Ebola control: A global Health case study

Ebola control
Ebola control

An evaluation and critical analysis of Ebola control: A global Health case study

Introduction

 Emerging infectious disease seems to be risk in conflict affected regions. For instance, the impact of Ebola outbreak in 2014-15 was highest in regions that were conflict affected in the recent past.  Despite the slow response, the 2014-15 outbreaks in West Africa received most attention than other public health issues. However, the public health institution has paid very little attention to evaluate the complex interaction of conflict, its consequences and its implication for the local, regional and international health systems (Corsi, 2014).

This research conducts a critical analysis on Ebola control to evaluate the elements of conflict affected societies that hinder effective control of emerging infections outbreak, and to evaluate the strategies that facilitate or hinder effective control of these emerging infections before a catastrophic situation occurs. The global perspective case study is expected to have implications for the types of strategies needed to facilitate effective response to Zoonotic diseases such as Ebola in conflict afflicted regions.

 Summary of the case study

A new outbreak of Ebola Virus (EV) was identified in West Africa in March, 2014. The first cases of EV virus were reported on the border of Guinea Conakry with Liberia and Sierra Leone. The transmission of the virus became intense in the aforementioned country, but there were few outbreak incidences in the neighboring countries including Nigeria, Senegal, and Mali.  

By January 2015, the EV virus outbreak in West Africa had affected more than 22,000 people and 8,800 deaths. Small unrelated EV virus outbreak also occurred in Democratic Republic of Congo (DRC) between the months of July and October 2014. The cases were also reported in other countries outside Africa including Spain (1 person was infected) and 2 incidences in America (McPake et al. 2015).

The first outbreak of EV virus took place in Zaire (now known as DRC) in 1976; and was named after a nearby river – Ebola River. Similar outbreaks was experienced Sudan, but the EV strain was different from that of DRC. Since then, there are more than 25 EV outbreaks that have occurred in Africa, and five EV virus strains have been identified (McPake et al. 2015).

The latest EV virus outbreak in West Africa was the largest ever, given the number of people it affected and the countries involved. This is followed by the 2000 EV virus outbreak in Uganda which affected more than 425 people. Prior to these aforementioned EV virus outbreaks, these regions were conflict affected in the recent past which suggests a complex interaction between conflict and emerging infections outbreaks (Okware et al., 2002).

Discussion

It is known that wars, conflicts and population displacement pose significant risk for outbreaks of infectious diseases due to overpopulation, combined livelihood, water and food shortages. Some of the health outbreaks related to conflicts includes re-emergence of African Trypanosomiasis in Angola, Uganda and Sudan (Ford, 2007). Bausch and colleagues also describes the impact of political unrest in DRC and delayed response to Marburg virus outbreaks (Bausch et al., 2003).  Several studies have confirmed the statistical relationship between the occurrence of conflicts, natural disasters and epidemics (McPake et al., 2015).

Undeniably, war drives a society towards marginal substance and is associated with multiple implications on the society’s health and economy. For instance, during conflicts vegetation may be deliberately become destroyed and residents may permanently or temporarily lose access to these lands, and often become separated from their normal means of livelihood. The conflict implications may last into post conflict periods.

Consequently, the states may become dysfunctional and weak. The fragile governance finds it challenging to deliver core functions to most of its people. This is because they lack political capacity and will to deliver the basic functions of a society such as security, human right, economic development and public health.

 Newbrander and colleagues describes conflict affected health systems as poorly coordinated with insufficient coordination and monitoring. This results into reduced equity of health resources due to poor mechanisms to develop, establish and to implement the health strategies. In these types of systems, the health information system is non-operational due to inadequate management capacity, lack of infrastructure, non existence referrals and inadequate capacity to deliver health services to a large population (Newbrander et al., 2011).  

Despite the fact that this list is comprehensive, it basically outlines the  typical characteristics of Middle income healthcare systems. The main domain that is absent in this list is health human resource shortages, making preventive care to stall during the conflict periods, thereby increasing the likelihood of emerging infections outbreaks (Corsi, 2014).

Other proposed description of health systems in conflict affected areas are best understood when one evaluates the consequences of violence and conflict. For instance, in most conflict affected areas, the health workers tend to desert especially if there is a specific risk factor that affects them in excess as compared to the rest of the population. Conflicts also damages healthcare infrastructures used to make disease surveillance and to monitor controls of emerging infections (Annan, 2014).

