Last year, our local health department worked intensively with King County healthcare systems and our community in response to the ongoing, unprecedented Ebola outbreak. Our director of communicable diseases, Dr. Jeff Duchin (now also health officer), was a leading figure in our local Ebola preparedness and response activities. At the national level, he worked with the Infectious Disease Society of America (where he is Chair of the Public Health Committee) to develop a position paper on the quarantine of healthcare workers returning from Ebola affected countries and also with the National Academy of Medicine (NAM, Formerly the Institute of Medicine), where he is a member of their Forum on Microbial Threats.

Though no Ebola cases were confirmed in King County, our department has monitored approximately 200 returning healthcare workers and travelers from Ebola-affected areas to-date. Several of the returning healthcare workers developed symptoms compatible with Ebola and were found to have other non-Ebola infections when evaluated at designated “Ebola-ready” King County healthcare facilities.

A year removed from the first Ebola case diagnosed in the US, we sat down with Dr. Duchin to learn more about the role of local jurisdictions in the global health context.

You joined key leaders in global health at a meeting sponsored by the US National Academy of Medicine (formerly the Institute of Medicine) and the UK’s Wellcome Trust to review the global Ebola response. What was the purpose of this meeting?

The meeting was part of an ongoing NAM initiative to develop a Global Health Risk Framework to improve the response to future outbreaks worldwide. The group I am a member of focused on governance of outbreak and health emergency responses. This includes how we make decisions, exercise authority, prepare our public health system, engage stakeholders and the local community and community, and implement plans. Governance, along with finance, resilient heath systems, and medical product research and development, is one of four distinct areas outlined in the Global Health Risk Framework, which is currently in development. The meeting was convened to identify potential changes (if needed) at the global leadership (WHO) level and related regional response systems, and will also provide context for further review of the need for changes in the 2005 IHR.

We heard the meeting was a veritable who’s who of global health (no pun intended). Who attended?

It was a privilege to meet with and learn from so many luminaries in our field at once. Meeting participants included Dr. Margaret Chan, Director-General of the World Health Organization; Dr. Peter Piot, the researcher who discovered the Ebola virus, and Director of the London School of Hygiene and Tropical Medicine; Dr. Harvey Feinberg, immediate past-President of the Institute of Medicine and author of the 2011 report reviewing functioning of the International Health Regulations (IHR); Dr. Joanne Liu, the President of Doctors Without Borders; Dr. Oyewale Tomori, President of the Nigeria Academy of Sciences; Dr. Chris Elias, President over Global Development at the Bill and Melinda Gates Foundation; Dr. Jeremy Farrar, Director of the Wellcome Trust, and other invited experts. The NAM website contains the full list of participants as well as the meeting agenda.
Given the focus on global health emergencies, what’s the local connection?

It was evident that a successful response to a global health emergency required a strong local public health system. And when I refer to public health system, I mean public health agencies as well as local health care systems, other public and private sector stakeholders, and local communities and their ability to work together and communicate effectively.

In addition, virtually all the major factors that were identified as critical for successful global health emergency response are relevant at the local level. For example, we underscored the importance of employing an Incident Management System framework during emergency response because of the clarity and efficiency IMS provides, the use of standardized, established communication mechanisms and channels, and the flexibility to adapt to different types of emergencies and incorporate a variety of response-related activities and input from multiple responders and stakeholders. We also recognized the importance of engaging with stakeholders, including government partners, politicians, elected officials, the community, and the private sector. Stakeholder engagement and collaboration is a critical “baseline” core public health activity in planning for health emergencies as well as for building a robust community health system, and should not – and cannot – be done effectively on an urgent basis during an outbreak or emergency response.

Continued efforts to improve integration and coordination of the public health and clinical healthcare delivery systems are an important part of this work. One example is that local health jurisdictions can probably do more to engage the business sector. Those folks have access to and the ability to provide important resources during an emergency in collaboration with the public health response, such as delivery and transportation logistics, food, medication, supplies, other humanitarian assistance, to the public at a scale that governmental agencies can’t do alone. At the global level, improved connections with the business sector mean faster vaccine delivery, drug development, and humanitarian resource dispersal.

What’s the bottom line with respect to local public health and global health emergency response?
The local health department’s ability to promptly detect, investigate, report and respond to outbreaks and health emergencies is critical to any outbreak and health emergency response, at the local or the global level. This requires strong relationships with clinical laboratories and health care systems, optimizing the use of available data sources, systems and health information technology, and adequate numbers of skilled professionals and infrastructure in the public health workforce. Local public health departments and systems provide the foundation for improving and maintaining overall community health and resilience both during and between health emergencies. Without robust local systems, global responders are tasked with developing needed capacity “on the fly,” resulting in a delayed response. During the Ebola outbreak, we saw an increased cost in the context of human suffering with preventable cases and deaths as well as potentially large economic costs.

In summary, desirable elements of health emergency response at the global and local level include:

• clear lines of authority and accountability;
• governance systems that are flexible/situational and transparent;
• proactive engagement of both governmental and non-governmental stakeholders in governance and preparedness and response activities;
• incident management as a framework for effective emergency response;
• a robust local public health system that is closely integrated with the clinical healthcare system;
• strong and culturally-appropriate communication and risk communication systems; and,
• community resilience and community engagement in formulating response strategies.