The truth about Australia’s Ebola hospital
Just over a year ago, one of Australia’s most senior infectious diseases specialists answered a call for help in dealing with the Ebola epidemic in West Africa.
The call came from someone involved in training the medical staff of the private-sector contractor the federal government had engaged to lead Australia’s contribution to the Ebola fight. And his request was urgent. He wanted a copy of the World Health Organisation’s triage protocols for dealing with the deadly disease.
“It was the day before they began training for the first tranche of people to go over there, and they wanted to know how to triage an Ebola patient,” he says.
And again, for emphasis: “They were flying out in a few days and didn’t know how to triage an Ebola patient. That really worried me.”
It was not just worrying, though. It was perplexing. Why had the government contracted this private-sector outfit, Aspen Medical, for the job when it already had available to it a group of public-sector professionals specifically trained for just such emergencies, at a cost to government of some $15 million a year?
Had the government wanted, it could easily and quickly have called on some 600 doctors, nurses, logistics experts, paramedics and others under its own Australian Medical Assistance Teams (Ausmat) mechanism. All of them senior employees of state and territory health departments, all of them having completed team training and many with specialist skills in surgical or infectious disease emergencies.
Yet the Abbott government bypassed its own specialist outfit and contracted a Canberra-based private-sector group to do the job. As the earlier anecdote clearly shows, it had no expertise in treating Ebola.
Now, as the anniversary of that deployment looms – Aspen Medical’s Ebola treatment centre in Sierra Leone opened on December 14 last year – unanswered questions remain about why. Was it an ideological decision based on the conservative preference for private sector solutions? Was it grounded in exaggerated fears of the dangers posed by the disease to Australia? Was it influenced by the political connections of the Canberra-based company and its history as a significant donor – a theory given impetus, ironically, by the government’s own attorney-general, George Brandis? Maybe it was a combination of all three and maybe there were other factors, too.
Whatever led to the decision, the defining characteristics of the government’s response to the Ebola crisis are these: odd, ineffectual and expensive.
Aspen Medical’s Ebola treatment centre, just outside Freetown, took its first patient on December 17. It shut down four months later, at the end of April this year, having cost the Australian taxpayer about $18.3 million.
That’s not a lot, compared with more generous contributions made by other countries. But costs have to be weighed against benefits, and there are big questions about how much good was done for the people of West Africa in exchange for that cost to the taxpayer.
During the four months Aspen worked in West Africa, its centre admitted a total of 216 people. Just 36 were successfully treated for Ebola and discharged. Sixty patients died – not necessarily all of Ebola.
Even including those who proved not to have Ebola, that averages out to a cost of $84,688 per person admitted to the centre. If you divide the cost by the number of patients successfully treated for Ebola, it is much higher, about $500,000 a person.
By way of comparison, the independent medical aid organisation Médecins Sans Frontières managed to treat people at an average of one-eighth that cost – $10,730.
And the comparison is even more unfavourable than that statistic indicates, for a much higher proportion of those admitted by MSF – 62 per cent – actually had Ebola.
Furthermore, MSF moved its people with the flow of the epidemic, seeking out cases and establishing infrastructure as it went. The Australian operation was static, treating those people brought to it, says Jon Edwards, head of advocacy and public affairs for MSF Australia. As a result, Aspen’s 50-bed facility never had more than 22 patients at one time.
“After the deployment,” recalls Edwards, “DFAT [the Department of Foreign Affairs and Trade] set up a regular consultation with Ebola partners, which included regular briefings from DFAT and Aspen Medical on the progress. I was on those calls.”
He put the MSF position: that the response needed to be more “flexible”.
“They needed the capacity to respond as the dynamics of the outbreaks changed. If they weren’t flexible, it would be a white elephant…” he says. “But they had the contract for an Ebola treatment centre and that’s what they were going to do. All they were going to do. It wasn’t part of the contract and certainly didn’t seem their intention to spend the funds earmarked in the most effective way.”
Slow to act
The World Health Organisation now believes the first case in the West African outbreak was on the day after Christmas 2013, in a remote village in Guinea. A number of other mysterious deaths followed, but it took several months before anyone realised the cause was Ebola. It might have taken longer had MSF doctors not been in the area, working on a malaria outbreak.
By late March, tests proved the suspicion. By late June the disease had spread to more than 60 locations in Guinea, Sierra Leone and Liberia. More than 300 people were dead and MSF – the only aid organisation treating people – warned the epidemic was “out of control” and that it was at the limit of its resources.
The world was slow to react. But in mid-September the United Nations unanimously passed a resolution setting up an emergency response mission, and calling on all member states to pitch in.
Speaking to the resolution, Australia’s representative said:
“We have much catching up to do if we are to succeed in bending down the epidemiological curve from its current explosive trajectory. The effects of the outbreak are still reversible, but only if the response and particularly isolation and treatment capacity are scaled up massively and quickly.”
By that time, China already had a 174-member medical team on the ground in West Africa. Other countries were also scrambling. But not Australia.
It was not until late October that cabinet decided to send a team. It was November 5 before DFAT decided Aspen Medical should be contracted to provide that team, and a further six weeks before Aspen was on the ground.
The decision to outsource the response to a private provider was taken without the usual tendering processes. But that is perhaps understandable, given the urgency. Inexplicably, though, the Health Department played no role in the decision. Nor, apparently, on the evidence of subsequent senate estimates committee hearings, were questions asked about the capacity of Aspen.
Defending the decision in estimates, Attorney-General Brandis stressed that Aspen had been contracted to work on past health crises overseas.
