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 Table of Contents 
COMMENTARY
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 463-467  

Politics of Ebola and the critical role of global health diplomacy for the CARICOM


Public Health and Primary Care, Faculty of Medical Sciences, The University of the West Indies, Trinidad, Tobago

Date of Web Publication29-Dec-2017

Correspondence Address:
Vijay Kumar Chattu
Faculty of Medical Sciences, The University of the West Indies, Trinidad
Tobago
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_75_17

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  Abstract 


The 2014 Ebola epidemic was the largest in history, affecting Guinea, Liberia, Sierra Leone, Nigeria, and Mali in West Africa. The International Health Regulations are legally binding in 194 countries including all the member states of WHO “to prevent, protect against, control, and provide a public health response to the international spread of disease.” Since the Caribbean Community region heavily depends on tourism, a single case of the disease anywhere in the region could have serious negative consequences for the rest of the region's tourism industry. Global health diplomacy brings together the disciplines of public health, international affairs, management, law, and economics and focuses on negotiations that shape and manage the global policy environment for health. The regional institutes such as Caribbean Public Health Agency should play a more proactive and pivotal role in the creation of regional response teams in all the island nations collaborating with the departments of public health and epidemiology at the regional campuses of The University of the West Indies. The role of global health diplomacy and its practice should be encouraged to reach a consensus among the stakeholders considering the threat to the health security in the region. There is a need for the cadre of global health diplomats who has a critical understanding of health and also the practice of diplomacy since such serious health issues have implications at the global level in this globalized world.

Keywords: Caribbean Community, Caribbean Public Health Agency, carnival, Ebola, global health diplomacy, International Health Regulations


How to cite this article:
Chattu VK. Politics of Ebola and the critical role of global health diplomacy for the CARICOM. J Family Med Prim Care 2017;6:463-7

How to cite this URL:
Chattu VK. Politics of Ebola and the critical role of global health diplomacy for the CARICOM. J Family Med Prim Care [serial online] 2017 [cited 2018 Jul 17];6:463-7. Available from: http://www.jfmpc.com/text.asp?2017/6/3/463/222056




  Context and Importance of the Problem Top


Epidemic of Ebola virus

The Ebola virus causes an acute, serious illness which is often fatal if untreated. Ebola virus disease (EVD) first appeared in 1976 in two simultaneous outbreaks, one in Sudan, and the other in the Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name.[1] The 2014 Ebola epidemic was the largest in history, affecting Guinea, Liberia, Sierra Leone, Nigeria, and Mali in West Africa. Ebola is by no means the first to plague the world. Notable pandemics over time include smallpox, tuberculosis, cholera, leprosy, malaria, yellow fever, influenza, severe acute respiratory syndrome, Avian flu, and HIV/AIDS. The Director-General of WHO on August 8 declared the EVD outbreak in West Africa a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (IHRs) (2005). This is the third time WHO declares a PHEIC following the H1N1 pandemic influenza in 2009 and the international spread of wild poliovirus in 2014.[2]

Caribbean Community

The Caribbean Community (CARICOM) brings together twenty countries (15 member states and 5 Associate members) in the Caribbean with broad objectives to improve standards of living and work; for full employment of labor and other factors of production; accelerated, coordinated, and sustained economic development and convergence; expansion of trade and economic relations with third states; for increased production and productivity; achievement of a greater measure of economic leverage; and enhanced coordination of member states' foreign policies and enhanced functional cooperation.[3]

International health regulations

The IHRs are an international agreement that is legally binding in 194 countries including all the WHO member states. The IHR define their “purpose and scope” as: “to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”[4] The regulations aim to provide a legal framework for the prevention, detection, and containment of public health risks at source, before they spread across borders, through the collaborative actions of States Parties and WHO.


  Global Health Diplomacy and Its Impact at Global Level Top


Global health diplomacy (GHD) brings together the disciplines of public health, international affairs, management, law, and economics and focuses on negotiations that shape and manage the global policy environment for health.[5] According to the WHO, the relationship between health, foreign policy, and trade is at the cutting edge of global health diplomacy.

The concept of health diplomacy emerged to address health issues that extend beyond national borders and expose countries to global influences, calling for closer and more cohesive coordination between authorities of the health and international relations sectors.[6] At the same time, they regard health diplomacy as the main instrument of global health governance. According to few authors, health diplomacy is a set of activities of political change with the dual purpose of improving global health while maintaining and strengthening international relations, particularly in areas of conflict and environments with meager resources.[7]

Cuban medical diplomacy is as old as the revolution that first brought Castro to power, but its motivation is not purely altruistic. Sending health workers abroad boosts the image of a country whose human rights record is criticized. Moreover, in some cases, as with a program that sent thousands of Cuban doctors to Venezuela, the island gets paid back in a trade, such as oil.

