Across the Globe, ICAP Works to Protect Communities from Major Health Threats
For almost four years now, medical trains have crisscrossed Ukraine, moving wounded soldiers and civilians from the conflict zone to distant hospitals. Deadly antimicrobial-resistant (AMR) bacteria often stow away on board. When a train arrives, a regular public hospital—not a military hospital—could get 50 patients at once, many carrying these resistant germs. “It’s like having a mass-casualty event every week,” says Andrea Howard, MD, clinical and laboratory unit director at ICAP—the global health center headquartered at Columbia Mailman School. Howard oversees a program in Ukraine to counter this threat in a comprehensive manner at a time when drug-resistant organisms are responsible for more than a million deaths every year.
In the context of active warfare, hospitals are understaffed and overcrowded, with few isolation rooms to protect against the spread of antimicrobial resistance. Supply shortages make it especially challenging to follow proper infection prevention and control (IPC) procedures or to apply the right antibiotics to treat these infections. Ill-equipped laboratories fail to identify these organisms, and even if they did, antibiotics to treat these organisms are often nowhere to be found. It is a perfect environment for AMR organisms to spread—and they spread far beyond Ukraine’s borders. “Antimicrobial-resistant strains of bacteria originating in Ukraine have been detected in multiple European countries and as far away as Japan,” says Howard. “Some of them are resistant to all classes of antibiotics, with deadly consequences.”
In Ukraine, Howard has seen firsthand how the country has advanced its ability to diagnose, prevent, and manage antimicrobial-resistant organisms. Early in ICAP’s time, there “we started having calls with multidisciplinary teams in three hospitals (which has since expanded to four, and soon five),” she says. In the beginning, the approach was didactic, with doctors, nurses, laboratory personnel, epidemiologists, clinical pharmacists, and infection prevention and control specialists participating. “But over time, we started incorporating case discussions and soon enough the discussion brought in the perspectives of the doctor, the laboratorian, the nurse, the IPC specialist. It has been wonderful to see how they are working as a team and tackling this difficult issue from multiple directions,” says Howard, who reflected in wonder at the devotion of the health workers in Ukraine, attending every webinar, sharing their insights—despite the fact that they had spent the night before in a bomb shelter.
These efforts have yielded admirable results. In one study of adherence to hand-hygiene protocols, compliance increased from 44 percent to 80 percent over 9 months at one hospital and from 63 percent to 88 percent at another.
Facing Our Collective Vulnerability
This scenario is one reason why global health security (GHS) has become a worldwide imperative. GHS involves a constellation of activities that, together, minimize the risk and impact of acute public health events that cross geographical regions and international boundaries. The World Health Organization launched its GHS initiative in the wake of the September 11, 2001, terrorist attacks, uniting countries and experts to fight the potential threat of bioterrorism. The work quickly expanded to encompass pandemic influenza.
ICAP’s GHS efforts started at the height of the 2014-2016 Ebola outbreak in West Africa. “We believed that although we had no experience with Ebola, we were confident that our teams had the skills to be able to do something meaningful,” says Susan Michaels-Strasser, PhD, MPH, ICAP’s senior director of human resources for health and lead for ICAP programs in Sierra Leone, South Sudan, and Zambia. It was a natural expansion of the work ICAP had been doing since its founding in 2003: partnering with ministries of health in countries with fragile, under-resourced health systems to build strength in program services, research, training, data, and laboratory systems.
With Wafaa El-Sadr, MD, MPH, MPA, ICAP Global Director, Michaels-Strasser went to Sierra Leone in 2014. Michaels-Strasser will never forget the experience. The Ebola virus, which causes a devastating hemorrhagic fever that was ultimately fatal in roughly half of patients, crossed borders, popping up in three countries in West Africa, a region that had previously never had an Ebola outbreak. In Sierra Leone, it is estimated that up to one in five health care workers died of Ebola. The countries hit hardest had limited resources and a shortage of health care workers. Elsewhere in Africa, with prior experience with Ebola, the response is usually brisk, but in Sierra Leone, the response was slow.
El-Sadr vividly remembers the silence and fear that permeated the air as she and Michaels-Strasser walked into a remote village in Sierra Leone experiencing an Ebola surge. “We shared with the villagers ways to protect themselves and their families, walking them through how to suspect Ebola and the importance of seeking care for diagnosis rather than refraining from doing so due to stigma or fear of being shunned and isolated,” she recounts.
ICAP’s approach, honed over a decade leading the fight against HIV in Africa, was well-suited to this global health security emergency. “We know the steps necessary to build a resilient response,” says Michaels-Strasser. “We work hand in hand with the country’s government, following their lead in many ways, working with the resources that exist and incrementally improving laboratory and surveillance systems, health worker capacity, as well as community responses.”
The importance of ICAP’s work hit home when Ebola arrived in the U.S. that same year. Ultimately, nine people with Ebola arrived in the U.S., and there were two cases of secondary transmission within the country. It was the first time cases of Ebola were treated in the U.S. This experience was a wake-up call that viruses do not stop at borders, making it imperative to act fast.
ICAP was ready in 2022, when there was an outbreak of Ebola in Uganda. Working in South Sudan, which borders Uganda, ICAP fast-tracked Ebola preparedness, trained rapid-response teams, strengthened surveillance, helped ensure cross-border coordination, and supported community hotlines. “We worked with the South Sudan Ministry of Health to modernize its laboratory system to international accreditation, and we worked with the response teams to do full-scale simulations to be ready if and when Ebola crossed the border. Thankfully, it did not,” says Michaels-Strasser.
