Dr. Khadimul Anam Mazhar thought diphtheria was a disease from the history books. He certainly never expected to see a case, much less to be part of the team trying to control a widespread outbreak. But starting late last year, diphtheria surfaced in the Rohingya refugee camps in Cox’s Bazar, Bangladesh. It became the focus of Dr. Mazhar’s work: he is a WHO surveillance officer assigned to monitor health risks in the camps.

A year on from the start of the crisis, more than a million people have fled violence in Myanmar - one of the largest population displacements in recent history. The area where the tired and hungry families sought refuge lacked even the most basic shelter and infrastructure.

In conditions like these, a disease outbreak was predictable.  “Their immunization coverage was really poor. We don’t have any data if they received the vaccines or not,” says Mazhar.

Humanitarian crises, forced migration, environmental degradation, climate change, reduced access to health services and prolonged conflict often provide exactly the right conditions for an outbreak to occur. Diphtheria - a bacterial disease that is preventable through a simple inexpensive vaccine – is one such example. Once affecting millions, it had been nearly eliminated over recent decades. It is now making a dramatic comeback - not only amongst Rohingya refugees, but in other vulnerable communities around the world.

While diphtheria was being tackled in Cox’s Bazar, thousands of miles away, WHO teams were responding to another crisis: an outbreak of Ebola in the Democratic Republic of the Congo (DRC), a country with long-running conflict, widespread poverty, and a weakened health system. The threat of further transmission was high because the disease affected four separate locations, including Mbandaka, a major city with connections to the capital, Kinshasa and to neighbouring countries. In addition, health workers had been infected, becoming potential vectors for the spread of the disease.

WHO and its partners sent teams to DRC within two days of the outbreak being declared, and more than 360 responders were deployed to the affected areas. They supported the country in coordinating the response, raising awareness in communities and facilitating access to vital supplies and medical equipment. On 24 July, health authorities in DRC announced the end of this outbreak in Equateur Province, 12 weeks after the intial cases were declared.

The outbreaks of Ebola in DRC and diphtheria among the Rohingya refugees have starkly different profiles. One was a naturally occurring zoonosis in a remote area, the other the result of a major migration of a highly stressed population. One was a response to a high-threat pathogen affecting a relatively small number of people, but with the potential for large spread; the other took place in a densely populated refugee camp. One caught the attention of donors and was well-funded, the other occurred in the midst of a long-running and under-resourced crisis, limiting the response of international agencies.

For all the differences, however, they also share similar traits: prolonged conflict, inadequate water and sanitation systems, and struggling health systems.

"For the first time in my experience I saw hope in the face of Ebola and not terror"

- Dr Michael J Ryan, WHO Assistant Director-General, Emergency Preparedness and Response.

The cases highlight two critical and often overlooked issues: 1) multiple countries around the world are facing severe health crises, and 2) many of these countries have several health crises occurring at the same time. In the case of the DRC for example, the country is also struggling with cholera, malaria, circulating vaccine-derived polio, and malnutrition. 

Geography and environment add layers of complexity to the health response. The monsoon season is threatening the makeshift housing in Cox’s Bazar and putting refugees at greater risk of outbreaks. In DRC, health workers have had to operate in hundreds of miles of thickly forested areas, which make up some of the remotest places on Earth.

With new suspected Ebola cases announced in North Kivu province on 1 August, responders and medical supplies are being deployed to support another response. This area too, poses its own distinct challenges.

“This new cluster is occurring in an environment which is very different from where we were operating in the northwest,” said Dr Peter Salama, WHO Deputy Director-General, Emergency Preparedness and Response. “This is an active conflict zone. The major barrier will be safely accessing the affected population.”

North Kivu hosts over 1 million displaced people, and province shares borders with Rwanda and Uganda with a great deal of cross border movement. WHO will continue to work with neighbouring countries to ensure health authorities are alerted and prepared to respond.

The WHO R&D Blueprint initiative was created in the wake of the 2014-15 Ebola outbreak, to allow the fast-tracking of research and development for tests, vaccines, and medicines that can be used to help avert a large-scale crisis during an epidemic.

In May this year, this work supported the deployment of an Ebola vaccine in DRC. Called rVSV-ZEBOV, the vaccine had been earlier trialled in Guinea in late 2015, where results showed it was highly effective and sufficiently safe to be used during outbreaks. In total, more than 3300 people in Equateur Province were vaccinated against the disease.

Dr. Michael J. Ryan, Assistant Director-General for Emergency Preparedness and Response, helped oversee the response on the ground. “For the first time in my experience I saw hope in the face of Ebola and not terror,” he said.

The R&D Blueprint committee members include experts from medical, scientific, and regulatory backgrounds. In their February 2018 report, they identified eight diseases for which there is an urgent need for accelerated research and development, based on their potential to cause a public health emergency and the lack of effective drugs and vaccines. In addition to Ebola, they include Crimean-Congo haemorrhagic fever; Marburg virus disease; Lassa fever; Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS); Nipah and henipaviral diseases; Rift Valley fever (RVF); Zika; and Disease X (a disease due to a yet unknown pathogen, but for which some preliminary work can start to ensure faster development of a vaccine and therapeutic or diagnostic tests).

In the longer term, countries need to strengthen the ability of their health systems to deal with the unexpected, to be able to manage and even prevent epidemics before they get out of control. The best ways to do that are often the least glamorous. The same basic tools and practices needed for everyday primary healthcare also form the basis of a response to outbreaks of the most dangerous diseases: well-trained and paid doctors, nurses, technicians and community health workers; laboratory capacity; functional drug supply chains; and infection prevention and control equipment and procedures, particularly such basics as soap and safe water, gloves and masks. 

Vaccines and new drugs play a critical role. In DRC, we have seen how fast-track research projects through the R&D Blueprint allowed the swift introduction of an Ebola vaccine and treatments that had not previously been available. 

But at the core of any outbreak response is a functional health care system. 

How does a disease outbreak end, and what does it leave behind?  A disease outbreak, if it is severe, can cause massive disruption in the health and wellbeing of a society long after the pathogen has ceased to be a threat. 

An outbreak can disrupt what is often an already over-stressed health care system, making it difficult for patients with chronic conditions or who fall sick to receive the care they need. It can disrupt a country’s economy, costing millions of dollars in lost trade and shattering livelihoods.

And once the emergency crews have put out the fire of the outbreak, the underlying conditions that contributed to the problem in the first place can remain. It is here that the broad health mandate of WHO, from Universal Health Coverage to global health security, comes into play.