On September 12th, in 2014, Cuba announced that it would send nearly five hundred health-care professionals to West Africa. Since then, a 165 Cubans have arrived in Sierra Leone and the second group of 83 doctors has arrived in Liberia and Guinea; 200 more are expected. No other country, to date, has contributed as many trained health-care professionals to the Ebola crisis as Cuba has. Cuba's outsize gesture in West Africa has not gone unnoticed and may pave the way for the start of some Ebola diplomacy between Havana and Washington.

On October 19th in 2014, Secretary of the USA named Cuba as a nation that had made an “impressive” effort in the anti-Ebola campaign. Ten days later, following a Havana conference on Ebola that was attended by two American officials representing the Centers for Disease Control and Prevention, in a highly unusual break with procedure between the two nations, which do not have normal diplomatic relations, Raúl Castro said, pointedly, “Cuba is willing to work side by side with all nations including the USA, in the fight against Ebola.”[8]


  Impact of Ebola on Caribbean Community Top


The unique and particular vulnerabilities of Small Island Developing States (SIDS) have been acknowledged by the international community since the United Nations Conference on Environment and Development in Rio de Janeiro (1992).[9] That commitment to a global partnership in support of the sustainable development of SIDS was strongly reaffirmed during the Twenty-Second Special Session of the General Assembly, which was held in 1999.

Currently, the small states in particular to CARICOM, the preparedness to Ebola epidemic is doubtful with various resource constraints and lack of preparedness, contingency plans apart from the infrastructure, and trained professionals. Technology and sophistication do not translate to being prepared for handling this epidemic. Moreover, the outbreak naturally prompts a debate on the social, economic, cultural, and political ramifications of the disease which are discussed briefly below.[10]

Economically, there are severe repercussions for the quality and quantity of the workforce, and ultimately the level of productivity. Moreover, many countries in this Caribbean region are heavily dependent on tourism for their survival. Small Island states such as St Lucia, Barbados, Grenada, and Jamaica are particularly vulnerable. The Prime Minister of St. Lucia, Kenny Anthony told the Miami Herald that “we are an exceedingly small country with very limited resources and inexperienced in dealing with a global health crisis.” Hence, there is an urgent need to strengthen and have effective, coordinated measures at ports of entry to prevent Ebola from entering the CARICOM. All Caribbean countries including Trinidad and Tobago face a real threat to investment opportunities.

Socially, the Ebola virus can eliminate huge sections of national populations. More than 20,206 cases were reported from nine countries, of which 7905 were deaths as of December 2014[11] and by the end of 2015, the cumulative cases rose to 28, 601 and deaths to 11,300 in the three countries such as Guinea, Liberia, and Sierra Leone.[12] Invaluable human lives and human resources are being rapidly wiped out as the disease continues to advance exponentially. Apart from the impact on the family life, there are far-reaching implications for travel and vacation as states continue the aggressive ban on citizens of affected countries and those in contact with infected persons.

Culturally, the annual carnival celebrations in this region are something that is unique and treated with utmost importance as it is an important way to express their rich cultural traditions. If we look at the celebrations of carnival in Trinidad and Tobago, they are special days and the greatest popular cultural manifestation. It is a mixture of fun, party, and theater, which involves art and folklore and takes many months of coming up with a theme and developing costumes for the dancers. Carnival season attracts many tourists, far living relatives, and international community from all over the globe which carries a greater risk of transmission of any infectious disease due to a high number of people entering the island through various routes.

Politically, the virus poses a serious threat to both human security and state security. The United Nations (UN) resolution affirms that Ebola outbreak in Africa constitutes a threat to international peace and security. It stressed that the outbreak is undermining the stability of the most affected countries which can lead to civil unrest, social tensions, and a deterioration of the political and security climate. Furthermore, it has brought certain political issues in limelight, especially imposing a ban on some citizens entering Trinidad, especially from Nigeria even after the WHO has declared Nigeria as Ebola free. However, at the same time, the government has not banned the travelers from the USA and also made a clear statement that it's not going to ban anyone from the USA although they had the confirmed 9th Ebola case in New York.

The Trinidad and Tobago government has lifted the ban on Nigerians in the later stage but it would remain in place for persons from Ebola-stricken countries of Sierra Leone, Guinea, the Democratic Republic of Congo and Liberia. People who visited those countries within the past 6 weeks will also not be allowed entry. Citizens who visited these countries will be quarantined for 21 days upon arrival in Trinidad. Hence, we see great political implications and government's approach toward the USA and the other countries, especially in implementing the same surveillance and control measures due to their bilateral relations and other political issues.

