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"Healthcare is First Casualty of War": Q&A with Annie Sparrow

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by Els Debuf

Ongoing attacks on medical facilities in places such as Syria saw the United Nations Security Council adopt a resolution this week aimed at protecting healthcare providers in conflicts. The high degree of concern over the issue was evident in a recent International Peace Institute forum, co-sponsored by the resolution’s drafters.

In this interview—conducted at an Independent Commission on Multilateralism (ICM) retreat in Geneva earlier this year—Annie Sparrow, Assistant Professor at the Icahn School of Medicine, also laments attacks on healthcare: “Let’s look at Syria, where you have the targeting of healthcare systems, the targeting of public health, of schools, of hospitals, the incarceration of doctors, the criminalization of doctors, and the obliteration and even commercialization of humanitarian space.”

Dr. Sparrow also took a broader view, saying that the conditions in contemporary conflict zones not only made it difficult to deliver medical care, they ultimately increased the incidence of infectious disease in the world.

She criticized this year’s report of the Secretary-General’s High-level Panel on the Global Response to Health Crises.

“I was certainly underwhelmed, to say the least, because it is a report that—although initiated and backed by the Ebola crisis—is not reflective of the true nature of what’s going on in the world today,” Dr. Sparrow told the ICM’s Els Debuf.

This interview has been edited for clarity and length.

You have pointed out repeatedly that healthcare is often the first casualty of war. From that experience, how do you think that the UN and other actors can respond better in conflict-affected regions? Do you think there is a need for a specific group of experts to analyze the challenges of delivering on public health in conflict situations and put forward recommendations? Or do you think the analyses and recommendations are there, but they are just not taken up by states and the UN?

Well, I was delighted when I first saw the Secretary-General’s initiative to create the high-level panel on response to these global health crises, because there’s no shortage of crises. We are at an unparalleled state of the world, and that was the appropriate response.

When I read the report, however, I was certainly underwhelmed, to say the least, because it is a report that—although initiated and backed by the Ebola crisis—is not reflective of the true nature of what’s going on in the world today.

I am particularly involved in Syria, which is the worst public health crisis that we know of. It’s not only the biggest, it has national, regional, and global ramifications. It’s the worst humanitarian crisis; it’s created the biggest refugee crisis; and it’s certainly the most expensive humanitarian crisis. Yet conflicts are not recognized in this document at all.

This was a job of the panel, but the panel was only as good as the advice it got from the UN Secretariat, so I was disappointed and underwhelmed that the report did not reflect the reality and is specifically focused on Ebola.

Conflict is a major driver of infectious disease—it’s not the cause of infectious disease—and let’s remember that, because it’s quite important. For example, there was no polio in Iraq for eight years during that war, but it reappeared two years after the Syrian war. In fact it was one of the drivers for the revolution in the first place—the lack of child health.

Let’s now look at Syria, where you have the targeting of healthcare systems, the targeting of public health, of schools, of hospitals, the incarceration of doctors, the criminalization of doctors, and the obliteration and even commercialization of humanitarian space, and you create the perfect conditions for epidemic disease. And of course it goes well beyond Syria to Yemen, to Iraq, to South Sudan, to the Central African Republic.

There’s no shortage of conflicts and there’s no shortage of infectious disease, and these pathogens are also not addressed in the panel’s report. It’s focusing on new pathogens rather than ones such as cholera, polio, and tuberculosis—despite the fact that there’s an urgent need to control these ones, and if we do those ones very well, we know that we can harness that to address epidemics such as Ebola. That’s exactly what happened with polio. So I was very disappointed with the high-level panel report, but very delighted about indications given in today’s meeting that the panel may revisit it and take some corrective action to insert conflict and health.

You said that each actor in the global public health sector needs to stick to what it does well. Could you expand a bit on that with a few examples of who does what well, and who does what less well? What do you think is required for this kind of division of labor to work and deliver on collective results?

Historically, the World Health Organization does reporting and technical advice well. Certainly the WHO was what we needed 30 years ago before the internet—we needed that technical advice, we needed the direct presence.

