by creating the illusion that the authorities have the ability to control a major crisis on the scale of the current Ebola outbreak. We declare no competing interests.
*Pierre Ozer, Aline Thiry, Catherine Fallon, Julia Blocher, Florence de Longueville [email protected] Department of Environmental Sciences and Management, University of Liege, Arlon, Belgium (PO); Spiral, University of Liege, Liege, Belgium (AT, CF); Center for Ethnic and Migration Studies, University of Liege, Liege, Belgium (JB, FdL) 1
2
3
WHO. Ebola Response Roadmap Situation Report 24 Sept 2014. http://apps.who.int/iris/ bitstream/10665/134771/1/ roadmapsitrep_24Sept2014_eng.pdf?ua=1 (accessed Sept 25, 2014). Philips M, Markham A. Ebola: a failure of international collective action. Lancet 2014; published online Sept 10. http://dx.doi.org/ 10.1016/S0140-6736(14)61606-8. Chan M. Ebola virus disease in west Africa—No early end to the outbreak. N Engl J Med 2014; published online Aug 20. http://dx.doi. org/10.1056/NEJMp1409859.
4
5
Wolz A. Face to face with Ebola—An emergency care center in Sierra Leone. N Engl J Med 2014; 371: 1081–83. Ansumana R, Bonwitt J, Stenger DA, Jacobsen KH. Ebola in Sierra Leone: a call for action. Lancet 2014; 384: 303.
Elections could rekindle health debate in Brazil Michael Kepp’s World Report1 on the upcoming elections in Brazil makes some ill-conceived assertions. Compared with other countries of its size, Brazil has made the most significant progress towards universal health coverage. Spending “a mere 3·5% of the federal budget” 1 to achieve this should not be cause to criticise Brazil’s policies, but rather an opportunity to applaud them for nearly eliminating catastrophic health expenditures2 and achieving unparalleled gains in health outcomes 3–5 with small budgets. Public consternation suggests, not underfunded services, but the collective ambition to even further expand the primary care system that has already reached well over half the population in only a little over 2 decades.5 The next challenge will be to bring that same innovative approach to secondary and tertiary care. Debate of issues around health in the run-up to election periods does not, in and of itself, indicate weaknesses and fractures in Brazil’s health reforms, but instead, a healthy democratic process. Health-care reform in Brazil is a process that has entailed political struggles by a broad health movement entwined with democratisation.6 The More Doctors programme is an emergency measure to address gaps in doctor supply, but the government has also taken other bold steps to address this. They have supported the integration of curricula with primary care services in medical schools; developed new residency programmes in primary care; improved professional accreditation for family doctors; and have
Published Online September 25, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61594-4
Published Online September 29, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61637-8
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
e47
Correspondence
introduced the world’s largest pay for performance programme, which has already increased funding to primary care services by 106% since 2010. Although the Brazilian public health-care system still needs improved resourcing, Kepp’s synthesis of the current context in Brazil, based largely on the experiences of just one region, is an oversimplification that can give the impression of a health system in chaos. Instead it is a health system in rapid expansion, in pursuit of equitable, comprehensive health care for all, and it should be judged on scientific evidence. We declare no competing interests.
Fabiana C Saddi, *Matthew Harris, Raquel Abrantes Pego, Sandro Rodrigues Batista, James Macinko [email protected] Faculty of Social Sciences, Federal University of Goias, Goiânia, Brazil (FBC, SRB); New York University, NY 10003, USA (MH, JM); Imperial College London, London, UK (MH); National Network of Research in Health Policy/CNPq, Brasilia, Brazil (RAP) 1
2
3
4
5
6
e48
Kepp M. Upcoming election could rekindle health debate in Brazil. Lancet 2014; 438: 651–52. Knaul FM, Wong R, Arreola-Ornelas H, Méndez O, for the Network on Health Financing and Social Protection in Latin America and the Caribbean (LANET). Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries. Salud Publica Mex 2011; 53: s85–95. Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto M. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014; 349: g4014. Macinko J, Dourado I, Aquino RM, et al. Major expansion of primary care in Brazil linked to decline in unnecessary hospitalization. Health Aff (Millwood) 2010; 29: 2149–60. Macinko J, Lima-Costa MF. Horizontal equity in health care utilization in Brazil, 1998–2008. Int J Equity Health 2012; 11: 33. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377: 1778–97.
www.thelancet.com Vol 384 October 4, 2014
