Thoughts on Ebola in a post-conflict community: A northern Ugandan perspective

1. BACKGROUND

Early this year the world was shocked by the outbreak of Ebola in Western Africa. The shock resonated noticeably in Uganda which experienced five Ebola outbreaks in the last fourteen years. The first among them occurred in Gulu District in Northern Uganda in the year 2000 at the peak of the war between the Government and the Lord’s Resistance Army (LRA). Back then the disease killed 224 people and even scared the LRA into leaving the region for over eight months and releasing all recent abductees. People still remember black humour from the era, saying that “Ebola should stay, so Kony goes away.”

The LRA left, albeit not because of Ebola, and Northern Uganda turned into a post-conflict community, similar to Ebola-affected West African states, which have all had recent experiences of brutal and protracted violence.

Since the most recent Ebola-outbreak in Guinea in February, which quickly spread to Sierra Leone and Liberia, the virus has claimed over 2,900 lives according to the World Health Organisation (WHO). The WHO further projects that, if nothing changes, 21,000 persons will become infected by November and the US Centers for Disease Control and Prevention (CDC) estimates that the number of infections will reach 1.4 million people by January next year.

Although the life toll is the scariest element of Ebola’s spreading, its destructiveness reaches beyond that. Among other risks it strains already struggling health systems (Liberia and Sierra Leone both employ only three physicians per one million people) and hampers or even prevents trade, which leads to price increases of most basic necessities such as food and medicine. In poverty-stricken regions and countries which are taking their first tentative steps towards post-conflict recovery, such changes can destroy a fragile security balance. An emergency like Ebola is a grim reminder that the neglect of people’s economic and social rights creates more than shocking images of barefoot children with inflated tummies – poverty can trigger a conflict which would not have occurred otherwise!

After Ebola cases were confirmed in the neighbouring Democratic Republic of the Congo in July, we, as an organisation who works with people in the community and as an organisation whose staff members have survived Ebola outbreaks in Uganda in the past, asked ourselves what we would do if Ebola was to break out in Northern Uganda again. A short survey among AYINET staff comprised of Ugandans and their international colleagues from the United States, Belgium, France and Slovenia, gave some interesting insights.

2. ROLE OF THE GOVERNMENT

There is a general agreement that in preventing and/or managing a public emergency, the state would have to play a very important role, both in ensuring technical preparedness and informing the public about Ebola.

2.1. TECHNICAL SUPPORT

The Ministry of Health was mentioned by many as the focal point which has to ensure (today) that health facilities in the country are adequately equipped with Ebola-relevant material and that health workers receive training which would allow them to contain the disease and not catch it themselves. Scenarios such as nurses’ strikes over the lack of protective gear, recently reported from the John F. Kennedy hospital in Monrovia, Liberia, must not occur. As prevention is more effective than treatment, many mentioned that the Ministry of Health and local health facilities would need to ensure sufficient isolation wards.

While some staff members mentioned that the work of medics and technical support from the government have successfully contained Ebola outbreaks in the past, others mentioned poorly resourced health facilities and warned that the government needs to continue the development of its health infrastructure as a matter of urgency. The government also needs to identify other institutions whose contributions would be critical in containing the epidemic and ensure that they are well informed and prepared to take on their responsibilities.

2.2. BUILDING TRUST

In many countries, which have experienced war, especially war in which the state was involved to a greater or lesser degree in a more or less favourable manner, the communities’ trust in government institutions remains low, even after the war ends. This description squarely applies to Northern Uganda. The “re-establishment of trust between the national government and its citizens on the local level” should be regarded as an important investment towards crisis prevention. If people do not (re-)establish their trust in the government, the success of early warning and other public outreach campaigns, the role of which is critical in pre-empting and containing epidemics, will suffer considerably, in particular if people will not only disregard the government’s warnings, but also continue to rely on traditional institutions, which might supply them with incorrect information. In Liberia and Sierra Leone, many patients have reportedly turned to witchdoctors for treatment and have thereby signed their own death certificates, even after they were informed of the method’s ineffectiveness. If the government does not improve its trust record, the population will be left to “guess who to trust.” Their uncertainty, for which they cannot be blamed, could exacerbate Ebola’s death toll and create a panic.