Apart from the above, Ebola may also have implications for domestic politics in Trinidad and Tobago in the light of an impending general election in 2015. The Health Minister Dr. Fuad Khan said “While Government is introducing more stringent measures to prevent Ebola from entering this country, it has 'absolutely no plans' at this time to postpone Carnival 2015.”[13] Would the opposition party be affected positively or negatively if the government is forced to cancel carnival next year?


  Critique of Policy Options Top


The officials of ministries of health in CARICOM may be confident about having an isolation ward for Ebola case management, having purchased sufficient hazmat suits for health-care workers involved in case management, but health-care workers should undergo a rigorous, training, and practice competence in personal protective equipment (PPE). Just having a PPE is not everything, but there is a great need to focus on other aspects as well. There should be no skin exposure when PPE is worn, and all workers should be supervised by a trained monitor. The whole process of using the suit is a complex process, and this is hard work which needs leadership and commitment from the top.

Regarding the Carnival 2015 which is few weeks ahead from now is being a hot discussion among the stakeholders whether it should be canceled. It's a question to decide whether “the greatest show on earth” and “the multibillion-dollar business” is more important than the precious human lives. Currently, there are two major groups who are divided with these separate opinions with their vested interests and the third group with no clear idea. Unfortunately, the diverse population (different races, religion, countries of origin, etc.) is also divided by the political parties which are again a complex issue that has no clear YES or NO answer for carnival. Thus, there is a great need for a good dialog among stakeholders (Government, Carnival Associations, Organizers, business groups, etc.) through proper negotiations ultimately ensuring health security for the nation.

Adhering to the IHR (2005) and implementing guidelines for effective surveillance and control measures is a key for successful containment, but it was observed in Trinidad that the travelers from the USA were not banned from entry even when they had few cases. It was also argued by USA attorney Jasmine Rand who was in Trinidad, and Tobago said if persons from Nigeria had been banned then in the pursuit of fairness, persons from the USA should also be banned.[14]

There is an urgent need to stop the Ebola spread to the region through various diplomatic interventions, and global health diplomacy is the key tool to address various stakeholders on a wide range of issues embedded as discussed in this paper. Both government and opposition need to collaborate with each other as well as with national, regional, and international stakeholders to combat this dreaded pandemic before pandemonium reigns. Much would depend on the government's capacity to effectively manage the crisis.

Since the CARICOM region heavily depends on tourism, a single case of the disease anywhere in the region could have serious negative consequences for the rest of the region's tourism industry. Moreover, the visitors will avoid travel to any region where the disease is present, and due to this reason, no single island or territory could wage such a battle on its own.

There is a lot to learn for the CARICOM from the enormous contribution of Cuba in assisting affected West African countries, and it would be very useful to collaborate with neighboring countries like Cuba which is a notable example for practicing global health diplomacy and to build capacity in the region.


  Policy Recommendations Top


Given the technical inputs and guidelines of Pan American Health Organization (PAHO)[15] and Caribbean Public Health Agency (CARPHA)[16] in the prevention of the spread of the Ebola, the policy recommendations can be categorized into national, regional, and global levels.

National level

  1. Strengthening and coordinating the preventive and control measures at ports of entry at all borders (illegal entry points too) so that the island community can be protected
  2. Adhering strictly (without exceptions due to political or any reasons) to the surveillance guidelines and harmonizing travel restrictions
  3. Strengthening of surveillance and epidemic response team by having more qualified staff and improving training, equipment, laboratories, and containment
  4. Encouraging participating in capacity-building programs at the global and regional levels to gain experience to handle such situations if the need arises at home
  5. Strengthening the information, education, and communication (IEC) campaigns with a focused message to educate all the citizens
  6. Can consider having a global health diplomat as an integral part of the Ministry of Health who can better handle and provide the technical expertise when dealing with international and regional partners on global health issues such as Ebola (where there is a threat to global health security)
  7. It would be wise enough to initiate a resource mobilization effort to start a fund to stop Ebola so that the donations can be collected from all the stakeholders so that the fragile states which highly depend on tourism industry can benefit from this fund.


Regional partnership

  1. There is an urgent need for education of the general public through intensive IEC campaigns to sensitize them on the crucial issues related to Ebola virus, its transmission and various containment measures
  2. The regional institutes such as CARPHA should play a more proactive and pivotal role in the creation of regional response teams in all the island nations collaborating with the departments of public health at The University of the West Indies located in different campuses in the region (Trinidad and Tobago, Jamaica, and Barbados). These Regional Rapid Response Teams should be able to reach any island state within 24 h to support the national response team to contain/stop an outbreak that happens in any island at the earliest phase itself
  3. Through Global Health Diplomacy, CARPHA needs to work with all its partners for a strong political commitment and implement all the measures by adhering to the guidelines and implement proper screening services so that the infection cannot spread
  4. There is a great need to establish a Regional Coordinating Mechanism on Ebola with CARPHA as Chair and including the CARICOM secretariat, Organization for the Eastern Caribbean States Secretariat, non-CARICOM countries (e.g., Cuba), and other regional bodies involved in the control and coordination efforts
  5. The expertise of WHO/PAHO can be well utilized through proper collaboration at all stages of any of the above-mentioned activities.


