Opinion
Tommy Trenchard / Al Jazeera

Ebola outbreak spotlights the limits of local and international response

Global and West African governments’ actions are inadequate for the danger

July 30, 2014 3:00PM ET

The Ebola epidemic in West Africa is unprecedented. The deadly virus, which passes through contact with bodily fluids and causes severe fever, nausea and hemorrhaging, has not previously been reported in the region, and the current outbreak is the largest on record. Amid fears that infections are widening, the disease has been reported in Guinea, Liberia, Sierra Leone and Nigeria. Since the virus was first reported, in Guinea in March, 672 people have died out of the 1,201 Ebola cases identified, according to the World Health Organization.

There is no sign that the spread is slowing. Last week the virus was reported in Nigeria for the first time. Authorities said a symptomatic man was quarantined immediately upon arrival in Lagos after flying from Monrovia (he has since died). Between July 21 and 23 more than 100 new Ebola cases were reported in Guinea, Liberia and Sierra Leone.

Even front-line responders are falling ill. On July 25, a Liberian doctor infected with Ebola died. The chief doctor combating the disease in Sierra Leone died this week, and two Americans working with the aid organization Samaritan’s Purse in Liberia — one a doctor — have become infected. Of the first 70 Ebola-related deaths reported in Guinea, four were of health workers. While consistent with previous epidemics, illness and deaths among the few health workers available to treat patients is deeply concerning.

The epidemic has highlighted a lack of resources, preparation and infrastructure at both the regional and international levels. In the countries affected by the current epidemic, limited resources are constraining the response to the crisis. All three countries severely hit in the latest outbreak have poor health care infrastructure. In two surveys conducted by Afrobarometer in 2012 and 2013, a large portion of citizens in Guinea (77 percent), Liberia (52 percent) and Sierra Leone (48 percent) said accessing a public health clinic or hospital was difficult. Moreover, those numbers capture only the challenge of reaching a clinic — not the condition of the clinic and whether it is adequately staffed. These countries already struggle with serious health worker shortages. For example, Liberia has just 0.014 doctors per 1,000 people.

Consequently, in responding to the latest Ebola outbreak these countries had to rely on assistance from international agencies including technical expertise, equipment, supplies and medical personnel. But even international agencies are stretched; the medical organization Doctors Without Borders (Médecins Sans Frontières, or MSF) has called on the international community to provide more resources, repeatedly warning that it has reached the limit of its capacity to provide care.

The world, in short, is being told that it is not up to the task of responding to this epidemic. Closer study should provide valuable lessons for resolving the crisis and preventing future outbreaks.

Fear and mistrust

People who are navigating the epidemic are — unsurprisingly — frightened, mistrustful and upset. Ebola is deadly and has no vaccine or cure. The context of weak public health care provision means people have limited experience with formal health care. In some areas the infusion of health workers from abroad (or domestic health workers from other parts of the country) has fueled rumors that the plague came with the medical personnel treating the infected. People are fearful and suspicious of medical staff working in clinics where they have watched many ill people enter and few leave. It doesn’t help that health workers must don head-to-toe protective suits. 

ebola west africa
Healthcare workers treating Ebola patients shown in full protective clothing.
Tommy Trenchard / Al Jazeera

Such fear and mistrust has led to violence at clinics treating Ebola patients. In April, a crowd attacked a clinic in Guinea, accusing MSF health workers of bringing Ebola to the country. Last week thousands in Sierra Leone marched on an Ebola treatment center, threatening “to burn it down and remove the patients,” reportedly following comments by one of the clinic’s former nurses, who allegedly said, “Ebola was unreal and a gimmick aimed at carrying out cannibalistic rituals.”

Locals are also protesting the regional governments’ handling of the epidemic. On July 23, a Liberian man set the country’s Health Ministry offices on fire in protest of the government’s handling of Ebola, reportedly after losing his sister to the disease.