Academic Rigor, Meet Real World
When the COVID-19 pandemic shook the world in 2020, GHS took center stage in ICAP’s work. “Beyond the shadow of a doubt, the pandemic proved that we are all intricately connected,” says El-Sadr. “We can imagine that borders between countries and wide oceans will protect us. But in reality, we live in one interconnected world. Our safety and security are dependent on everyone else’s health and well-being.”
The success of ICAP’s work in GHS is embedded in its DNA. “ICAP is unique in that we are at an academic institution, a school of public health, in a big city—New York City. We have one foot in that academic world, and another firmly placed in the ‘real world.’ We anchor what we do in scientific evidence, then work diligently to design novel interventions and go to implementation and scale-up, always in partnership,” says El-Sadr.
The emphasis on evidence, data, and evaluation that is so ingrained in academic public health is evident in an ICAP project in South Sudan, a country racked by civil strife and suffering from fragile health systems. Working to improve the capacity of national health information systems to produce and use high-quality health data, ICAP strengthened community-based surveillance, detection, investigation, and reporting, critical elements in an effective infectious disease response. In one key aspect of this project, ICAP worked with the country to establish a national digital platform and monitoring system to support both routine data and, importantly, critical surveillance data to detect and monitor outbreaks. Similarly, ICAP’s work to enhance the quality of South Sudan’s laboratories prepared them for both day-to-day health monitoring and for unexpected health threats.
Primary Care Providers: The First Line of Defense
A key focus of global health security is ensuring that public health professionals can respond swiftly and accurately to an infectious disease outbreak. A guiding principle in responding to unexpected health threats is the 7-1-7 approach: identifying an outbreak within 7 days, informing government authorities within 1 day, and completing essential actions within 7 days. Achieving this goal shaped ICAP’s work in Sierra Leone, where, in partnership with the global health organization Resolve to Save Lives, ICAP worked to establish Epidemic Ready Primary Health Care—an approach that aims to strengthen primary health care systems to prevent, detect, and respond to outbreaks while maintaining essential health services.
Frontline health providers are the first line of defense. They play a critically important role in GHS. “Epidemics don’t present themselves at a national emergency operations center in the capital city,” says Michaels-Strasser. “They show themselves first at a rural clinic, most likely to a nurse who has never seen that condition before. So, this is where we must put our efforts and resources.” This means strengthening primary care workers’ knowledge and ability to be vigilant about uncommon presentations—from handwashing to the proper use of personal protective equipment (PPE) when necessary. To build these skills, ICAP used trained actors to make unannounced visits to rural clinics describing symptoms consistent with Ebola, for example, as experts watched to note how the nurses performed. Did they ask the right questions? Did they rapidly don protective equipment? Did they move “the patient” to an isolation room in the clinic?
The project ultimately grew from 80 clinics in phase one to 200 sites at completion. “The health workers are so proud. The program showed them how to be attentive to details, what to do, how to protect themselves and others,” says Michaels-Strasser, who also leads a fellowship for pandemic preparedness with NewYork-Presbyterian Hospital. Over the course of the project, there were measles and Mpox outbreaks in the country. At the same time, almost 3,000 health care workers at 450 health facilities were trained on standard infection prevention and control precautions—such as waste management practices, appropriate use of face shields and masks, and optimal cleaning practices.
“It is so heartening to note that the health workers were able to successfully focus on the four Is: identify, isolate, investigate, and inform. We could see the difference in the safety and speed of care that was provided to isolate infection and keep themselves and their colleagues safe,” Michaels-Strasser adds.
Scaling Up for Impact
While evidence and innovation form the foundation of ICAP’s work, its purpose is to bring to life, to implement, and to scale up. El-Sadr notes that the last stage in ICAP’s process is “scaling up” interventions that work. In the case of South Sudan, ICAP has dramatically increased the ability of the country’s small, local labs to detect a wide range of infectious diseases, “be it COVID-19, Mpox, Ebola, Hepatitis B and C, tuberculosis, and meningitis, among others,” says Habtamu Worku, MPH, ICAP’s South Sudan program director. The country has historically had only one central lab capable of detecting a range of infectious diseases. By comparison, in the U.S., there are more than 200 comparable labs. ICAP’s efforts enabled a strengthened decentralized laboratory system, accelerating the identification of infectious diseases before they spread.
Shaping a Generation of Disease Detectives
Capacity (at scale) is the premise of the Field Epidemiology Training Program (FETP) that ICAP has led in Eastern Europe and the South Caucasus since 2022. The goal is simple—to enhance local capacity to evaluate and strengthen public health surveillance systems, investigate outbreaks, and conduct field studies. In five workshops, participants from Ukraine, Georgia, Moldova, Armenia, and Azerbaijan learn to conduct disease surveillance, analyze data, detect and investigate outbreaks, and communicate with scientific and nonscientific audiences. Between these workshops, participants go back to their jobs and work on field projects to reinforce classroom learning. Field projects have focused on leptospirosis in Ukraine, anthrax in Georgia, brucellosis in Armenia, and salmonella in Moldova—offering real-world experience to put theory into action. Thus far, says Howard, FETP has graduated 68 individuals from the region across four cohorts.
From Day One, ICAP has believed in investing in people and systems, and this is true of its approach to GHS. “That is what is durable,” says El-Sadr. “The investments we and others have made have created a world in which people can work effectively together within their own countries and across borders to secure safe and thriving communities. Whether in Ukraine, facing war and destruction, or in remote rural areas of Africa, the resilience and determination of health workers is truly astonishing and inspiring.”
Photos courtesy of ICAP/Hugh Siegel. Banner image shows a technician testing HIV samples at the National Public Health Laboratory in Juba, South Sudan.