The Ebola menace persists, let’s stay on this topic

on Thursday, 30 October 2014.

Last time we shared lessons from Uganda on Ebola Virus Disease (EVD) response. Prophetically the title was “Let’s all prepare for Ebola” did I expect that the message would apply to the whole world and not only Africa. The situation in the three most affected West African
countries is much worse; it is sadly grim and dire. “Africa is burning. We need every body’s help now” is a message I received from a colleague who is in the front line over there.


I want to applaud the enormous and valiant effort by individuals and institutions as well as the resources that have been thrown into the EVD response in so far. There are many volunteers from many countries in Africa and all over the world at the front line and I know many others
want to join but do not know how. I want to express my administration to these brave health workers from Africa and all countries who have volunteered to support the EVD response in West Africa.

Many have given their lives. It reminds us very forcefully that throughout history, our profession is intrinsically fraught with professional hazards that threaten our lives. These risks are part and parcel of the job. We take all precautions but some of us will still fall victims. A soldier colleague at the height of the Uganda outbreak told at us at an Ebola funeral “in the army we expect death; we have departments of “death” to manage this expectation”. No consolation but just sobering reality.

All countries are now at risk! The mighty global system has swung into action and has established “The Global Ebola Response Coalition” led rightly by the UN with head office in Accra, Ghana. The African Union has set up a support operation, ASEOWA and the Chairperson of the AUC has visited the affected countries. Yet the number of new cases continues to rise exponentially. Who will stop Ebola? What are we not doing right? What
can we do better? These are questions that are begging for answers from all of us. Here is my own contribution.

In our last discussion, I listed three categories of the response from the Uganda experience; namely (i) winning public trust, (ii) engaging the communities and (iii) using technology, to identify, isolate and treat the infected; vaccine development fits here. Of these three, the first two are of the highest priority and hold the key to stopping the current Ebola outbreak quickest. Moreover, the two approaches also constitute the long term sustainable solution to managing future Ebola outbreaks and to laying the foundations for strengthening  health systems and attaining universal health coverage in these and other African countries. How can
this be achieved?

First and foremost, local government structures need to be in place for reaching all individuals and households in rural and urban areas. These cells of governance structures should be established with the full participation of the local people and their leaders should know the
communities well and also be trusted by them. The cells of governance structures should be linked to the higher echelons of the government and health system and be able to take action and transmit information both ways. These governance cells are present in Uganda and were effectively used for communication, confidence building and most importantly case

70 – 80% of sub-Saharan Africans live in rural areas and governance structures of these communities is sometimes either nonexistent or dormant. When government is absent, disease outbreaks occur, fester, fizzle out or spread unnoticed. This is what I have described many times before as “embedding the health of the people in the routine governance of
society”. It is these local government leaders who can ensure that epidemics are picked up, children are immunized, the pregnant women attend ante natal clinics, that early marriages do not take place, pit latrines are in place, food security is assured, and law and order exists enabling the communities to go about normal business, link with NGOs etc. This is the foundation of the health system and of Universal Health Coverage that leaves no one behind.

Actions along these lines are possibly already taking place in the worst EVD affected countries. I still urge all key actors over there to give this approach more consideration and resource investment, of course not to the neglect of others. Addressing post recovery stigma, providing psychosocial support and promoting societal stability will also benefit from being close to households by trusted actors. This time of crisis is sometimes the best time to introduce or strengthen such governance measures and they are likely to last and be sustained in the future.

It would also be good to see more visibility in the media of the national and regional leadership from the affected countries as this will strengthen their credibility among their own people which is essential for the success of this approach.

Finally I wish to urge all other African countries to give this approach some serious consideration as we plan for our health systems and universal health coverage.

Friends, your contributions at this difficult time will be highly appreciated.


Comments (7)

  • Sylvia


    30 October 2014 at 16:08 |
    Thanks Francis for this update. It's good to know that there is finally a good response, even though it is not quite adequate as the needs continue to expand.
    I wanted to let you and the readers of this listserve know that MSH is organizing a virtual seminar for 3 days (October 28-30) on the Ebola response. people would have to register (free) on LeaderNet which is a community of professionals who are interested in improving leadership, management and governance in health care. The site is available in French and English. Click here to register on LeaderNet - invites to the Ebola seminar (and all future seminars) will be sent to LeaderNet members automatically.

    best wishes and success to us all in stemming the Ebola tide.