The scientist Louis Pasteur once said that fortune favours the prepared mind. The central and local governments would do well to follow his advice. If they want to manage Ebola, they need to plan for the worst-case scenario today and assure the population that Uganda’s institutions are ready to fight and root out an epidemic, which, with a bit of luck, will not occur.

3. SELF-INITIATIVE

Although the role of the government in managing Ebola was stressed as being principal, no-one neglected the importance of personal initiatives or initiatives carried out by local civil society organisations. Meditating on what we could do as AYINET, we took into consideration that we are not a clinic and would not deal with Ebola cases as such. Rather, our strengths lie in the familiarity with the people’s habits and beliefs and in their trust toward our work.

3.1. SENSITISATION

Informing the community and local capacity development were stressed as the most effective plan of action. The population needs to be informed about what Ebola is, its signs and symptoms and ways of treating an Ebola suspect or patient. Considering that people often have wrong ideas as to how to prevent the spread of a disease, it is also important to identify such misleading information and neutralise it. Our Peace Corps Community Health Volunteer, for example, was once told that HIV can be killed if one washes the inside of his or her body with detergent after unprotected sexual intercourse. In the case of Ebola similarly incorrect information will perpetuate bad decision-making and threaten life itself.

The methods proposed for reaching as many people as possible included the distribution of comprehensive and simple pamphlets about the disease, everyday chats with friends and strangers on the street, community field visits and the use of radio and other social media. The responsibility to get the word out rests on every individual. As AYINET we believe that the relationships which we have built with communities and state institutions over the years would allow us to contribute greatly to sensitisation efforts.

Finally, an important consideration that is too often ignored in public health emergencies is that any emergency is best addressed if potential victims are involved into crisis-aversion efforts. Local knowledge and custom can be a liability, as outlined above, but they can also be an important asset. Community members such as traditional leaders need to be involved in the planning and implementation of sensitisation campaigns as understanding local religions and other (spiritual) beliefs (e.g. burial customs) will increase success and prevent contradictory information to be passed out from different sources of authority.

3.2. ADVOCACY

As fighting Ebola is a costly and highly technical engagement, some staff members emphasised that AYINET could use its visibility to move the international community, including donors, to assist the development of local disaster management and response capacity, not only during, but, more importantly, before a potential emergency. During an epidemic, which, this time around, will hopefully not reach Uganda, the international community could be approached to provide health personnel and necessary equipment such as gloves, aprons or mortuary sacks. Nobody should be put at risk due to a lack of gloves.

4. PSYCHOSOCIAL SUPPORT

As an organisation who spends a lot of time counselling community members, we cannot ignore the psychosocial implication of Ebola for the survivors and the families of the victims.

As it is important to inform the population on what the dangers of Ebola are, it is important to prevent stigmatisation of those which have suffered from Ebola and survived the disease. Marginalisation is a foreseeable risk, which can be addressed by community discussions.

Families, who might lose their members to this horrific disease, will require support to deal with anger and powerlessness, provoked by the loss of a loved one to yet another (unmanageable) threat, not completely unlike the randomised violence most Northern Ugandans experienced during the over two-decade long LRA insurgency. AYINET could liaise with the Ministry of Health to find the best approaches to address these additional Ebola-related problems.

5. MILITARY DEPLOYMENT

United States President Barack Obama has recently announced the deployment of 3,000 American troops to West Africa in order to help manage the emergency. As the Uganda People’s Defence Forces (UPDF) play an important role in Uganda’s government and security and as the scenario of their involvement in managing a potential outbreak in Uganda is not unlikely, we will follow the implications of the militarisation of Ebola management in West Africa, which might set a powerful precedent, with interest.

6. CONCLUSION

The recent Ebola outbreaks have not reached Uganda and they hopefully won’t cross our borders. Nevertheless, our team recognises its dangers and feels solidarity with our West African and Congolese brothers and sisters who have fallen victim to the disease. As Ugandans and Ugandans at heart we pray for their resilience and recovery and the further strengthening of the already generous and crucial regional and international support. At the same time we seek answers from our own government: what is being done to alleviate poverty, what is being done to address the trust deficit between the state and its people and, finally, are we prepared?