I recently wrote of the need to understand the Ebola epidemic from the perspective of health systems. As the epidemic continues to spiral out of control throughout Liberia, Sierra Leone, and Guinea, it’s important for us to adopt a critical perspective not only on the broad aspects of the epidemic, but on the nuances of what is contributing to the spread of the virus, and what is working effectively to contain or constrain it within these health systems.
Among the many assessments of the epidemic’s spread have been reports of the shortages of essential medical supplies: gloves, gowns, aprons, boots, etc. All too often this is portrayed with a fatalist tone of a common problem in low-income countries, but this is an incredibly important and overlooked aspect not only of the epidemic, but of the failures of the global public health systems to adequately prepare developing health systems for even minor threats.
First, let’s consider the commodities that we are discussing. Disposable medical goods like gloves and aprons are not sophisticated pieces of technology, and do not require elaborate manufacturing processes or complex supply chains in the way that something like drugs or vaccines do. As the IRC’s field director in Liberia reports “The supplies they need to contain the outbreak aren’t expensive, but there just aren’t enough available.” The bottleneck in the system is not a shortage of manufacturers, nor is it an intellectual property concern. Rather, it’s more likely the result of a supply chain that has been ignored in the grand scheme of health systems strengthening.
Regrettably, this is an all-too-common occurrence in global health. A great deal of attention has been paid within the access to essential medicines debates to discussing intellectual property and the role of patents in restricting the availability of lifesaving therapeutics, but this discussion seems to stop at the factory and restart at the bedside. In between the manufacturer and the patient lies a very complex system with many weaknesses that plays a crucial role in ensuring the availability of drugs, devices, and supplies for hospitals and clinics.
The consequences of a poorly managed supply chain extend beyond the obvious. In the absence of trained and dedicated logisticians, health care workers (often nurses and pharmacists) are the ones often left responsible for ordering supplies and ensuring they arrive and are stored properly. This has two consequences: you end up with a poor supply chain manager, and you remove a clinician from actually providing patient care. Neither is desirable, and both contribute to the fragility of weak healthcare systems.
Poorly managed and regulated supply chains are also vulnerable to the intrusion of substandard, falsified, and counterfeit medicines, which proliferate in environments where the state is either unable or unwilling to control a lucrative private pharmaceuticals market. The end result is that patients are left with drugs and devices that offer no medical benefit or, worse, will directly harm them. There are countless examples of pills being found to contain nothing more than talc or cement, and injections that contain nothing more than water.
When these supply chains fail to deliver, it should lead us to seriously question the successes of the global public health system’s architecture. The failure to be able to meet even basic medical commodity demands should surely serve as an embarrassment to us, and should prompt a few things to occur: first, and most urgently, immediate logistics support is required to replenish depleted stocks in the Ebola outbreak and to establish reliable supply chains for the continued availability of medical necessities like gloves, gowns, body bags, and other items. Second, global health programs must adopt a focus that recognizes the essential nature of supply chains in the provision of safe and reliable patient care (this is already happening and there were some great presentations at HSR2014 on this). Third, the research community must broaden its scope in discussing access to essential medicines to include the complexities of supply chain and market dynamics, and abandon this almost exclusive (and myopic) focus on intellectual property as though it were the sole determinant of access. Until we do this, we will continue to see stockouts and supply chain ruptures and the continued amplification of disease epidemics rapidly spiralling out of control at least in part because of our inattention to a basic concept.