Frontline Capacity, Protection, and Governance Challenges

Context and the Rwanda Marburg Experience

• The Threat: Marburg Virus Disease is from the same family as Ebola and has historically had a reported fatality rate as high as 90%.
• The Outbreak (Sept. 2024): Rwanda declared an MVD outbreak. The initial cases involved a miner, his pregnant wife (who fell ill and died after having a baby), and the baby (who also died).
• Healthcare Worker Impact: The wife was treated at an epicenter hospital. Eight HCWs were exposed to a nurse who was coding in the ICU; all eight developed symptoms, tested positive within a week, and four of them died.
• The Turning Point: The outbreak happened in city referral hospitals where advanced medical interventions (dialysis, mechanical ventilation) were available.
  • Rapid Therapeutics Access: Within 10 days of identifying Marburg, novel therapies (experimental drugs and monoclonal antibodies) and an experimental vaccine were made available through diplomacy with the US government/CDC and agencies like WHO, Africa CDC, CEPI and more.
• The Outcome: This coordinated effort—combining therapeutics, widespread testing, and years of investment in a resilient healthcare system—helped curb the fatality rate down to 23%.

Barriers and Enablers in Outbreak Preparedness

• Fragmented Systems: Emergency and surveillance functions often operate in silos, leading to delayed or missed outbreak identification (e.g., inconsistent travel screening at JFK during early COVID-19 vs. African countries).
  • Solution: Empowering Emergency Departments and the community as the sentinel site can bridge this gap.
• Limited Frontline Capacity and Protection: Clinicians are often undertrained and underprotected and are frequently not part of the decision-making for surveillance.
• Weak Governance and Accountability: Unclear command structures and lack of feedback discourage early reporting.
  • Enabler: Strong governance and accountability in Rwanda helped contain the virus.
• Dependence on External Programs: Many low-income countries rely on outside sources for vaccines and therapeutics, slowing response.
  • Solution: Invest in local production (e.g., Rwanda’s pre-outbreak investment in developing its own mRNA vaccines).
• Lack of Resource-Smart Innovation: Gaps exist in things like integrating digital triage tools and surveillance systems.

Four Pillars of a Responsive and Equitable Emergency System

1. Workforce: Invest in pre-service and in-service training, mentorship, and fair compensation to ensure a skilled, protected, and motivated team.
2. Integration into the Health System: Emergency care (including pre-hospital services) must not operate in silos; it needs to be embedded in national health strategies and linked to surveillance, referral, and financing systems.
3. Equity in Design and Policy: The system must address the needs and protection of vulnerable groups and work closely with policymakers.
4. Data: Utilize real-time data and dashboards to provide a feedback loop between clinicians and policymakers, enabling tailored and innovative interventions.

Advice for Clinicians in Global Health Work

• Start Small and Build Trust: Meaningful work requires humility and relationship over scale or visibility. Focus on local priorities and sustainable change through long-term partnership, not just presence. Avoid the “savior mindset”.
• Be T-Shaped: Be deep in one specialty (e.g., EM) but fluent across other critical areas like policy, finance, and data, as these drive decision-making.
• Focus on Knowledge Transfer: True impact means making yourself less essential over time. Prioritize mentorship, co-creation, and sharing leadership opportunities.

Looking Ahead: Global Threats Shaping the Next Decade

• Climate and Environmental Crisis: Extreme heat, floods, and vector-borne illnesses will strain emergency systems.
  • Preparation: Invest in climate-resilient infrastructure for both EDs and the community.
• Outbreaks and Biosecurity: Future outbreaks will emerge faster than current systems can handle, coupled with challenges from anti-microbial resistance.
• Conflict, Displacement, and Urbanization: Mass migration and overcrowded cities will require new models of emergency care that are mobile, scalable, and inclusive.
  • Preparation: Building resilient healthcare systems ready for crisis mental health and cross-border coordination.
• Digital Tools and AI: These can augment solutions, but investment is needed in data governance and ethical AI that preserves local control and adapts to local capacity.