(1st part of two-part communication – you find the second part here )

 

Despite widespread global awareness of the ongoing Ebola crisis in West Africa, humanitarian and relief organizations on the ground say the current response is inadequate to effectively contain the epidemic, even if some progress is noticeable. The debate on the international response has been fierce in recent months. But has Africa, at the epicenter of this crisis, demonstrated the necessary leadership in the ongoing fight against Ebola? This first part of a two-part communication spotlights African responders and responses to the Ebola epidemic. A second piece will then weigh the pros and cons of Africa’s response so far, with a focus on whether things are headed in the right direction to stem this crisis where it began. (We are well aware we are chasing a moving target here.)

Africa is facing its most horrific Ebola outbreak to date. Till now more than 18,000 cases and over 6500 deaths have resulted from this Ebola epidemic, which began in Guinea and spread rapidly to Liberia and Sierra Leone. In spite of a heightened sense of urgency, the human and medical resources needed to address the epidemic still far outweigh the capacity of humanitarian and relief organizations offering critical support through health personnel, medical supplies, food, quarantine services, and community education. The number of cases being reported daily has fallen, at least in Liberia, but transmission continues in the three hardest hit countries, with Sierra Leone currently as the biggest worry. Aid and healthcare workers are constantly at risk of infection, with several such cases garnering international media attention. The UN Mission for Ebola Emergency Response (UNMEER)’s 70-70-60 goals – to get 70% of the cases isolated and treated, and 70% of the deceased safely buried within 60 days starting from 01 October to 01 December turned out to be too ambitious. Nevertheless, the hope is that in 2015, African and the world will manage to get this Ebola outbreak under control.

Expert opinions differ about who should bear primary responsibility for the crisis in West Africa. Lately the mantra has been that we should ‘stop the blame game’, at least until the crisis is over (Margaret Chan did so, but see for example also here). That seems to make sense. Anyhow – just as some background for this communication then – some observers attribute challenges with containing the infection to delayed  international awareness and hence a belated response to the crisis. Others blame the rapid spread of the epidemic on fragile health systems in West African states; depending on the perspective of analysts, they refer to civil war & post-conflict reconstruction difficulties or, instead, to neoliberal policies, structural violence and/or a GHI “vertical” focus on diseases to explain these weak health systems (and the weak governance situation in general). No doubt last week’s WHO High level meeting in Geneva on building resilient systems for health in Ebola-affected countries also offered some explanations for poor health systems – the background document gives some more detail on the pre-Ebola health systems (as well as on the current health system situation).

As is well known by now, the WHO and especially its regional office for Africa (WHO AFRO) and some country offices have been harshly criticized for their response, as demonstrating poor and incapacitated leadership (see for example an editorial in the Lancet). According to last week’s Economist issue, WHO top staff in the three main affected countries have even been removed by Margaret Chan, presumably not because she was extremely happy about their performance. Prominent African voices have also critiqued government and regional responses across Africa as being marginal, and shamelessly dependent on Western aid to handle the crisis – not the least because of the seemingly colonial carving up of the response (with UK assisting in Sierra Leone, the US in Liberia and France in Guinea). Conversely, though, other documented responses portray a resurgent Africa fighting Ebola with grassroots initiatives that make apt use of social capital and media. Like SARS and the HIV/AIDS pandemic before it, Ebola has entered the niche of truly global threats to health that defy confinement to their place of origin – what David Fidler calls ‘post-Westphalian’ public health. With incapacitated health systems, West Africa is unlikely to effectively contain the epidemic without international support. They’re working on it, including on “post-Ebola” health systems, together with the international community – see last week’s ‘building resilient health systems’ meeting in Geneva. But the question we’re interested in here, is: despite limited capacity, has Africa somehow demonstrated the resolve to take leadership in stemming this horrific global crisis? Let’s try to map the responses, without aiming to be exhaustive as the situation still changes fast.

 

African governments, regional institutions and other stakeholders

 

The Economic Community of West African States (ECOWAS), WHO Afro and other West African stakeholders including ministers of health, donors, and industry representatives already obtained member state consensus at an emergency meeting in Accra, Ghana in early July, convened by WHO Afro, on how best to interrupt ebola transmission and limit the human, economic and social impact of the epidemic and any future outbreaks (WHO & governments of Guinea, Liberia & Sierra Leone Ebola response plan W/A). The two main goals agreed upon then were to stop transmission in affected areas by scaling up proven interventions, and to limit spread through better preparedness and response. This led to the adoption of a strategy for an accelerated response to Ebola which ECOWAS is implementing. National governments in Guinea, Liberia, and Sierra Leone pledged $0.7 million, $6.2 million and $17 million USD respectively to support national responses from July to December 2014. This left an overwhelming shortfall of over $71 million to implement the response plan.  In September this year, the WHO launched a global appeal for more than $1 billion USD to confront Ebola. By the end of October 2014, no African countries were on the UN list of international donors to fight Ebola. Pledges of support from African countries in terms of personnel and resources were also yet to be fulfilled at the time.

