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WHO health promotion officer comments on helping control Ebola in West Africa

Aug 21, 2014, 9:44 AM

Momodou Gassama of the WHO country office has been sharing information with The Point about the Ebola virus disease outbreak in West Africa. Gassama is the health promotion officer.

He sent us this report:

I was in Sierra Leone from 10th June to 30th July 2014, as one of WHO consultants, to support ongoing efforts to control Ebola Virus Disease in that country.As I speak to you, WHO has mobilized and deployed 52 local and international experts to support Sierra Leone, not to talk about 22 others who had left after finishing their assignment. These experts include clinicians, nurses, epidemiologists, logisticians, laboratory scientists, data management specialists, anthropologists, social mobilization and risk communication experts and drivers.

The world already knows more hands are needed in these affected countries to stem the tide against Ebola.Let me also recognize MSF, Red Cross, UNICEF and other partners I happened to work with whilst I was on mission.The situation in Sierra Leone and other affected countries is beyond a single country or organization.The world is seeing the worst outbreak of Ebola since the first epidemic started in 1976.The latest information posted on WHO’s website as of 16 August 2014, since the beginning of the epidemic in March 2014, speaks of a total number of 2240 cases (confirmed, probable and suspected cases combined) and a cumulative death toll of 1229 reported from the affected countries.Out of this, Guinea alone registered 543 cases and 394 deaths; Liberia, 834 cases and 466 deaths; Nigeria, 15 cases and 4 deaths and Sierra Leone registered 848 cases and 365 deaths.

What is even more worrying is that the disease is killing our health workers, people who are saving lives. For example, as of 12 August 2014, a cumulative total of 51 health care workers in Sierra Leone were infected with the Ebola virus and 27 of them have already died.This is devastating for any country because these are skills that are not easily replaceable.For the entire affected countries, a total of 170 health workers have been infected and 81 of them have already died.

This is the worst Ebola epidemic if you compare it with previous Ebola outbreaks.What I have been able to glean from WHO records looks like this:

A total of 24 Ebola outbreaks were recorded globally between 1976 and 2012.The cumulative total of cases recorded was 2387 with 1590 deaths.So the cumulative total of cases recorded in this ongoing epidemic (2240) is very close to the total recorded for the 24 outbreaks.

But counting the number of cases and deaths is not the end of the story.The epidemic is seriously disrupting livelihood; it is affecting socio-economic activities and disrupting people’s very cultural lives.

For example, schools have closed, movements are restricted and farming or agricultural activities are disrupted.So the impact of this epidemic is beyond the health sector alone.This is why Sierra Leone has established an inter-ministerial standing committee on Ebola.

Despite these challenges, I must confess that health authorities and health workers in general have done and are doing their best to control the epidemic in Sierra Leone.But we must remember that we are dealing with a new and deadly enemy for the very first time in West Africa.So we have a lot to learn about the disease, I guess. A senior health official told me, and I quote:“We thought we were prepared for Ebola, but we were not until when the disease struck”.So reading between the lines, this shows how challenging the situation is and can be in any country experiencing Ebola for the first time.

To sum it, the outbreak has overwhelmed everyone including Sierra Leone and the entire international community.The health system is overstretched.The experience and expertise to deal with this new enemy are limited.In a situation like this, you need enough experts on the ground and other resources to fight this invincible enemy.

The bottom line is we can see ourselves out of this situation if we all join hands in identifying and tracing sick people and taking them to the treatment centres immediately.For this outbreak to come to a successful end there is need to quickly trace and monitor those who were or are in close contact with the sick persons.We need to identify those who are sick with Ebola and report them to the health authorities immediately. We also need to identify as quickly as possible those who been in contact with people who have died of Ebola.

