West Africa’s current Ebola epidemic is the deadliest in recorded history. Since Patient Zero, a two-year old boy from rural Guinea, died in December of 2013, the outbreak has spread through the country and into Nigeria, Liberia, and Sierra Leone, crippling already fragile healthcare infrastructures and garnering anxious international attention. The disease has no existing vaccine or cure and finds its natural host in fruit bats or other traditional bushmeat, making rural communities far-removed from reliable medical clinics and international food markets particularly susceptible. For affected countries, poverty is intensifying the already daunting task of controlling Ebola’s threatening spread. Nigeria is the least statistically impoverished, at 45th on the IMF’s list of the world’s poorest countries. Guinea and Sierra Leone make the top 25. Liberia sits perilously in fourth.
Even before fear of Ebola spurred research grants from Europe, Asia, and the Americas, foreign aid was an integral part of the economy in West African countries. The African Health Observatory’s statistical summary of federalized Sierra Leonean healthcare notes that “the sector is substantially dependent on external resources for funding.” The Free Health Care Initiative Policy, when implemented in the country in 2010, had an estimated cost of $35,840,173, of which 86.5 percent was provided by development partners that included the World Bank, the United Nations Children’s Fund, the United Kingdom’s Department for International Development, and the Asian Development Bank.
Despite socioeconomic modernization efforts in Sierra Leone, government and donor expenditures on healthcare continue to fall short of goals set by the Abuja declaration, a follow-up by the African Union to the Millenium Declaration of 2001. In 2011, the Ministry of Health and Sanitation received just 8.2 percent of the total government budget. Guinea spent 4.7 percent of their total budget on healthcare in 2007. To compare, the United States’ 2011 federal budget allotted 23 percent of the federal budget for healthcare initiatives.
Community funds exist and have, to an extent, evolved to cope with the deficit in federal aid. Such funds generally cover expenses that include obstetrics, nutritive supplements, and chronic illness, but a rampantly spreading pathogen as difficult as Ebola has drained existing resources and prompted responses from medical and non-medical NGOs alike. Fiona McLysaght, the Country Director in Sierra Leone for Concern Worldwide, a nonprofit organization that works to overcome the challenges of extreme poverty through sustainable solutions, acknowledged in a conversation with the HPR the limited funding available to combat Ebola: “The health systems in Sierra Leone are not equipped to deal with a public health crisis of this magnitude. Health systems like those in Europe and the United States have a much greater capacity to handle and contain an outbreak than do Sierra Leone or Liberia.” Without a recognized virus-specific option, treating Ebola follows the standard protocol of other intensive care; aid workers can only replace lost fluids and blood for those who are infected. With limited volunteers, equipment, and space, the existing infrastructure in Guinea, Liberia, Sierra Leone and Nigeria is simply too weak to maintain even this basic care for an extended period of time. For a country like Sierra Leone, whose medical capabilities are scarce enough that the 2008 healthy life expectancy at birth was less than 50 years, dealing with an infectious disease that’s claimed upwards of 1,500 lives has critically overtaxed human and technological resources.
Targeting Tradition
Cultural factors, such as consuming bushmeat and performing funeral rights—which even for victims of Ebola include washing, touching, and kissing the body—are exacerbating the spread of the disease despite campaigns for public education. Many civilians refuse to give up practices they believe are harmless. “Education is at the core of our response,” confirmed McLysaght. “Confusion is fueling the outbreak.”
Even foreign aid offices and NGOs with longstanding ties to communities affected by Ebola have been frustrated by the difficulty of convincing people to forgo tradition in lieu of preservation for the sake of pubic health and safety. As McLysaght pointed out, “Ebola is relatively difficult to spread, so having the basic information to prevent the disease can keep people from getting sick. However, we then have to deal with the ramifications of what some of that behavior change will mean. For example, if families who hunted for food can no longer eat that meat, what are we giving them as an alternative? Telling people not to eat wild animals can compromise a rural community’s food security. It is incredibly difficult to reverse deep-rooted cultural traditions and get ahead of the rumor mill.”
Jussi Laurikainen, a program coordinator for Finn Church Aid, the largest Finnish development cooperation organization and the second largest provider of humanitarian aid in Liberia, addressed the public stigma attached to foreign support in an interview with the HPR: “The fact is that Liberia is very dependent on foreign development aid. At the same time, Liberia is very corrupt, and many think that aid is going to the hands of politicians and government officials. During the first and second waves of the Ebola outbreak, February to March and June respectively, the common man might have thought that Ebola was a new way for the elite to pocket foreign aid.”