The African Union (AU), criticized for not responding until 4 to 6 months after the crisis began, released $1 million USD for medical supplies from its emergency fund for drought and famine in August 2014. In September, staff and members donated an additional $100,000. The AU also formed the African Union Support to the Ebola Outbreak in West Africa (ASEOWA) (humanitarian) mission, finalized a concept of operations, and deployed the first set of paid volunteers to Liberia in September. The task force comprises epidemiologists, clinicians and communications personnel, and facilitates existing field response operations by means of “technical expertise, resources, political and financial support”. The mission also includes expertise from WHO, UNOCHA, IFRC, US Mission to AU, CDC and others. Plans are underway to deploy volunteers to Sierra Leone and Guinea.

The (response) track record of the African Development Bank (AfDB) looks a bit better. It contributed over $3 million USD in May and approved a further $60 million in grants to support the emergency response, as part of an overall $210 million investment to strengthen health systems in West Africa. The investments will focus on boosting human resource capacity, epidemic preparedness and response, mobile technology (m-health), governance and regional institutions. AfDB has also signed a $300,000 grant protocol together with ECOWAS, to support affected countries, ECOWAS and the Mano River Union to deal with Ebola. (figures from a while ago)

Colonial lines were drawn again for (international) Ebola aid  (in line with institutional aid relationships between the United States and Liberia, the U.K. and Sierra Leone, and France and Guinea ), but the three national governments of affected countries also took action, even if perhaps belated. Like their population, they had to go through a ‘learning curve’ (see for instance the involvement of the military) in dealing with Ebola, and cope with low levels of trust and limited governance capacity in general. Liberia re-institutionalized its Ebola response unit within the Ministry of Health and Social Welfare, and employed the CDC’s incident management system to increase national autonomy over managing the Ebola response in the country. The Liberia Institute for Biomedical Research is also receiving training from WHO on safe collection of oral swabs and identification of cause of death. After initial skepticism to play down the severity of the epidemic, the President of Guinea is now very directly involved in stemming Ebola infections and transmission in the country – and you can take that quite literally. The grim situation in Sierra Leone (the most worrying setting for the moment) raises awkward questions among the population and abroad – see  Laurie Garrett for example in Foreign Policy, on the question why the situation in Liberia seems to improve steadily while the Ebola outbreak in Sierra Leone is still spiraling out of control. WHO’s Bruce Aylward even thinks that part of the reason is that the people in Sierra Leone didn’t go through the same behavioural learning curve yet (as in Liberia & Guinea).

Nevertheless, Sierra Leone also demonstrates the selflessness of health workers fighting Ebola on the frontlines, with no guarantee of recovery if infected in the line of duty, and with often shaky payment modalities. These African health workers and their heroic response stand in stark contrast with the rather marginal contributions from most African leaders and institutions. Foreign aid and health workers suspected of contracting the infection are typically flown outside to Western countries for treatment, where they stand an arguably better chance of recovery. On the contrary, local health workers are treated in-country, with few survival stories. Worse, The Lancet just reported that local doctors went on strike in Sierra Leone after it emerged that they would not be able to access a specialised British-run Ebola treatment unit for health-care workers. We hope this can be solved soon. Anyhow, no matter whether they’re local or foreign, health workers engaged in the fight against Ebola are all heroes, as Time Magazine acknowledged last week. The same goes for the burial workers, a very unthankful but vital job.

Nigeria, Senegal, DRC, and some communities within Guinea, have successfully contained the spread of the disease (and Mali seems to be heading in the same direction, touch wood). These and other countries in the region are – to some extent at least – sharing their resources and expertise to limit the spread of infection (even if neighbouring countries also sealed off borders, regrettably). WHO helps (is helping?) countries in the region prepare for the event of an Ebola outbreak. Among others, The Gambia and Botswana also gave a monetary contribution. Nigeria pledged $3.5 million to the three affected countries, to the West African Health Organization (WAHO) and to the ECOWAS Pool Fund. In Senegal, public awareness through an existing SMS  platform proved successful in combating the epidemic. The DRC promised to send 1000 volunteers to the affected regions. The Telimele district in Guinea set an example by becoming Ebola-free by supporting healthcare interventions with a crisis committee involving religious, community and political leaders to promote awareness and aid case containment.

