Global efforts to contain emerging pathogens will continue to fail, and pathogens will continue to have a field day, as long as some countries shirk their responsibilities and others annex responsibilities that aren't rightfully theirs. Clear and distinct roles must be defined for both developed and developing countries and, crucially, each country must be held accountable for lapses in performing its defined role.
In Round Two, Louise Bezuidenhout and Chandre Gould discussed the concerns about national capacities in disease surveillance and response that Maria José Espona and I, separately, had earlier raised. Bezuidenhout and Gould noted that concerns about capacity are "addressed to a large extent in the 2005 International Health Regulations." These regulations, as Bezuidenhout and Gould wrote, require states to "develop minimum core public health capacities." But in 2011, six years after the regulations were agreed upon, the World Health Organization reported that only 32 percent of African countries had established legislation in support of the regulations. Only 33 percent had established the capacities in human resources necessary for implementing the regulations.
Meanwhile, Africa's perennial weakness in surveillance and reporting is demonstrated by an ongoing Ebola outbreak in Guinea. The first case in the outbreak appeared no later than December 2013 but Guinea did not notify the World Health Organization until March 2014. This represents no improvement over the Ebola outbreak that 19 years ago struck Kikwit, in the Democratic Republic of Congo (then Zaire). At that time, the interval between the outbreak and the notification of health authorities was about three months. When it comes to improvements in rapid response to pathogens, Africa has remained in the slow lane.
What's responsible for this inability to rapidly contain emerging pathogens? In addition to corruption, and the failure to prioritize health issues—themes I addressed in Round Two—many developing countries seem to have settled into a condition of dependency regarding health and emerging pathogens. Developed countries, meanwhile, have a tendency to cling to sovereign control of disease surveillance processes. One example should illuminate my point.
During the 1995 outbreak of Ebola in Kikwit, an international study team led by the World Health Organization was on hand to help contain the epidemic. At the closing ceremony, a discussion took place about how to disburse the funds that countries around the world (a few of them African) had donated to control the epidemic. I suggested that some of the money be used to upgrade a laboratory in Kinshasa that the French government had begun to construct but subsequently abandoned. Upgrading the laboratory would have enhanced African scientists' capacity to provide support for disease surveillance and would have enabled them to handle dangerous pathogens on their own. Without improved laboratory support, as I explained, any African country undergoing a future Ebola epidemic would have to call for external help, which would work to the detriment of local scientists. No one present, whether from a developing or developed country, took my suggestion or my prediction seriously. Since then, Africa has experienced over a dozen outbreaks of Ebola; the affected countries have included Gabon, Sudan, Uganda, and now Guinea. Africa has been unable to contain any of these outbreaks without resort to international aid. In 1995, African countries missed an opportunity to "own" the processes of disease surveillance. Developed countries missed a chance to surrender their control.
It isn't that Africa has made no progress. Rather, progress has been too slow and too fragile. When the continent has registered successes, they've usually been built on a foundation of assistance from international agencies—assistance that comes with time limits.
African and other developing countries must wake up from their dependency stupor regarding health, including disease surveillance and prevention. African countries must make more vigorous efforts to develop the core capacities required under the International Health Regulations—and countries that don't meet their agreed targets should face sanctions. Unfortunately, the International Health Regulations don't allow for sanctions or other accountability measures. But, for example, travel restrictions could be imposed on individuals from countries where certain diseases are endemic. But above all, each African country must commit its resources to ensuring appropriate surveillance for emerging and re-emerging pathogens. Meanwhile, developed countries should ease off on the dominance, on their control of the processes of global disease surveillance. Only then can developing countries truly "own" these processes.