Ebola Outbreak Crisis and Response

Introduction

The first case of Ebola was reported in December of 2013 in Guinea. In August of the next year, the World Health Organization declared the Ebola outbreak a Public Health Emergency of International Concern. By the end of its outbreak, nearly 30,000 people had been infected with Ebola. The United Nations was forced to create the UN Mission for Ebola Response to help, which did not take effect until September of 2014. The containment of the virus and lift on travel bans did not occur until the end of 2016. The containment was on account of organizations from both global and local facilities.

Background

In order to understand the extent of the epidemic, it is important to understand what Ebola is and how it is transmitted. Ebola is a virus that causes zoonotic disease, meaning it is transmissible from animals to humans. Humans become infected by coming into contact with the bodily secretions of an infected animal, or by preparing the meat of an infected animal. Animals act as the reservoir of the virus, with fruit bats being the main suspect of recent Ebola outbreaks (Scott, Vera, et al. 2017). The virus is transmitted from human to human through bodily fluids of an infected person. Ebola infection requires close contact and humans are only infections when they are symptomatic. The symptoms are extremely visible when fully realized, making the disease not typically infectious.

        When a person becomes infected with Ebola, it takes 2-21 days for the virus to incubate. Symptoms usually appear 8-10 days after the initial exposure. Its early symptoms of fatigue and diarrhea can be indicative of other infectious diseases (Bell et al. 2016). Vomiting, bleeding, and other gastrointestinal systems develop with the progression of the disease. There are currently no approved drugs or any cure for Ebola. Treatment includes early rehydration to replace lost fluids, and treating any specific devastating symptoms which can increase the chances of survival (Scott, Vera, et al. 2017).

        Ebola was first documented in 1976 with simultaneous outbreaks in rural Democratic Republic of Congo and Sudan. The virus was named after the Ebola River in the Congo. Since those initial outbreaks, there were 21 other outbreaks recorded until the massive epidemic in 2014. Usually the Ebola virus breaks out in small numbers and is limited to rural populations of Central or Western Africa. Before 2014, the largest outbreak was in 2000 in the with 425 confirmed cases and 224 deaths (Mobula et al. 2018).

According to the United States' Centers for Disease Control and Prevention (CDC): [...] an international response team developed an early strategy to stop the outbreak, focusing on the identification, isolation, and care of persons with Ebola symptoms; meticulous contact tracing; engagement with community leaders; culturally sensitive and safe burials; effective infection control; and reliable laboratory testing (Bell et al. 2016). These tactics were developed after the initial 1976 outbreaks, and were used to help control subsequent epidemics. Responses to Ebola infections between 1976 and 2014 were generally adequate because of their rural locations and limited geographic spread. However, the Ebola epidemic that ravaged West Africa from 2014-2016 was unprecedented and overwhelmed the capabilities of actors at every level. In this paper I will examine the environmental and social factors which made this outbreak a devastating complex emergency. I will also analyze the humanitarian response to the epidemic through its successes and setbacks.

Development of West African Outbreak

        The first case reported of the 2014 West African Ebola epidemic came from a rural southern part of Guinea which borders both Liberia and Sierra Leone. The initial patient was a two-year old boy, reported in December 2013. There were a considerable amount of external societal factors that facilitated the rapid spread of Ebola in this particular outbreak. Deforestation in the area has exposed the surrounding rural populations to wildlife in deeper areas of the forest. West African countries like Sierra Leone were logging at heavy rates as a source of national income.** It has been suggested that poverty and chronic food shortages in the three countries have led to communities penetrating deeper into the forests to look for food and fuel, potentially exposing them to bats and other animals which are host to the Ebola virus (Scott, Vera, et al. 2017). 

        The Ebola epidemic in West Africa is a prime example of a complex emergency. The virus itself posed a large health issue on its own, but was exacerbated and propelled by the countries' unstable governments, civil wars, poverty, and in turn weak preexisting health systems. The weak health systems in Liberia, Sierra Leone, and Guinea made disease surveillance extremely difficult at the onset of the epidemic, and may be why the virus was able to spread from rural to urban areas to quickly. Once Ebola entered urban spaces, it became a new kind of outbreak. Each previous outbreak was mainly limited to rural areas, which limited its potential for spreading. The 2014 outbreak was characterized by its infection of rural and urban areas. As the disease waged its war on the people of West Africa, quotidien life was halted. Businesses, schools, and other public spaces closed for fear of contamination, and because of the general atmosphere of chaos and fear.