They’ve done surveillance very well in the past. They must do robust surveillance and that is something they can do and should do very well. They cannot do emergency response. They have never done it, it’s not in their mandate, they have no history of it, they cannot quickly acquire it—it’s not in their DNA. It’s in Doctors Without Borders’ (MSF) DNA. That’s why MSF is good at it. MSF is an independent operation. The WHO in its current incarnation is not independent. Therefore it cannot have an independent emergency response, which is particularly important in countries in conflict.

It was very important in Ebola also. The other key players, of course, are the local actors. They are the most important of all in any crisis, whether it’s a disaster or a war. They are always first responders, so we have to support them because they’re the ones who are responding to health, doing the actual surveillance on the ground, and they must be well supported. We have no shortage of great examples. In fact, Syrians can literally write the book on how to do this in war zones, and we should learn from that.

What do you think are some concrete steps that can be taken to improve early detection, preparedness, and response capacity for health crisis?

Let’s remember what I think (American physician) Larry Brilliant said, “Epidemics are inevitable, but pandemics are optional.” Epidemics are inevitable—we’ll always have outbreaks—but pandemics are optional and that’s where preparedness comes in. That’s another disappointment in the report because there’s a lot of discussion about pandemic preparedness. We should not be having that discussion, because if we are well prepared then we won’t be having a pandemic, and the better prepared we are, the less operational you have to be, and the less money it costs. We certainly discussed a lot of finance and methods today. Bigger is not necessarily better; we need to use money very smartly.

One thing that is absolutely essential, particularly in the setting of conflict and security, is how to test diseases. This is a gap in global surveillance that my colleagues and I have identified in Syria; we cannot detect things well.

Polio still takes 28 days to grow in a laboratory. That’s ridiculous, because polio can spread a long way in 28 days, but in all these countries there’s no laboratories or no access to laboratories across front lines, conflict lines. Or the national laboratory is unreliable because it’s under the control of the government—that’s exactly what happened in Syria, for example. Then the absence of laboratory evidence is taken as absence of evidence of disease, and of course that is not true.

A child crippled by polio is still a child crippled by polio even if you can’t isolate a polio virus in a laboratory. The same thing happened with Ebola. One country only counted lab-confirmed Ebola, and we know that the numbers led to a huge underestimation. So we must get a lot better at that—at fast, reliable testing, and put a lot more research into these tests.

We’re lucky that we have a PCR (polymerase chain reaction) for Ebola that we can do in 24 hours. Why don’t we have one for polio? Why don’t we have a very effective and reliable one for cholera? We need a much better one for TB, which is a difficult disease. It’s airborne, it’s a very serious one, and it takes six weeks to cultivate, so it would raise back things that we can do and we should do that would make a huge difference to our ability to do early detection and response.

I believe you also made some suggestions of improvements and steps that can be taken to improve on vaccination immunization efforts?

One of the most extraordinary things you could do to change the world would be to change the vaccination schedule and make measles vaccine mandatory. The report talks about smallpox eradication as if the WHO did a vaccination campaign in 10 years. Small pox eradication took almost 200 years. Edward Jenner made the smallpox vaccine in 1796, and there had been decades and centuries before that of dealing with smallpox. You couldn’t go to school unless you had the smallpox vaccination. So when we eradicated it, it wasn’t much a question of vaccination as surveillance, contact tracing, and it is still the success story.

Now, measles is special, because any child who is given the measles vaccine is not only protected against measles but it has a reduction by 50% of other infection diseases such as sepsis, pneumonia, or ear infections—the big ones, the bad ones, and the less serious, but the ones that also affect school development. It would be super interesting, for example, to look at Ebola survivors. Did they survive? What was the last vaccine they had? Was it measles? Because that protective effective of measles only lasts until the next vaccine that you have, and it can be by killed vaccines such as for diphtheria or tetanus, for example. So it would be a simple and cheap intervention that we already know is well-proven, we’ve used it for decades, it’s the most cost-effective thing that we could do. That could be a truly revolutionary way to protect everybody from these egregious pathogens, whether it’s Ebola or Zika, because even though we don’t have the evidence for Ebola or Zika yet, we could certainly examine that very closely. I think it should be a priority area for research into protecting and creating a kind of globally enhanced immunity.

Originally Published in the Global Observatory