“There have been numerous contracts awarded to Aspen during the period of the previous Labor government … [including] the PNG cholera outbreak in 2009 and 2010.
“That was at a time when the Labor Party was in receipt of extremely generous donations from Aspen, too, I might say.”
Labor senator Penny Wong immediately countered: “I think you got a lot more from them than we ever did.”
Brandis: “No, that is not right.”
It’s hard to establish who is right in that exchange. Aspen certainly gives to both parties, but it does not file donor returns to the Australian Electoral Commission.
When The Saturday Paper asked the company how much it had given to political parties, it refused to say. “Aspen Medical meets all its obligations under the Commonwealth funding and disclosure scheme established under Part XX of the Commonwealth Electoral Act 1918.”
The words of senators Wong and Brandis suggest, however, that Aspen is a substantial donor. Neither party was helpful when asked about the subject. And Aspen’s political contributions are spread among different branches of the major parties.
By way of indication, in the year preceding the awarding of the Ebola contract, to June 30, 2014, Aspen kicked in $30,000 to the federal Liberal Party and a further $15,000 to the ACT branch of that party. The NSW branch of Labor got $1500.
The company’s financial support of the major parties is rendered more opaque by the fact that the monies were not recorded as a “donation” but as “other”.
The fact of Aspen’s financial support certainly raises doubts in the minds of the medical experts. But they acknowledge other factors, too.
The infectious diseases specialist who provided Aspen Medical with that advice on how to treat Ebola recalls the temper of the times.
“There was a lot of heat at the time on our own preparedness. Certain fringe politicians like Bob Katter were agitating against the people going with MSF and ICRC [Red Cross]. No politician wanted to be responsible for the Australian person who brought Ebola here.”
That argument is bolstered by the strange offer made by the government to MSF in mid-September, on the sidelines of a UN briefing on the Ebola crisis in Geneva.
An Australian diplomat told them the government would contribute an extra $2.5 million to the organisation, says Edwards.
“Our people in Geneva never agreed to anything,” says Edwards. “Within 24 hours they were on the phone to us saying they’d decided to give us money, ‘Just tell us how to do it.’ ”
Then, on September 17, they publicly announced the unsought and unaccepted donation.
“When I said we wouldn’t be taking it, they were quite dumbfounded,” he recalls. “We refused for the very practical reason that it was not what we were asking for. The situation needs more medical teams and equipment.
“MSF had already gone beyond our capacity. Giving us another $2.5 million was not going to create, overnight, a whole new bunch of doctors and nurses.”
But the government continued to resist sending people. Excuses were advanced – principally that it would be logistically difficult to repatriate any Australians infected while fighting the outbreak, and that the government was constrained by its duty of care for medical personnel.
“There were ways around that,” says one senior medical specialist. “They could have got an agreement with the UK [to treat any infections] much more quickly than they did.”
Edwards agrees: “In our meetings with DFAT, the issue of duty of care was raised as being a key barrier to deploying a medical team, and in particular the Ausmat team. We politely disagreed, pointing out we also had duty-of-care responsibilities under Australian law and believed we could meet them.
“It was a legalistic argument, but clearly there was a reluctance on the part of the Australian government to deploy, when there was a lot of fear.”
He points out that MSF had no trouble medically evacuating several staff to European hospitals.
Richard Di Natale, the leader of the Australian Greens and a doctor by training, paid his own way to West Africa to gain insights into the Ebola response after the government refused to fund his trip. He is less critical than others of Aspen’s role, although he holds the circumstances of the contract to be “a big question”.
“My view is they should have gone with the people in Australia who are trained to do the job – Ausmat and those NGOs already working in the space.
“But I met with quite a few of the Aspen people, and to be fair the centre they were working from was as good as any.
“The big issue was not Aspen, it was the timing.”
The Ebola crisis was already receding by the time Australia got there.
According to Di Natale, the reason for the delay was simple: the government does not want to spend money on international development generally.
“I think they’re a bunch of miserly, insular reactionaries,” he says. “I don’t know how else to put it. You’v]e got an epidemic, potentially a global epidemic, and they kept making excuses, like, ‘We can’t evacuate.’ That was nonsense. There was no question they would have got support from the international community.”
So, one year down the track, what lessons can be learnt from the sorry episode?
Alexander Rosewell, an epidemiologist with School of Public Health and Community Medicine at the University of New South Wales, and co-author of a study of the response, says more work and resources need to be put into strengthening Australia’s public health responsiveness.
“It’s about systems and human resources and mechanisms for deploying the large number of health experts that we have in Australia in a co-ordinated way that would demonstrate Australia’s leadership on issues,” he says, “rather than what transpired, which was sending zero public health experts into the field under the name of the Australian government.”
Di Natale agrees. “First, when you’re talking about a global outbreak of that scale, you need to move early. Second, utilise existing expertise. We’ve got expertise within the Ausmat ranks and within the NGO community, and we should have been listening to them.”
The Ebola crisis is now over. Last month, there were just three new cases reported. The disease was very deadly but not very communicable. Its rapid spread was due largely to the poor public health systems of the affected countries. But that might not be true of the next epidemic.
How we respond to these things is a worry: particularly if the government’s preference is to ignore its own public health infrastructure in favour of a private company that happens to be a big donor, in a process without tender, for outcomes that are less than ideal.
Because it’s not just about helping the developing world but also about protecting ourselves. The countries we don’t assist are the incubators of the pandemics of the future.
This article was first published in the print edition of The Saturday Paper on Dec 5, 2015 as "The truth about Australia’s Ebola hospital". Subscribe here.