Global level – Role of Global Health Institutions (Pan American Health Organization/WHO and other United Nations bodies)

  1. Involving all the stakeholders of Global Health Governance such as PAHO/WHO, the UN, other development partners, and Funding/Philanthropy organizations for their serious commitments to address the epidemic through their regular meetings to assess the effectiveness of the collective response
  2. The role of global health diplomacy and its practice should be encouraged to reach a consensus among the stakeholders considering the threat to the health security in the region. There is a need for this cadre of global health diplomats who have a critical understanding of health and also the practice of diplomacy since such serious health issues have implications at the global level in this globalized world [17]
  3. The global health institutions need to play a lead role and also assist the regional and individual states by reviewing the standard operating procedures, guidelines and reinforce the effectiveness of the measures that are being implemented.


Acknowledgments

The author acknowledges the authors of all those articles, journals, and books from where the literature for this article has been reviewed and discussed. The author is also thankful to the reviewers and staff of JFMPC for their valuable feedback.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. Geneva: World Health Organization. Available from: http://www.who.int/csr/disease/ebola/situation-reports/en/. [Last accessed on 2017 Mar 20].  Back to cited text no. 1
    
2.
WHO. Ebola Outbreak in West Africa Declared a Public Health Emergency of International Concern; 2014. Available from: http://www.euro.who.int/en/health-topics/emergencies/pages/news/news/2014/08/ebola-outbreak-in-west-africa-declared-a-public-health-emergency-of-international-concern. [Last accessed on 2017 Feb 06].  Back to cited text no. 2
    
3.
CARICOM, (Caribbean Community). Available from: http://www.caricom.org/about-caricom/who-we-are. [Last accessed on 2016 Mar 20].  Back to cited text no. 3
    
4.
International Health Regulations. WHO-IHR; 2005. Available from: http://www.who.int/topics/international_health_regulations/en/. [Last accessed on 2017 Feb 06].  Back to cited text no. 4
    
5.
Chattu VK. The rise of global health diplomacy: An interdisciplinary concept linking health and international relations. Indian J Public Health 2017;61:134-6.  Back to cited text no. 5
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More Cuban Doctors and Nurses Arrive in West Africa to Fight Ebola. Available from: https://www.theguardian.com/global-development/2014/oct/22/cuban-doctors-west-africa-fight-ebola. [Last accessed on 2017 Feb 06].  Back to cited text no. 8
    
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United Nations. United Nations Conference on Environment and Development. Brazil, Rio de Janerio; 1992.  Back to cited text no. 9
    
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Panel Discussion with the Health Minister & Other National Level Stakeholders about Ebola and Carnival 2015. Trinidad, St. Augustine: SALISES, UWI; 20 October, 2014.  Back to cited text no. 10
    
11.
WHO. Ebola Response Roadmap, Situation Report; 31 December, 2014.  Back to cited text no. 11
    
12.
WHO. Ebola Response Roadmap, Situation Report; 31 December, 2015.  Back to cited text no. 12
    
13.
Health Minister's Statement Released by Press on the Ebola & Carnival. Trinidad; 2015. Available from: http://www.socawarriors.net/forum/index.php?topic=63488.0. [Last accessed on 2017 Feb 06].  Back to cited text no. 13
    
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Block Americans Too. Available from: http://www.trinidadexpress.com/news/Block-Americans-too-says-US-attorney-280140662.html. [Last accessed on 2017 Feb 06].  Back to cited text no. 14
    
15.
Pan American Health Organization: Ebola Guidelines and Documents. Available from: http://www.paho.org/hq/index.php?option=com_content&view=article &id=10189:ebola-guias-y-documentos-tecnicos& catid=7385:general&Itemid=41124&lang=en. [Last accessed on 2017 Feb 06].  Back to cited text no. 15
    
16.
CARPHA Statement on Ebola Virus Disease; October, 2014. Available from: http://www.carpha.org/Portals/0/articles/documents/GeneralEbolaStatement.pdf. [Last accessed on 2017 Feb 06].  Back to cited text no. 16
    
17.
Kickbusch I, Told M, Wyss P. Resources from Global Health Diplomacy Certificate Course Under Global Health Program. Geneva: Graduate Institute; 2014.  Back to cited text no. 17
    




 

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