The right to health does not mean the right to be healthy…but it does require… policies and action plans which will lead to available and accessible health care for all…Mary Robinson, former UN High Commissioner for Human Rights

Disruptions & Collateral Damage

The initial slow and insufficient global response has been rightly criticised for allowing the Ebola epidemic to spread and disrupt health services longer than necessary. The WHO reports that the pace of new cases is slowing. Ultimately this epidemic will be a public health success story, albeit with many lessons to be learnt if we are to improve future international responses.

But what about maternal and child health services? What about a mother in labour in need of a C-section, terrified of going to a health facility associated with Ebola deaths? What about a young woman who didn’t receive her long-lasting contraceptive injection and has an unintended pregnancy? These are legitimate questions, as shown by reports from the field:

• Pregnant women have a 95% fatality rate if infected with Ebola, much higher than that of the general population. Uninfected women were also severely affected by the lack of maternity services in Monrovia during the height of the epidemic.
• An entire section of Sierra Leone was reported to have no access to C-sections during the Ebola epidemic. The risk of health care workers’ exposure to Ebola during the procedure is high, and some facilities stopped offering C-sections. One hospital reported an increase in maternal mortality from 1% to 4% during this time, and with overall facility deliveries down this is likely an underestimate.
• In a district of Sierra Leone highly affected by Ebola, there was a substantial decline in care-seeking behaviour among pregnant women—first antenatal care visits declined by 29% and post natal visits within 48 hours declined by 21%.
• Breakdown of routine health services has been widespread. For example, childhood immunization campaigns have been interrupted, with a consequent increased measles outbreak risk, whose potential death toll would compare with that of Ebola.
• There are big challenges in providing obstetric care during an Ebola epidemic. For example, deciding whether or not to intervene when a woman’s Ebola status is unknown – there are few studies of Ebola and maternal and neonatal outcomes to guide such decisions; or how to balance meeting maternal health needs while protecting health care workers.

Is the breakdown of routine services during an epidemic like Ebola inevitable? This is a question the global community needs to discuss during reflections on the response and in developing plans for future responses.

Access to Reproductive Health Services

Despite the many field reports, few statistics capture the secondary effects of Ebola, such as the number of unintended pregnancies due to the lack of access to family planning, or the number of women who died in childbirth because emergency obstetric care was absent. These metrics are not captured in WHO epidemic monitoring reports. Perhaps this is with good reason: in the face of a crisis, we focus on indicators essential to managing its trajectory. But if there isn’t active monitoring of collateral damage of an epidemic, how can the response act to mitigate these secondary effects?

Reproductive Health Rights & Accountability

What does the right to health mean in the context of a humanitarian crisis like the Ebola outbreak?

In 2013, through working with health & human rights experts I learned about existing international treaties to protect the right to health and various accountability mechanisms. Certainly women in Ebola-affected areas did not have available, accessible, acceptable and quality health facilities, goods and services, a framework for understanding if the right to health has been fulfilled. It seems from the outside that the policies and action plans may have been insufficient. At the very least transparency and accountability are called for to understand how the Ebola response helped and failed these women.

Ebola Response Accountability

The London School of Hygiene & Tropical Medicine in collaboration with the Harvard Global Health Institute has convened an independent panel to review the global response to the Ebola epidemic. The panel aims to offer solutions to resolve major weaknesses in the global health system that were exposed by the Ebola outbreak. I hope lessons will be learned about provision of the routine care that mothers’ lives depend on. Epidemics will continue to happen, as will other humanitarian crises leading to disruptions to the health system. We must learn from the Ebola experience so that we are better prepared to tackle future disruptions in the next round.