  • John Paul Bagala

    John Paul Bagala

    30 October 2014 at 16:24 |
    Dear Prof. Francis and All.

    It is really a trying and challenging moment that has confronted Africa at a time when we are still fighting the HIV, Malaria, TB burdens together with the other emerging non communicable diseases claiming many lives.
    However, we have to face it, we have to confront it, we have to join efforts thus calling for any input from all potential individuals across this continent geared towards controlling this scourge. Members in the unaffected areas and countries have no reason to keep our hands folded because it can still knock at our doors any time if neglected.

    I greatly commend the different local and international individuals,governments and organisations that are working tirelessly to contain the disease and strongly agree that we need to put extra emphasis on i) winning public trust and ii) Engaging the community, as using technology comes along. The crisis definitely has created a great demand in these ring countries which has out weighed their available efforts to control it coupled with the post-conflict history that some countries suffered. EVD made an ambush that no one expected necessitating us to accept the problem and own it for suitable sustained control measures.

    The key contributor to the increasing demand created by the crisis is the fast rate of spread of EVD within the local population and mostly within the densely populated rural communities. Getting down to the grass root, it strongly indicates that extra emphasis, efforts and measures must be laid to halt the fast spread of the disease and narrow the inflow of patients who have contracted the diseases and seeking healthcare. this calls for additional preventive measures to reduce the risks of wildlife-human transmission, reduce the risks of human-human transmission and also strengthen our outbreak control measures through increased community engagement, aggressive community sensitization and education about the disease and its presentation, the possible control and preventive measure in a home and community, and aggressive social mobilizations to address the cultural aspects that favor the spread of the disease.

    It is also important to create avenues and channels of linking health workers, volunteers, communication experts and other key professionals willing to give a hand in the fight but are failing to find their way to the affected areas. this will probably boost the numbers of services providers at the front line of the fight not forgetting the required support that they will definitely need.

    We need also not to neglect the potential of the Clinical year Medical students, in the affected countries and the possible contribution they can make to this struggle if some extra public health emergency skills are added to them. During their training in medical schools they have exposure to the patients during the ward teachings, thus putting them at high risk of contracting the disease if not equipped with infection control skills and measures. On the other hand, if acquainted with the basic skills they can be strong weapon in this fight and their engagement can significantly boost the numbers of already existing healthcare workers and public health workers. Looking at their possible potential, We are forming the Medical Students Task-force on Ebola Crisis with the primary aim of joining the efforts of medical students and bringing medical students aboard to join the fight against EVD. We greatly welcome any support from the members
    willing to join hands with us.

    Together We Can End to Ebola.

    John Paul Bagala
  • Kalimugogo


    30 October 2014 at 16:44 |
    Educating the public is vital to the efforts to contain Ebola or Marburg epidemics. The role of the media and community leaders in this regard is important. This is because of the sad reality that a large percentage of patients in Africa (especially rural) first consult traditional healers (including witch doctors) before reporting
    to hospitals. The initial 'causes' of ill health may be attributed to quite unrelated issues but which the patients and relatives will believe.

    Some religious leaders also advise patients that prayer is enough to cure any illness! This leads to delayed diagnosis, dissemination of communicable diseases or even refusal to access available services. If possible therefore, health workers should collaborate closely with community/religious leaders, the media and traditional healers.

  • Dr. David Okello

    Dr. David Okello

    30 October 2014 at 16:53 |
    Dear Prof Omaswa,

    Thank you for re-stating the importance of this topic. The current outbreak in West Africa is unprecedented; and you are right to point out that all countries are now at risk. From where I sit, there is a concern that decision makers at national level are in some cases being forced to take desperate measures to contain Ebola. We must not allow fear, anxiety or outright speculation to overpower scientific evidence.

    Thank you.
    Dr. David Okello
  • Prof. Miriam Khamadi Were

    Prof. Miriam Khamadi Were

    30 October 2014 at 17:01 |
    Dear Francis & Colleagues,

    I have been up county here in Kenya in relation to the death of our Mama. Hence this rather delayed response to your latest communication. You have stated the issues very well and I want to comment on the proposal you made about local leadership.

    I wish to make the case that all countries in Africa need to establish Community Health Services in the context of which SUSTAINED local leadership is developed and sensitized to issues of health and epidemics.
    This system is working in Ghana, Ethiopia, Kenya and is being developed in Zambia and in a number of other African countries. The attraction of this approach is that it provides health care personnel and SUSTAINED local leadership at all times. The problem has been that there is very little funding support from the Global Health Community and so the approach is implemented in a piece-meal way. Africa needs to make the case for support from the Global Health Community so that all African countries do establish COMMUNITY HEALTH SERVICES or COMMUNITY HEALTH AND DEVELOPMENT PROGRAM. If this program was present in countries which are under the Ebola epidemic now, I believe that containment would have been achieved much earlier and the struggle would be very much less now.

