Ranu S Dhillon

Global health security: the wider lessons from the west African Ebola virus disease epidemic

Summary The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security—its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including WHO reform, it will be important to distil lessons learned from the Ebola outbreak. The Lancet invited a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for next steps. Their contributions describe some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed. Their common goal is a more sustainable and resilient society for human health and wellbeing.

5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting

Introduction Despite decades of experience with community health workers (CHWs) in a wide variety of global health projects, there is no established conceptual framework that structures how implementers and researchers can understand, study and improve their respective programs based on lessons learned by other CHW programs. Objective To apply an original, non-linear framework and case study method, 5-SPICE, to multiple sister projects of a large, international non-governmental organization (NGO), and other CHW projects. Design Engaging a large group of implementers, researchers and the best available literature, the 5-SPICE framework was refined and then applied to a selection of CHW programs. Insights gleaned from the case study method were summarized in a tabular format named the ‘5×5-SPICE chart’. This format graphically lists the ways in which essential CHW program elements interact, both positively and negatively, in the implementation field. Results The 5×5-SPICE charts reveal a variety of insights that come from a more complex understanding of how essential CHW projects interact and influence each other in their unique context. Some have been well described in the literature previously, while others are exclusive to this article. An analysis of how best to compensate CHWs is also offered as an example of the type of insights that this method may yield. Conclusions The 5-SPICE framework is a novel instrument that can be used to guide discussions about CHW projects. Insights from this process can help guide quality improvement efforts, or be used as hypothesis that will form the basis of a programs research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested. This paper is part of the thematic cluster Global Health Beyond 2015 - more papers from this cluster can be found at http://www.globalhealthaction.net

Community Trust and the Ebola Endgame

In May, Ebola resurfaced in parts of Guinea thought to be free from the virus. Some infections in known hot spots arise from unknown transmission chains, which suggests that other cases may be hidden. Only by building community trust can we bring the epidemic to an end.

Addressing the "Global Health Tax" and "Wild Cards": Practical Challenges to Building Academic Careers in Global Health.

Among many possible benefits, global health efforts can expand the skills and experience of U.S. clinicians, improve health for communities in need, and generate innovations in care delivery with relevance everywhere. Yet, despite high rates of interest among students and medical trainees to include global health opportunities in their training, there is still no clear understanding of how this interest will translate into viable and sustained global health careers after graduation. Building on a growing conversation about how to support careers in academic global health, this Perspective describes the practical challenges faced by physicians pursuing these careers after they complete training. Writing from their perspective as junior faculty at one U.S. academic health center with a dedicated focus on global health training, the authors describe a number of practical issues they have found to be critical both for their own career development and for the advice they provide their mentees. With a particular emphasis on the financial, personal, professional, and logistical challenges that young “expat” global health physicians in academic institutions face, they underscore the importance of finding ways to support these career paths, and propose possible solutions. Such investments would not only respond to the rational and moral imperatives of global health work and advance the mission of improving human health but also help to fully leverage the potential of what is already an unprecedented movement within academic medicine.

Community health worker programmes after the 2013–2016 Ebola outbreak

The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security.1 Chronically fragile and under-resourced health systems2 enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016)3 in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating.4 Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services.1 Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.

Containing Zika while we wait for a vaccine

Develop point-of-care diagnostics to target behavior change and prevent spread

Outsourcing: how to reform WHO for the 21st century

### Summary box #### What is already known about this topic? #### What are the new findings? #### Recommendations for policy The Ebola epidemic has drawn unprecedented attention to the WHO and its deficiencies.1–3 However, WHOs shortcomings are not limited to its mishandling of Ebola alone and extend more widely. Checchi et al 4 highlight fundamental challenges in terms of structure, governance and prioritisation of political considerations. In addition, Laurie Garrett of the Council on Foreign Relations states that “WHO has struggled to remain credible, as its financial resources have shrunk, tensions have grown between its Geneva headquarters and its regional offices”.3 The size and scope of the WHO lead to considerable management challenges with a senior member of the Organization lamenting “I think it may be one of the most complex organizations that exists”.5 Others have noted that the organisation lacks the confidence of donors amidst continuing underperformance.6 In a number of recent reports and esteemed panels, including the Harvard-LSHTM Independent Panel on the Global Response to Ebola, the need for fundamental and extensive reform of the WHO has been made clear.1 ,5 ,7 The institutional failures of the WHO have serious consequences for global health as evidenced not only by shortcomings in the Ebola response but also in Sri Lanka in 2009, Haiti in 2010, South Sudan in 20134 and …

Overlooking the importance of immunoassays

We share the enthusiasm shown in the Personal View by Lieselotte Cnops and colleagues for the development of fi lovirus assays that “are rapid, precise, easy to implement in resource-limited settings, and sufficiently robust to operate under outbreak conditions”. However, in advocating for point-ofcare nucleic acid tests (NATs), we think the authors overlook the importance of immunoassays as a diagnostic tool and as a complement to NATs in future outbreaks. First, their statement that “nucleic acid detection is...the most common procedure for diagnosing viral diseases” is not consistent with our experience. Immunoassays are over whelmingly the front-line method for detecting HIV, Epstein-Barr, dengue, hepatitis C, infl uenza, and most other viruses. Quantitative NATs are crucial for managing HIV and Epstein-Barr virus infections under certain circumstances as noted by the authors, but are not the mainstay of initial diagnosis. Second, Cnops and colleagues posit that Ebola rapid diagnostic tests (RDTs) “have low sensitivity and specificity.” In two field studies during the 2013–16 Ebola virus disease outbreak, RDTs had sensitivity of 100% and specifi city of 92%, though these results were questioned because of the imperfect performance of the gold standard PCR. A recent fi eld trial of another Ebola RDT conducted by the US Centers for Disease Control and Prevention found that the test was 100% specifi c. Ebola RDT sensitivity might not be perfect, but even the most pessimistic estimates of their effectiveness are better than WHO’s case defi nition, which is only 31·5% specific. As Zachariah and Harries note, “68% of patients who would be selected for admission to a holding unit would not actually have Ebola virus disease”. Even immunoassays with lower sensitivity, such as those for dengue virus (uniformly below 90%), are important in diagnosis. Third, NAT deployment in resourcelimited settings and outbreak conditions can be a challenge because of the poor laboratory infrastructure and access to reliable electricity. There are also serious problems associated with supply chain, technical support, and repair that could be mitigated by automated NATs such as the GeneXpert MTB/RIF test for tuberculosis, although their implemen tation remains constrained by high costs and the need for specialised personnel. Consequently, immunoassays remain the preferred diagnostic platform for malaria, HIV, dengue, and other diseases prevalent in Africa and other developing countries. In addition to performance, usability and price need to be primary factors when considering the design and development of diagnostics.

The Blind Men and the Elephant — Aligning Efforts in Global Health

Aligning Efforts in Global Health Should we pursue global health initiatives to ensure health security, promote development, or achieve health equity as a human right? Perhaps we can delineate actionable issues incorporating key priorities from each perspective and integrate diverse activities.

Authors' response — WHO must prioritise its roles and then be positioned and supported to execute effectively

We are pleased to see that our article has incited debate and discussion. While the responses reflect a wide range of perspectives, what is clear is that there is a need for fundamental reform in how WHO is organised and functions. And, while we offer thoughts on how this could be carried out, we are less inclined to ‘sell a solution’ than we are to ‘solve a problem.’ Any approach to WHO reform will undoubtedly entail imperfect trade-offs which can best be understood and navigated for the overall greatest good through critical discussion from a wide range of perspectives as offered by the respondents. Each response offers important insights and criticisms that serve to further and deepen …