The Gambia and any other country in the preparatory stage can learn a lot from the current outbreak in Sierra Leone. Leadership in any country or in any given situation is critical to the successful implementation of any programme . We need a strong and committed leadership to change the situation in the countries. I think the Presidents of the Manor River Union need to be commended for the extraordinary meeting held in Guinea on 1 August 2014. The communique from that meeting also speaks of their strong commitment to ending the Ebola epidemic in their countries.

The President of Sierra Leone has demonstrated this.He visited the Ebola Operations Centre, housed at the World Health Organization Country Office, three times, and participated in technical meetings to get firsthand information about the epidemic.He visited the treatment camps and hospital staff/health workers in the affected areas.This has boosted the morale of the health workers and the communities.

Another lesson we can learn from Sierra Leone is the need to train and equip our health workers.Health workers need to have the protective gears and put them on when attending to patients and suspects.Knowledge about how to put them on and take them off correctly must be enhanced.Remember, we cannot afford to make any mistake in doing this.This is how some health workers got infected in Sierra Leone. To address this, the WHO Office Country in the Gambia is in the process of printing copies of these procedures and on hand washing/ hygiene, which will be distributed to all parts of the country.This will off course go along with training and equipping our health workers.

We can also learn from the way communities were engaged and involved in tackling the outbreak.In fact, without the participation of the communities, the Ebola outbreak will never come to an end.Take for example the treatment centres.How useful will they be if people are not going there? We all know the sick people live in the communities; they have families and friends whom they come in contact with. I must say I am very impressed by the local bye-laws communities put in place to control the epidemic. These initiatives are fully supported by the central government. This is fantastic!For example, some communities have made bye-laws which impose strict penalties on any one not reporting cases or suspected cases as well as family members who have not reported their dead to the health authorities or hiding them in their homes.Penalties are also imposed on those who hide visitors from affected districts without notifying the paramount chiefs.Some communities have even imposed penalties on those found molesting health workers during the course of their work.

The high level of consciousness about hand-washing and the slogan “Don’t touch” are commendable, and we can learn from it.Majority of the people are fully aware of the fact that coming into contact with a sick person or people who die of Ebola– their body fluids – is dangerous and should be avoided.Our rapid appraisal has shown that people are putting words into action.For example, people have stopped washing or touching their dead bodies (those who died of Ebola), and are fully cooperating with the health authorities in ensuring that the dead is buried within 24 hours.

So an important lesson we can learn from Sierra Leone is that during an outbreak, it is no longer business as usual. We have to respect Ebola as a dictator, unfortunately.We have been engaging communities with this mindset. It is one of the communication tactics we were using in Sierra Leone to give a human face to Ebola.We describe Ebola as a dictator because it is telling us to stop doing many things we are used to doing in normal life and many other things we will find difficult to stop.

For example, the “dictator” is not allowing us to perform our cultural and traditional ways of handling and burying our dead bodies. This is important, because Ebola has killed three Imams in a village called Daru in Kailahun district for simply defying the simple medical advice – “don’t touch”.This shocking news was narrated to our team by the Paramount Chief of the area, Mr. Mousa Kallon. You cannot stop tears coming from his eyes when he was narrating this story.So the Gambia can learn from this because we are a very religious country.Muslims and Christians take good care of and prepare their dead bodies for decent burial.

We can also learn from Sierra Leone that most of the people affected are females including very young children.This is simple common sense; our women are mostly the care givers.They take care of sick, and in doing so they can get infected.So the current epidemic is telling us to change our culture of care and care seeking.To empower women for the fight, our team have identified and trained women groups who are leading the fight against.I learnt from my Mende friends that when a Mende woman ties her head-tie to the waste, she can beat a man.In other words, she is determined and goes all out to achieve what she wants to achieve. So I left a group of Mende women in Kailahun district who are resolved to end the epidemic as soon as possible.This is commendable, and we can learn from this by involving our women in the campaign against Ebola right away. We have vibrant women groups who can even do more.