McLysaght agreed, “Some believe that the disease is politically motivated or spread by NGOs or the government.” Beyond the fear of corrupt politics, she continued, civilians mistrust the treatments available in Ebola-specialized clinics: “There is a widespread rumor that if you are diagnosed with Ebola, you are given an injection in a clinic to speed up your death, which is prompting people to flee and spread the disease.” In response, NGOs are leveraging their established relationships with village leaders, who according to McLysaght “are critical partners in building awareness, understanding what Ebola is, and curbing the hysteria.”
Work done by NGOs with community leaders is often independent of government direction. Regarding the administration of ground-level organizations, Laurikainen explained that such organizations receive updates about the disease from Ministries of Health, although “coordination of [their] Ebola response is done without the clear involvement of the government. There are many NGOs now who are trying to find out who is doing what, where and when in order to plan their own intervention. If the government would have taken Ebola seriously from the very beginning, then coordination mechanisms could have been set up earlier.”
Ethical Dilemmas and the Public’s Trust
Controlling the outbreak also means a delicate, diplomatic strategy is necessary for aid workers. Their efforts are further challenged without an approved vaccine or medication for Ebola, though the American biopharmaceutical company Mapp has developed an experimental drug known as ZMapp meant to combat the disease. The drug came into the spotlight when Dr. Sheikh Umar Khan, a virologist at Freetown’s Connaught Hospital responsible for treating more than a hundred Ebola patients, fell ill mid-July. International aid workers and doctors assigned to Dr. Khan’s case struggled with the ethical dilemma of providing an untested drug to a patient of his medical status. Not only was there the risk of an adverse reaction, but Dr. Khan’s condition was so far advanced that there was a significant possibility that even if the humanized monoclonal antibodies found in ZMapp were to function as planned, it would be too late to control his symptoms. Workers were worried that if the public were to learn that an important Sierra Leonean doctor had died after receiving Western medication, whether or not the medication caused his death, public mistrust would run rampant and encourage those seriously ill to avoid help at the peril of their own health and the health of those around them.
Suspicion of Western medicine has lingered as a result of the Trovan case. In 1996, Pfizer provided a drug called Trovan to treat a meningitis outbreak during which 12,000 people died in the Northern Nigerian state of Kano over a six-month period. The oral antibiotic was offered to 100 children, but after 11 children died and dozens were left physically or mentally disabled, Pfizer was sued by the government and the affected families. Because of the communicable nature of meningitis, autopsies are too dangerous and official documented causes of death were shrouded in ambiguity. This ambiguity allowed Pfizer attorneys to argue that the disease had caused the deaths, not the drug, but northern Nigeria persists as one of the few areas in the world in which polio remains endemic due to lingering suspicion of Western medicine.
The team on Dr. Khan’s case decided not to administer ZMapp, and he succumbed to the disease on July 29. Two American medical workers for the missionary agency Service in Mission (SIM), Dr. Kent Brantly and Nancy Writebol, were flown out of Liberia in early August, after also contracting Ebola. Both were treated at Emory University’s medical center with ZMapp, and have since recovered from the virus, though it is unclear whether the drug, the transfusions of blood from an Ebola survivor in Liberia, the substantially augmented care Emory provided, or a combination of all three were responsible for the patients’ recovery.
The international community is anxious to find a cure for and control the spread of the disease. Laurikainen explained that he “tend[s] to agree with experts who say that the situation will still get worse before it gets better. The UN Humanitarian Air Service is starting operations in the affected countries, so they are expecting this situation to last.” Either way, arresting the outbreak will require the cooperation of a multinational healthcare force, and will set the stage for discussions about the need to reform crisis management protocols in impoverished countries. McLysaght sees the involvement of NGOs evolving with the outbreak to best serve the medical and psycho-social needs of affected communities. Efforts to contain the outbreak are ongoing, and while medical and NGO personnel continue working to heal patients and communities, they are also looking to develop strategies to prevent the disease from resurfacing. This is the twenty-eighth recorded Ebola outbreak since its discovery in 1976; averting a twenty-ninth will be the most important effort made towards healing the countries, relationships, and lives of those left behind.
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