The protests and the violence are no doubt counterproductive to eradicating Ebola, but it is instructive to view the situation from the perspective of those living in the midst of the worst-ever epidemic. Most of these countries have never experienced Ebola before. As such, the death of patients at clinics treating the disease may force people to wonder whether white doctors covered in odd suits are in fact the cause of the problem.

This is not to say the efforts by medical staff — both domestic and international — should  bring negative responses from the public. But it is important for the health care providers to recognize why it is crucial to work with local communities to combat this epidemic and minimize the potential for fear and suspicion. Such practice has already proved effective. For example, in Guinea, when local community organizations worked closely with MSF to fight Ebola, the survival rate was 75 percent. In the long run, provision of adequate public health services will reduce the mistrust of medical staff and also increase human resources to handle future epidemics without such strong dependence on foreign assistance.

Regional leaders should improve their response by providing for health care workers and by shunning dramatic but empty gestures such as criminalization of health care avoidance or border closures.

A lack of coordination

There are a number of other challenges complicating government response in the short run. First, the epidemic is spread out across multiple regions in the three countries severely affected and has required coordination across a myriad of domestic and international agencies. Second, without a clearly defined leader in global health governance, it is difficult for international health agencies to motivate domestic government responses. Third, because of the cross-border nature of the current epidemic, eradicating Ebola will be successful only if all the three countries — and international partners — respond effectively.

ebola cdc map
CDC

So far, the regional response to the current epidemic has varied widely. Initial response underestimated Ebola, and the governments were slow in responding. At the end of April, reports suggesting the decline of the disease led to premature “relaxation” of effective control measures. Once the gravity of the outbreak became clear, the governments of Guinea, Sierra Leone and Liberia took actions in accordance with their international obligations (e.g., reporting cases to the WHO).

However, recent government efforts in these countries raise serious concerns. On June 30, Liberian President Ellen Johnson Sirleaf proclaimed that the government would prosecute anyone “reported to be holding suspected Ebola cases in homes or prayer houses.” Sierra Leonean President Ernest Bai Koroma made a similar statement. But these threats of prosecution are toothless. If a government is ill equipped to provide basic health services in far-flung regions of the country, how can it prosecute evasion of health care? Furthermore, punitive measures may have the opposite effect, encouraging families not to go public about the potential infection of loved ones, increasing the chances of Ebola’s continued spread.

On July 27, in an even more dramatic move, the Liberian government announced plans to close all the country’s borders except major entry points. In mid-June, Sierra Leone closed its borders with Guinea and Liberia. Border closures are more a performance act than an infectious disease response strategy. Isolation works at the individual level, but the WHO actually advises against border closures.

Similarly, on July 28, the Nigerian government announced that the hospital where a Liberian man died of Ebola has been shut down for the next week and that some hospital staff who came into close contact with the victim had been isolated. Ebola is not an airborne disease. It requires contact with bodily fluids from an infected person. If the staff members who came into close contact with the patient are isolated, it is not clear why the hospital needs to be shut down.

An inability to respond

Border closures and the shutting down of hospitals underscore the governments’ inability to respond to the epidemic. Were the state better equipped to deal with the outbreak, anyone coming into contact with a presumed or confirmed case could be identified and isolated. The severe health worker shortage impedes capacity to do so.

Given the shortage of health workers, it is imperative that governments protect the few responders they have on the front lines. Failure to provide health workers with protective gear and adequate pay undermines the ability to curb the spread of the virus. The infection of health care providers reduces the number of personnel available to treat patients, but there are also follow-on impacts: Health workers will be wary of going to work, for example. For example, lab technicians went on strike in mid-July after the government failed to follow through on promised hazard pay for those working at Sierra Leone’s only Ebola-testing facility.

Governments cannot effectively ramp up their capacity to provide care overnight — particularly not during the throes of the worst Ebola epidemic. But they can improve their response by providing for those who are on the front lines and by shunning dramatic but empty gestures such as criminalization of health care avoidance or border closures.

Kim Yi Dionne is Five College Assistant Professor of Government at Smith College.

The views expressed in this article are the author's own and do not necessarily reflect Al Jazeera America's editorial policy.

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