Aside these positive developments, we can also learn from some of the challenges:

Pockets of denial and resistance were a bit of a challenge in some quarters during the early days of the epidemic.This has made people become complacent and not taking the right protective measures or heeding to medical advice.

Struggle with cultural and traditional practices of handling corpses has resulted in some avoidable deaths.I already mentioned about the three Imams who died in Daru village.So we need to share this information with our religious leaders.I am sure we have very able religious/intellectuals and groups who can work closely with the health authorities at this early stage to prepare the nation for this type of situation.

Another important lesson to learn has to do with late reporting and hiding of the disease.Some people, because of fear or ignorance have failed to report either themselves or sick people in their immediate environment to health facilities or treatment centres.In some cases, people have hidden sick people in their homes for too long to get the right treatment.This has cost many lives. Ebola kills very fast.The longer you delay the chances of survival are limited.

From community experience and from the little research we have carried out, we came to understand that the disease had instilled and is still instilling a lot of fear in people.In fact, before I left, we had identified 5 foods for Ebola, which were fuelling the epidemic in Sierra Leone.These are: Ignorance about the disease.But this has now gone down thanks to the massive sensitization on radio, TV and other media outlets. In an outbreak, we have to blend complementary strategies.There is no one-size-fits-all. Door-to-door and house- to-house sensitization, in addition to other methods, have been widely used in Sierra Leone.The other foods are fear, confusion, panic and denial. The fear cuts across different groups– health workers, communities, men, women and children.Fear is making people hide the disease. This is typical of Ebola outbreaks.People fear when they know they are vulnerable or susceptible to catching the disease and when they know people are dying or when they see loved ones dying in their own eyes.People also fear when they lose hope and start losing members of their household or when they do not trust care givers.The fear became so serious that some people don’t even want to see health workers or vehicles (ambulances) in their communities or report ordinary ailments to the health facilities.In fact because of fear people were not reporting malaria and other diseases/ailments to the health facilities. I will give you my own example.I contracted malaria on 9 July 2014 and could complete a village meeting in Daru, one of the hot spots. If I had not overcome fear and get myself treated early, I would have died of malaria. This situation is off course changing as confidence is being gradually built among the people. Out of fear, panic and confusion follow.So you can see the challenges we were facing in Sierra Leone.Denial was also an issue.Some people did not believe and have politicized the whole situation.This has cost inaction in some quarters according to our investigation.

But this is becoming a thing of the past.For example, before I left Kailahun district, all the political parties had united under one umbrella “All political parties against Ebola”, which has been going into the communities to sensitize their people on Ebola.My advice to the Gambia and residents in the Gambia are as follows.

1.Let us stick to the facts about Ebola.It is a very contagious disease that can kill very fast. It is not airborne and when we can only get it through coming into contact with body fluids of an infected, sick or dead person or that of a sick, infected dead animal with Ebola.It is important to note that an individual is infectious – can spread the disease to others– only when they show signs and symptoms of the disease, which include sudden onset of fever intense weakness, muscle pain, headache and sore throat.This is followed by vomiting with or without blood, diarrhea with or without blood and rash.I must reiterate her that most of the cases in Sierra Leone have not presented with bloody diarrhea and or rash.So we have to be emphatic in our messages to the public that they should be vigilant of ordinary diarrhea and report them.There is nothing like taking chances.It is important to take note of these signs and symptoms and report as quickly as possible anyone presenting some of these symptoms to nearest health facility.Any delay can cost lives.

As I said earlier, it is important to note that people become infectious only when they develop signs and symptoms of Ebola because a group of youth came to a health facility in Kailahun district, when I was there, requesting health workers to perform Ebola test on them. Some of them claimed to have been in close contact with Ebola patients in their households or communities. This is interesting but a good sign that people are concerned about their health.Again, I repeat, the virus can only be detected in the body when a person has started showing signs and symptoms of Ebola.When you don’t show this, conducting a test will be futile and waste of resources because the virus will be seen in the body fluid.

