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Ebola funding needs to spur health services and research capacity in the worst hit nations, writes Linda Nordling.
This year’s widespread outbreak of Ebola led to the international community releasing unprecedented levels of funding for emergency health services and research.
The response has targeted the three West African countries in which the virus has claimed thousands of lives so far: Liberia, Sierra Leone and Guinea.
“As it stands, there appears to be worrying signs that local researchers have been left behind in the scientific effort to curb Ebola.”
On the research side, studies of vaccines and therapeutic drugs have been fast-tracked by funders, and safety trials of new drugs are either underway or about to start in African countries, including those most affected by the disease.
However, it is important to monitor how this money will be distributed. As it stands, there appears to be worrying signs that local researchers have been left behind in the scientific effort to curb Ebola.
In September, six months into Liberia’s Ebola outbreak, the University of Liberia-Pacific Institute for Research and Evaluation (UL-PIRE) Africa Center in Monrovia, Liberia, was somewhat moribund.
The epidemic, which had been gnawing away at the country’s already dilapidated health system, had led to the closure of public institutions. There was temporary skill loss as foreign researchers working in the country returned home to wait out the epidemic in safety.
Research supplies were becoming more expensive with transport in and out of the country being problematic. The UL-PIRE Africa Center had had to shelve a survey it was undertaking of traffic accidents, and postpone funding applications for other projects in its pipeline.
Since September Stephen Kennedy, the centre’s principal investigator has tried to plug into the growing clinical and health service delivery research targeting Ebola. To date he hasn’t succeeded in obtaining any of his own grants. A study funded by the Wellcome Trust, and led by a researcher from the University of Oxford in the United Kingdom, has started in the country, however. Kennedy is the local principal investigator for the project—but his research centre will not have a role.
Kennedy’s problem exemplifies a new type of inequality in Africa; growing support for global health has seen vast sums of money pumped into African health systems, but this support has not benefited all countries equally.
This has led to a situation whereby researchers in some countries — Kenya, say, or Ghana — which have enjoyed a lot of support so far are in a better position to make use of funding boosts for public health research from international donors than other countries.
“The Ebola epidemic in West Africa is a tragedy of epic proportions. But the investments flowing into Ebola research present an opportunity to build up some of Africa’s weakest health systems.”
The programme with the most profound effect in this respect is arguably the United States President's Emergency Plan for AIDS Relief (PEPFAR). Over the past decade PEPFAR has spent over US$50 billion on HIV/AIDS treatment, prevention and care in developing countries, with a lot of it ending up in Africa. 
Because of its size, PEPFAR has had a noticeable effect on health systems in the countries where it has been active over and above just dealing with the HIV/AIDS epidemic.
Indeed, countries where PEPFAR has had a strong presence since the start such as the Democratic Republic of Congo and Nigeria , were able to contain their Ebola flare-ups this year, although it may be difficult to scientifically establish direct influence of such funding on the virus’ control.
The worst hit countries — Guinea, Liberia and Sierra Leone — have not been regular recipients of PEPFAR funding, aside from US$500,000 spent annually on tuberculosis diagnosis in Sierra Leone’s laboratories in recent years.  Compared with the tens and hundreds of millions of dollars PEPFAR spent in the Democratic Republic of Congo and Nigeria respectively in 2013 alone, the former figure is small fry.
Experts have also blamed limited poor health systems as a key factor in the way Ebola could spread in Liberia, Guinea and Sierra Leone. One of the contributors of this situation could be the marginal role these countries have had in programmes such as PEPFAR.
There is clearly more to it than that. Mali and Senegal are not huge recipients of PEPFAR funding, but have been able to contain their Ebola outbreaks. But both Senegal and Mali have better research capacity than Sierra Leone, Liberia and Guinea. Accordingly, they are among the countries that will conduct human safety trials of new Ebola vaccines. 
So what drives this unequal distribution of research and health systems support? Guinea, Liberia and Sierra Leone all have relatively low rates of HIV in their populations, which make them less of a target for PEPFAR. Liberia and Sierra Leone also emerged from devastating civil wars only a decade ago, which decimated their healthcare systems.
Development support and research funding to Africa also often goes to countries that the funders already have established relationships with, perhaps based on old colonial ties, or issues to do with a country’s record in observing human rights.
Current pathways for distributing funding pose a problem, says Rose Leke, an immunologist from the University of Yaounde 1 in Cameroon. Earlier this month, at the launch of the second phase of the European & Developing Countries Clinical Trials Partnership in Cape Town, South Africa, she reiterated a message she first articulated in an article published in The Lancet in 2010.  She said that donors are not always present in the countries that need them the most.
Investing in the future
Leke’s wisdom rings true in Ebola’s ability to ravage countries with weak health systems where international programmes such as PEPFAR have not had a big presence.
That should not belittle these programmes’ achievements in Africa. However, it forms the basis of a cruel irony whereby scientists such as Kennedy in Monrovia sit on their hands while the rest of the world scrambles to study a disease occurring in his own backyard.
Kennedy himself believes he and his colleagues have much to offer the fight against Ebola, especially when it comes to conducting operational research that can inform policy decisions and treatment programmes on the ground.
His story should persuade funders and aid organisations working on Ebola to make sure they do not leave the local research community behind as they roll out their studies in the region over the coming months and years.
The Ebola epidemic in West Africa is a tragedy of epic proportions. But the investments flowing into Ebola research present an opportunity to build up some of Africa’s weakest health systems.
Doing so will not raise the dead from their graves, but it will certainly save lives next time around.
This article has been produced by SciDev.Net's Sub-Saharan Africa desk.
 US State Department Overview fact sheet — PEPFAR (PEPFAR, 2014)
 US State Department PEPFAR dashboards (PEPFAR, 2014)
 US State Department Background briefing on UNAIDS and PEPFAR (US Bureau of Public Affairs, 2014)
 World Health Organisation WHO Ebola R&D effort — vaccines, therapies, diagnostics (WHO, 2014)
 Rose Leke Global health governance — the response to infectious diseases (The Lancet, 2010)