Humanitarian Response

        Because of the complex nature of the epidemic and the lack of national resources of affected countries, humanitarian response was critical. At the confirmed start of the epidemic, Doctors Without Borders/ Medecins Sans Frontieres (MSF) sent specialized teams to set up Ebola treatment units (ETUs) and begin outbreak control measures. MSF alerted humanitarian actors and the general public that this outbreak was unlike any of its predecessors it required extreme additional support from humanitarian organizations around the world. Medecins Sans Frontieres  employed around 4,000 members to run management center and coordinate disease tracking. They treated one-third of all confirmed Ebola cases, and spent $180 million USD on the effort (Report 2016).

        The United States Agency for International Development (USAID) was the head of the United States' Ebola response. Their office of US foreign disaster assistance coordinated with the CDC, the US military, and US Public Health Service. In total they gave over $800 million across the three affected countries. This money was used to supplement NGOs, UN agencies, and other channels of humanitarian aid. They wanted to help close the gap  between aid and the needs of the people. One initiative they supported was getting health care workers trained in preventing the spread of the disease. This was desperately needed because of the repeated close contact of infected patients and their doctors. People* focusing on clean water management extended their services to address the need for safe and healthy burials. USAID helped facilitate coordination between humanitarian organizations and bridging gaps between needed and provided services (Mobula et al. 2018).

Social Mobilization

        Due to the complexity of the Ebola outbreak and the cultural gap between humanitarians and local populations, unique factors contributed to the spread of the disease. One factor was unsafe burial practices, which were unfortunately a part of West African culture: family and community members often touch and wash the body of the deceased in preparation for funerals (Nielson 2015). The sicker the person, the higher the viral load of Ebola carried in their bodies, and the higher the chance for spreading the disease. Deceased persons had extremely high viral loads, making their corpses ample sites of Ebola transmission. Lack of allocated resources made managing burials and cemeteries extremely difficult throughout the affected area. Unsafe burials, in fact, accounted for 20% of Ebola infections (Scott, Vera, et al. 2017). Ebola prevention guidelines specify that corpses should be contained in leak-proof puncture-proof bag, and either cremated or buried at least 2 meters deep. There was backlash by members of the community who strongly believed in traditional burials and ignored what health care advocates preached in their community.

        Cultural resistance to humanitarian aid further complicated and prolonged the Ebola outbreak. The environment of mistrust, resistance, and overall chaos prohibited the implementation of prevention and control measurements early on in the crisis. Both Liberia and Sierra Leone had fairly recent civil wars that left the countries in poverty and with a mistrust of authority. In addition, several rumors and myths about Ebola, its treatment, and international aid were circulating at rates rivaling the spread of credible information.* Some rumors said that ETUs were poisoning people instead of treating them. Others believed that Ebola itself was manufactured as a weapon against the people of West Africa. Some people even went so far as to instruct people to spit out their prescribed medications and disconnect IV lines to avoid being further poisoned. In September 2014, these rumors came to a head and eight officials and local journalists were murdered. They were sent to the community to educate locals about Ebola, but the atmosphere of fear and lack of trust in authority led frightened vigilantes to murder innocent people (Mobula et al. 2018). This incident proved the importance of social mobilization and coordination. The rumors not only raised the infection and death rate of the virus, but led to the murder of aid workers.

        Inevitably, it was the job of those same humanitarian workers to successfully connect with the communities they were aiding, work with local organizations, and navigate health practices and information with cultural norms and societal factors. They had to find the right avenues of communicating ideas that would save lives. For example, WHO reported that Guinean people respect the Red Cross as it is an established and respected institution there. Therefore the best way to communicate the life saving information was through Red Cross workers. In addition, they were tasked with communicated hygiene and health information to a largely illiterate population and different local languages. TV and radio broadcasts proved and effective medium for getting Ebola health standards and precautions to the pubic. Information was broadcasted in French and other local languages,with special micro-programs in rural areas.

        Although media relayed information to millions of people, there were still people who did not have access to radios and televisions, or simply refused to trust the information that came from them. Social mobilization helped close the gap where other traditional tactics could not reach. Mosques, churches, schools, universities, women's associations, and other public institutions became places of information and outreach during the Ebola epidemic.

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