Notably, the flight of healthcare human resource in conflict affected areas does not result to generalized shortages, but skewed shortages in areas perceived as most insecure- often rural and remote areas. In some incidences, the prolonged conflicts could result into missing a generation of healthcare providers due to prolonged periods of no or little recruitment and training.

This may lead to absurd events such as having inexperienced staff being promoted in senior positions such as the management of public health at national level and representing negotiations with other international health agencies. This undermines the ability to effectively collaborate with the international agencies to monitor or provide support in order to curb potential outbreaks in the conflict affected region (Newbrander et al., 2011). 

For instance, Ebola virus outbreak in Uganda (2000) emerged in conflict afflicted region – Gulu district. The index case of this outbreak is yet to be identified, but it is associated with movement of people across Sudan, Uganda and DRC. The incidence was speculated that the disease was carried by Sudanese rebels that operated in Gulu district, or Uganda armed forces that had returned from Congo. This highlights that movements of people from conflict affected areas to other regions may carry emerging disease pathogens with them.  This has also been demonstrated by cholera outbreaks in Haiti (McPake et al., 2015).

The EV virus outbreak in Uganda was controlled effectively and the success can be attributed to prompt action and proper coordination of care.  Effective public communication created an appropriate community protocols that were effective when dealing with infectious diseases among the communities. There was also extensive surveillance mechanism that reached into rural communities, and in cases of suspicious death, they used trained burial teams.

Okware and colleagues report that media have major role to play during outbreaks in conflict affected areas. Fortunately, the media reports back then was supportive and performed a major role in controlling behaviors by delivering reassuring news that limited anxiety and panic. This implies that the government should use the media strategically to advise their community about the effective precautions and control measures (Okware et al, 2002; Linda and Ndebe, 2015).

Some of failures in healthcare system in this case study are that the healthcare providers were forced to work even in areas that still had conflicts. The healthcare providers were escorted by Ugandan army to insecure areas. Due to the continued conflicts, medical supplies were insufficient during the early phase of the outbreak, which led to infection of 14-22 health workers. Initially, the health workers were not compensated for additional risks and there were no compensations to their families incase of their deaths until two months later into the EV virus outbreak (McPake et al., 2015).

In addition, during an outbreak, the communities have their own perspective about the disease. In this case, the community would seek for traditional treatment and when it failed, the illness would be classified as a curse and most people responded by isolating the sick. In the first phase, burials were the main source of transmission, especially in females exposed to traditional practices.

Another common issue evident in this case study is the issue of distrust between the locals and the international social workers. It is suggested that most people feared visiting the hospitals due to rumors that their body parts would be stolen if they died. This stigmatization between the locals and foreigners also contributed to the spread of the outbreak. Therefore, it is evident that distrust between the national government and the regional conflict constrains the outbreak control efforts. For instance, there were high suspicions regarding the rationale behind the rapid and isolated burial tradition (Roca et al., 2015).

The Sierra Leone EV virus outbreak in 2014-15 is believed to have originated from a 2 years old child in Guinea forest, in 2013, who was most likely infected by a fruit bat. The disease reached the health workers by January 2014, but the ministry of health was notified in March.

Although basic control measures such as early diagnosis, quarantine, infection control strategies, contact tracing, disinfection and safe burial were implemented; they were implemented slowly in the three West Africa countries due to shortages of staffs trained in infection prevention and control (McPake et al., 2015). They also lacked protective gears and had limited clinical management as well as surveillances capacities.

The success of outbreak control measures were hindered by lack of cooperation between the residents, States healthy system and international response. In addition, the deep rooted cultural values and beliefs resulted into lack of trust on the government- which could be linked to distrust created by increased regional conflicts and rivalries. The disease transmission spread across the borders due to population movement. In addition, the initial media response was unhelpful as it pointed fingers to the government claiming that incompetence in ministry of health and corruption failed to support the public health adequately (Ebola, n.d.).  

Despite the fact that the international agencies declared the outbreak as a “Public Health Emergency of International Concern,” the international response in West Africa was sluggish. In addition, the health workforce in the West Africa was inadequate, unequally distributed and lacked skillful training for the task at hand. Medical teams in middle income countries are generally understaffed, de-motivated, overworked and ill equipped to manage an outbreak of such magnitude.

