Securing the Spread: Community Engagement and the Military Management of Ebola in Sierra Leone

Britain’s increased efforts come in the context of a rising total of 4,447 deaths since 8 October in seven affected countries including those with widespread transmission (Sierra Leone, Liberia, Guinea), and more localised transmission (Spain and the United States).The UK’s military involvement is aimed at supporting Sierra Leone’s public health service to oversee and construct medical facilities and a training academy for the treatment of Ebola, as well as the use of helicopters for rapid movement of personnel and supplies in a country plagued by poor infrastructure.   

The UK has not only stepped up its efforts abroad but is preparing itself at home to identify and contain the medical risks. Airport screening has started at Heathrow this week soon to be followed by Gatwick airport and Eurostar rail terminals, an outbreak simulation was conducted to test the response of the NHS and calls to the NHS non-emergency number 111 are being monitored, with some being questioned about their recent travel history. 

Amidst these preparations for a worst case scenario, and with a growing belief that Ebola poses a risk to public health in the UK, the Ebola virus has highlighted the danger of an interconnected world without an adequate universal health care system, and where the defence of Britain again means the deployment of troops to another part of the world. It has also exposed the importance of social factors in the containment of disease.

Factors behind the outbreak

'No country is safe', said Anthony Banbury, head of the UN Mission for Ebola Emergency Response (UNMEER) but some are a little more safe. In particular,  the World Health Organisation (WHO) has highlighted a number of factors that have contributed to the devastating effect of Ebola. Two of the most significant are the lack of resources and trained medical staff (around 2.2 doctors for every 100,000 people in Sierra Leone, and one for every 70,000 in Liberia, with most concentrated in urban areas), but even those who are trained do not have the equipment to protect themselves when treating patients. Recent figures suggest around 233 healthcare workers have died treating patients in affected areas around the region. The extent of this danger does not stop at the availability of protective clothing but also in training medical staff how to use it appropriately, this has been highlighted today by a second US healthcare worker contracting the disease in Texas whilst in contact with Thomas Eric Duncan, the first person to be diagnosed and eventually die of Ebola in the United States. 

There are clear failings between those who seek to contain the virus and the engagement with the general population. In order to contain the virus a clear strategy of containment has been laid out by the WHO. This relies on:

• Infection prevention control
• Contact tracing
• Case management
• Surveillance
• Laboratory capacity
• Safe burial
• Public awareness
• Community engagement
• National legislation and regulation to support country readiness

A number of the above criteria rely on the direct or indirect involvement of the population in information gathering and cooperation. Early detection and isolation is imperative but in a region where common diseases such as malaria and typhoid fever are present with similar symptoms, patients may feel reluctant to come forward, especially when the population is dubious about those in positions of authority with rumours circulating that if they report deaths, their loved ones bodies may be used in order to harvest organs. There is also a stigma to having Ebola if the individual survives; only once these concerns are addressed will people feel comfortable enough to come forward with suspected cases. The assumption that medical professionals or the advice of the government would be received in the same way in Sierra Leone, Liberia or Guinea as in the UK is a fundamental mistake.

The view that the international community in conjunction with the government are conspiring against the people is a real fear which has led to healthcare workers being attacked and killed in Guinea. The containment of Ebola is not just a medical endeavour but also a social one. This is one area where international intervention and the national government must improve. Dr Peter Clement in Liberia presents one example of an attempt to tackle social community concerns. He worked to engage with rural and urban communities alike and through local actors he explained treatments and answered concerns these communities had. In this way he was working to build trust and therefore encourage locals to come forward either with symptoms for treatment or notification of deaths and appropriate burial.

A large aspect of the social problem is that people now have to adjust the way they care for their sick, and alter their traditions around death. Ebola has meant people can no longer wash or kiss the bodies, rituals that bring comfort and familiarity. If the international community expects people to abandon these practices, time must be taken to explain the wider reasons for doing so, and how the bodies will actually be treated.

Bridging the Gap

Both Liberia and Sierra Leone have come out of brutal civil wars, the aftermath of the Ebola virus could have the potential to exacerbate existing tensions that peacebuilding actors have sought to address.

Although there are reports of the incidence of Ebola doubling every three to four weeks, the UN special envoy David Nabarro believes with community engagement it could be contained within three months. The wider social effects in the aftermath, however, may take longer to contain.

Mission4Salone (M4SL) a local level NGO is an example of an organisation embedded within the community trying to fill the gap between the national government, international actors, the medical community and the general population. Their main effort has been focused on educating people from their own chiefdoms on hygiene in rural areas and offering aid in the form of food to those quarantined in their local area, they told me of a village near Bo where 85 children have been orphaned and family homes torn apart, on 3 September 2014 in Kalia a village situated approximately 5 miles from Bo a population of 350 residents with 42 household heads lost 30 of their main breadwinners to Ebola leaving 85 children orphaned. Their houses were barred and belongings were burnt in the Kailahun Ebola Treatment Centre, it is only the Medicine San Frontiers [MSF] that gave each one of them one shirt and one bed sheet, and le 10,000 [USD$ 2] as their start-up kit in order to start a new life. 

Conclusion

The international response to the Ebola virus has stepped up in recent weeks, however, money, resources and manpower are not enough to combat the mistrust and lack of communication between a population who are scared for their lives and medical professionals who are concerned with doing their job to the best of their ability. Trusted local level actors are needed to quickly bridge the gap and will be crucial in the aftermath of the virus when the full impact of this devastating disease on the lives of ordinary people and the health of the state as a functional entity are revealed.