2.Even though Ebola Virus Disease has no known cure or vaccine, people can still survive this deadly disease.The supportive care given to patients has saved and is saving lives.We have been engaging survivors to support us in the fght and confidence building. For example, we managed to have an interview with a survivor in one of the villages in Kissi Kama in Kailahun district to share her experience with the general public. This was important because it has cleared so many misconceptions surrounding the treatment centres and the disease itself. It has also built trust in the health care delivery system.It has also raised public confidence.This particular village is Lolor in the Kissi Kama Chiefdom of Kailahun district. The woman and her daughter both survived but got the disease from the husband of the woman who died of Ebola.So it is not all that hopeless.The key message is seeking treatment at the right time.

3.Regular and proper hand washing with soap and water is the most important thing to do in an Ebola outbreak.I think we can practise this in our homes, offices and work places so that people become used to it.When I say hand washing, I don’t mean hand-rinsing. Off course we can use other detergents to clean our hands if we can afford.

4.It is also important to the mindful of some of the cultural practices we do.For example, burying the dead and the culture of hand shake.As Muslims and Christians, we wash our dead bodies and prepare them for decent burial. We therefore touch or hug them during this process.This, unfortunately, cannot be done during in an Ebola outbreak.We only report the dead to the health authorities and burials to be done by specifically trained burial teams.Off course we can do our rituals or prayers by not touching the dead. By extension, the culture of hand-shake should be minimized or restricted during an Ebola outbreak. This is because we use our hands to do many things.A contaminated hand can find itself in our mouth, nose, eyes, etc.These can all help spread the disease.In Sierra, the message is clear, “Don’t touch”.So it is important to work closely with our religious leaders, members of the community and the general public at this early stage to prepare the minds of Gambians.I must also emphasize here the need to involve our traditional healers in this campaign.I investigated the genesis of the outbreak of in Sierra Leone (Kailahun district) and came to understand that the disease entered the country through people who got infected from the burial of a famous female traditional healer in Guinea, who claimed to have a cure for Ebola.People were going to her for treatment and she infected herself. Unfortunately, she, her husband and her entire household got infected and died of Ebola.So those who attended her burial and touched the dead body all came back home infected.One of them was a pregnant woman who also infected a midwife (known as Messi) and a traditional birth attendant working in a local health centre in Koindu near the Guinea border when they were attending to her delivery.They both got infected and died alter. The nurse was buried in her home town where many mourners who attended her burial and touched the body all got infected.This is how Ebola spread and got out of control in Sierra Leone.To sum up, our traditional leaders must be involved in the campaign, and we must use them to spread the message because these are important and respect people in our communities

5.Our surveillance systems should be strengthened to detect any case or suspected case.I thank the Ministry of Health and Social for the concrete steps being taken at our border points, particularly at the airport, where people are screened upon entry.

6.Empowering and health workers with the requisite training and equipment.I am happy that an initial training was done for health workers and that more trainings, supported by the United Nations System under the leadership of WHO, are in the offing to prepare our health workers for this deadly disease.This is commendable and we need to strengthen it, and be very vigilant.

7.Although Sierra Leone is in the response phase, we can still learn from the way they are handling the epidemic.There is a central Ebola Operation Centre based in Freetown which is attended by all partners and MoH takes the lead in this process.The centre is housed at the WHO Country Office.Aside, they have established servaeral other sub-committees: Case management, Surveillance, logistics, social mobilization/psychosocial support. These committees meet every day to discuss the issues and challenges surrounding their activities. Off course we are not yet in response phase but we have to be fully prepared.

Having seen what the Ebola is doing in Sierra Leone, my last word is to emphasize the fact that the impact of Ebola is beyond health.Every sector is affected.Schools have closed; agricultural activities are affected, etc. etc.

So we need an expanded response by bringing all the different sectors together to start preparing for these consequences.Massive sensitization on radio, TV, in the communities on hand washing and infection control must be mounted.