Other African countries also committed money, staff and/or medical supplies, whereas Ghana serves as a base for UNMEER. Kenya, Namibia, and Cote d’Ivoire have each pledged $1 million USD; Ethiopia $500,000 and 200 volunteers, and South Africa approximately $4.5 million and diagnostic laboratory support. Uganda has deployed health workers to support the ongoing response in affected countries. South Africa has been instrumental in some more ways. A South African diagnostic center in Sierra Leone is training local personnel to assist with diagnosing Ebola. The UNDP is deploying South African-produced sterilizing units suited to low resource environments, to limit infection spread through medical waste. South Africa’s National Institute of Communicable Diseases is set to host a regional center of excellence to diagnose Ebola. Private and public sector donations of approximately R50-million have also been mobilized for the international Health and Humanitarian Response in Guinea, Liberia and Sierra Leone. Additional financial pledges have been made by leading businesses in Africa ($28 million – probably far more by now).

So it’s not like nothing has been done by African government actors, regional institutions and other stakeholders. Nevertheless, the overall feeling was one of ‘relatively little, and rather late’.

 

Grassroots initiatives

 

The grassroots picture has been more uplifting. Local non-governmental organizations and Africans in the diaspora are using social mobilization and public awareness campaigns to inform affected communities, reduce fear and resistance to health personnel. Below you find some of the key examples.

Africacare has raised over $70,000 USD to support medical supplies for health workers and behavior change messages to help contain ebola. More than 200 primary healthcare workers and 350 community health volunteers in Liberia have been trained and given necessary supplies. Over 100,000 community residents have received behavior change communication to limit infection spread. ActionAid (Liberia), Africa 2.0, and Restless Development (Sierra Leone) support social mobilization, provide a stable supply of personal protective equipment to frontline responders and train a local WASH Committee for monitoring active cases using the Ministry of Heath guidelines. LunchBox Gift provides food to victims and affected families in hospitals, orphanages and quarantine zones in Sierra Leone. HOPE provides Sierra Leonean families with food and sanitation kits, and trains community leaders to provide awareness, education, and psychosocial support. THINK helps to connect affected children and youth to transit quarantine centers to facilitate treatment and integration into foster families, with regular monitoring visits. More Than Me (Liberia) has launched a mobile application to track the infected cases and families, assist ambulance teams to capture vital information, and track movements of health workers. A Liberian student at Ashesi supports real-time tracking of new cases, and potential contacts to limit the spread of the disease. Africans in the Diaspora (Liberia) supports grassroots organizations through the Africa Responds platform – to pool their resources and networks to increase solidarity. African celebrities including Tiken Jah Fakoly, Amadou & Mariam, Salif Keita, Oumou Snagare, have collaborated to promote awareness through a song whose lyrics explain how to stop the spread of Ebola. The song went viral. Several African football stars have collaborated with Hollywood actor Idris Elba (of African descent) to  launch a campaign to support health workers on the frontlines with the necessary supplies to protect themselves from infection. This campaign recognizes the health workers, the burial teams, and all stakeholders on the ground for the heroic act of working to save lives, while putting themselves in harm’s way.

As for religious stakeholders, it is clear that especially at the beginning, traditional healers, pastors and other religious groups didn’t always play a positive role – from a public health point of view – but recently there has been progress, and religious leaders have played a more constructive role, for example in raising awareness. The picture for the (mass) and social media was equally ambiguous, not unlike in the West (see the US). Fearmongering and sound information redressing misconceptions – with Ebola deeply, founded by Isha Sesay from Sierra Leone, as a key example of the latter, were both present.

Previous discussions on an African-based Center for Disease Prevention and Control (ACDCP), an African equivalent for the CDC and a long awaited centre to help in addressing emergencies on the continent, have been revived in the wake of the crisis and are now being fast tracked by the AU. This might be one of the key tools necessary to ensure implementation of the International Health Regulations across Africa (together with the WHO health system resilience actions considered at last week’s meeting in Geneva). Forty-three of 46 African countries reported assessments of the core capacities for these regulations, yet none have begun implementation, according to a Lancet Letter from a few weeks ago.

Let’s hope that will change soon. For a preliminary analysis of the African response till now, check out the second part of this two-part communication!