It is also documented that these countries delay payment of financial incentives to attract, motivate and retain health workers in rural areas. In this case, the environment is not conducive to practice infection preventive surveillances and control. The collective factors increased attrition from healthcare providers and reduced trust between health services providers and users. Therefore, the service users became more accustomed to seeking treatments from traditional healers (Annan, 2014).

Recommendations

 From this critical analysis, the study identifies the main recommendations that will help improve detection and control of infectious diseases. To start with, detection and control of emerging infectious diseases demands for functional healthcare systems. This implies that the government should invest in human resources, infrastructure, training and provision of the necessary medical supplies such as drugs, vaccines and equipment. 

The international agencies such as non-governmental organizations and United Nations Agencies must recognize their roles in middle income countries, especially those conflicts affected   in order to provide adequate humanitarian assistance and coordinate care during outbreaks (McPake et al., 2015).

In such incidences, good hygiene and appropriate standard infection control strategies in the region are required so as to reduce potential transmission and amplification of the disease.  The healthcare providers should give the correct guidance on the rationale of infection control and use of PPE, and quarantine based on the potential exposure and the risk of infection. The guidance should be supported with consistent supply of PPE, disinfectants and drugs because shortages in these supplies may become a breach in infection control (Annan, 2014).

 Surveillances on the disease incidence and trends are essential because they help to identify priorities, plan and implement interventions. The surveillance system should rely closely with NGOs, community and international organizations so that they can provide resources and capacities of present organizations. The system must demand for immediate reporting for potential outbreaks to the relevant authorities (Linda and Ndebe, 2015).

Lastly, every nation should establish and implement epidemic preparedness such s training of staff on ways to manage an outbreak, use of surveillance tools to manage epidemic prone infections and equipping the conflict affected regions with appropriate infrastructures and means of communication. They should have ample isolation facilities, lab and mechanism to transport the specimen to the relevant authority (Roca et al., 2015).

Conclusion

 Beyond the public health objectives of preventing the emergence and spread of infectious disease, it is important for the international agencies to alleviate the impacts of the outbreaks on the vulnerable conflict- affected areas.  This is because the conflict afflicted regions represent the weakest links in health security globally, and must be prioritized by the international agencies so as to provide adequate support in operational and technical support, and to implement core capacities to detect and respond to potential epidemics effectively. 

References

Annan, N. (2014). Violent conflicts and civil strife in West Africa: causes, challenges and prospects. Stability. 3(1):3

Bausch, D.G., Borchert, M., Grein, T., et al.(2003). Risk factors for Marburg hemorrhagic fever, Democratic Republic of the Congo. Emerg Infect Dis. 9(12):1531–7

Corsi, Jerome R (2014). “Ebola Continues to Rage in Sierra Leone.” WND. Available at: http://www.wnd.com/2014/12/ebola-continues-to-rage-in-sierra-leone/

“Ebola: The world needs humanitarian workers in West Africa.” International Committee of the Red Cross. Available at: https://www.icrc.org/en/document/ebola-world-needs-humanitarian-workers-west-africa

Ford, L.B.  (2007). Civil conflict and sleeping sickness in Africa in general and Uganda in particular. Conflict Health. 1:6.

Lind, J., & Ndebe, J. (2015). Return of the rebel: legagies of war and reconstruction in West Africa’s Ebola epidemic. Sussex: Institute for Development Studies, Practice Paper in Brief; 2015. Retrieved from http://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/5852/ID560%20Online.pdf;jsessionid=12DFE0335D13760EE2E8646708A2BF9B?sequence=1.

McPake, B., Witter, S., Ssali, S., Wurie, H., Namakula, J., & Ssengooba, F. (2015). Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone. Conflict and Health, 9, 23. http://doi.org/10.1186/s13031-015-0052-7

Newbrander, W., Waldman, R., Shepherd-Banigan M. (2011). Rebuilding and strengthening health systems and providing basic health services in fragile states. Disasters. 2011;43(4):639–60.

Okware, S. I., Omaswa, F.G., Zaramba, S., Opio, A., Lutwama, J.J., Kamugisha, J, et al. (2002) An outbreak of Ebola in Uganda. Trop Med Int Health. 7(12):1068–75.

Roca, A., Afolabi, M. O., Saidu, Y., & Kampmann, B. (2015). Ebola: A holistic approach is required to achieve effective management and control. The Journal of Allergy and Clinical Immunology, 135(4), 856–867. http://doi.org/10.1016/j.jaci.2015.02.015

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