Which deaths (should) count in a Global Health Epidemic? – by Laura Sochas
By Laura Sochas
The 2014-15 West African Ebola outbreak was the deadliest outbreak of viral haemorrhagic fever in history, killing more than 11,300 people, including nearly 4,000 people in Sierra Leone. It took hold in three countries with extremely weak health systems, and this, combined with failures in international, national and sub-national leadership, led it to claim many more lives than it should have.
The extent of this impact, however, went far beyond the number of lives claimed directly by the virus. Our team estimated  that in Sierra Leone, in the year following the start of the outbreak, over 550 women and 2,150 newborns lost their lives and nearly 900 babies were stillborn, due to diminished access to essential services such as contraception, antenatal care, delivery services and postnatal care. In other words, nearly as many lives as were lost to Ebola directly. Other authors have estimated  that as many as 2,800 excess deaths were caused by malaria, HIV/AIDS and tuberculosis during the outbreak in Sierra Leone.
None of these estimated deaths were caused by the disease in question being aggravated by the Ebola virus. Instead, they occurred because people were unable to access the life-saving care they needed as a consequence of available clinics being unsafe, because they were turned away due to lack of space or for fear of infection, or because available clinics were simply closed, unstaffed or destocked.
Sinead Walsh and Oliver Johnson, in their recent book covering their lived experience of the Sierra Leonean Ebola outbreak, “Getting to Zero” , often come back to this point, painfully and poignantly. In one particular passage, Ambassador Walsh recounts how restoring non-Ebola health services was consistently on the list of priorities in the Ebola response, but was always displaced in favour of efforts to reach zero new Ebola cases. The UK response in particular was strongly in favour of concentrating all efforts on the epidemic itself as opposed to its indirect effects. As Dr Johnson explains, this made some sense at the time: after such a slow initial response, during which the epidemic had been allowed to get out of control, any further delay would have resulted in exponential increases in infections and deaths.
Indulging for one moment in what, I argue later, is a false dichotomy, the numbers alone seem to indicate that this may not have been the best call. The estimated death toll presented above suggests that on the basis of just a few causes of deaths (and excluding two of the biggest killers, lower respiratory infections and diarrheal diseases (GBD 2017)), indirect deaths may have exceeded reported Ebola deaths by a factor of 1.6 to 1. This type of comparison, however, could not have been made at the time because indirect deaths were not tracked during the course of the outbreak and therefore did not directly inform resource allocation in the same way that Ebola infections and deaths did.
What is more useful to take away, however, is that the so-called tension between human rights and the emergency response may not be as firm as we think. Many, including Walsh and Johnson, have recounted how forced quarantine and the lack of support for other life-threatening health conditions exacerbated communities’ lack of trust in the Ebola response, a massive impediment to bringing the epidemic under control. From a dynamic perspective, meeting people’s right to health in non-emergency times by building health system resilience is also instrumental to preventing outbreaks from getting out of hand. It is telling that even before the Ebola epidemic hit, Sierra Leone had the largest maternal mortality ratio in the world, a statistic indicating widespread, unfair and avoidable loss of life, which is also often used to assess the overall strength of a health system.
There are bigger reasons why bringing a global health emergency under control and ensuring that general healthcare remains available is not an either-or choice. The first reason, as Paul Farmer is often keen to remind us, is that while global health specialists often operate on the assumption that the resource pie for health is fixed, this need not be the case. If we care enough, we can reallocate resources from non-health domains in order to prevent Ebola infections AND maternal deaths. It is a question of distributive justice. In fact, many resources were pulled from other areas during the response, such as defence and aero-spatial surveillance. More could have been reallocated.
The second reason comes down to our reasons for intervening in a global health emergency in the first place. If this is to save lives on the basis of the right to health, then which disease or condition is causing the loss of life should be irrelevant. The fact that the world’s attention switched on when an American missionary aid worker became infected hints to fact that this was not, in fact, the sole basis of the intervention: bringing the epidemic under control was also about avoiding the outbreak taking hold in high-income countries. Maternal mortality, unfortunately for pregnant women in Sierra Leone, cannot get on a plane to infect British, French, or American mothers. There is no doubt that the Sierra Leonean health system would look very different today if it could.
References & Footnotes
 Sochas, Channon & Nam (2017). Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. Health Policy and Planning, 23(3), pp. iii32-iii39.
 Parpia, Ndeffo-Mbah, Wenzel & Galvani (2016). Effects of Response to 2014–2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa. Emerging Infectious Diseases, 22(3).
 Walsh & Johnson (2018). Getting to Zero: A Doctor and a Diplomat on the Ebola frontline. London: Zed Books.
Laura Sochas (twitter: @LauraSochas) is a PhD candidate in the Department of Social Policy, LSE, where she is researching maternal health inequalities in Zambia using mixed methods. Prior to starting her PhD, Laura worked as a consultant on maternal and newborn health policy and research for clients such as DFID, UNFPA, and the UN Secretary General’s office.
Image by Jon Butterworth on Unsplash.