    Since Kenya began implementing this program in 2008, over 40 % of Sub-location have Community Health Services established. And even with this still less than 50% implementation rate, cholera epidemics that used to hit the country annually have not occurred for the last five years because implementation made the loci for cholera epidemics a priority. One can also say that when Kenya is 100% covered with Community Health Services, the country can handle ANY epidemics that come to it..

    It is noteworthy that the scheme of Service for Community Level Health Personnel incorporates the Community Health Committee as the Governance and oversight structure for Community level health Services. THE COMMUNITY HEALTH COMMITTEE IS THE LOCAL STRUCTURE THAT IS PROVIDING SUSTAINED LOCAL LEADERSHIP. We have found that in various Sub locations, very senior retired individuals are taking up the challenge of being in the Community Health Committees. This include retired health workers who now live in their communities. It also includes teachers, policemen and so on. Curricula have been developed for each of the cadres in the Community Level Health Personnel and are all under implementation.

    I APPEAL TO COLLEAGUES AND TO OUR GOVERNMENTS TO ADVOCATE FOR THE IMPORTANCE OF HAVING COMMUNITY HEALTH SERVICES or COMMUNITY HEALTH DEVELOPMENT PROGRAM ESTABLISHED IN ALL OUR COUNTRIES. THIS WOULD BE ONE OF THE BEST PREPAREDNESS TO HANDLE EPIDEMICS. This cannot be done when an epidemic is in full swing since it request planned Community Dialogue Days and Community Action Days.WE need to have these systems as a preparedness feature in place so that we can respond appropriately. As soon as the epidemic has been contained in the affected countries, we should move in and assist in helping in the establishment of nation-wide Community Health Services so we can contain future epidemics.

    With prayers for the hurting countries and hope that we shall arise,
    Miriam Khamadi Were.

    Prof. Miriam Khamadi Were
  • Fred Hartman

    Fred Hartman

    30 October 2014 at 17:15 |
    Dear colleagues,

    I would like to cross post this summary from day one of a 3 day LeaderNet seminar that MSH is organizing at the moment. There are two days left. I am also following your conversation - trying to be a cross-pollinating bee. By the way, the LeaderNet seminar is in French as well and the summary is available on the LeaderNet site for the French speakers among you.

    "Many thanks to all 240 individuals from more than 50 countries who have signed on to participate in the LeaderNet Ebola seminar, I am very impressed with your interest and enthusiasm in discussing, and ultimately controlling, this massive Ebola outbreak.

    One consistent theme that has appeared in the comments is the emphasis on community mobilization and involvement in the response. Our focus is in Liberia, so I will respond based on our current experience. The Government of Liberia, with the active support of the US Government, is building 17 X 100 bed Ebola Treatment Units (ETUs). These are large and run like hospitals with intensive care in isolation units that require physicians and nurses for the overwhelming numbers of active Ebola cases that are now counted.
    However, only 50% of the ETU beds are full. Where are the patients? Several suggestions have emerged: 1) The peak epidemic curve has passed and we are now on the downside. However, if true, it is probably temporary, and we need to be ready to respond; and/or 2) Patients are staying home and not presenting to the ETUs. There is plenty of evidence that #2 is occurring. Thus, there is a need to move Ebola care closer to the community in a culturally appropriate setting.

    The concept of Community Care Centers (CCCs) is now being actively pursued, smaller 10-20 bed units located in "hot spot" communities, managed by members of the community (including trained health workers) and supported by NGOs. Community "champions" will be supported to detect all new suspect cases, support the families and patients to enter into the CCCs and be cared for by family members with MOHSW staff supervision. The NGO will train and support the MOHSW staff, and also family members will receive appropriate Personal Protective Equipment (PPEs) and be supported in the care of their family member. In this way, Ebola patients and their families will be cared for and supported in a culturally appropriate way in the community, including safe and appropriate burial practices. We believe that once Ebola care and isolation is located within the community, more patients will come forward and more effective contact tracing will occur, thus breaking the chain of transmission.

    Liberia has decided not to support home-based care, feeling that it is not of high quality and will perpetuate the chain of transmission through infected care givers. Even though home care kits exist, they are not officially endorsed nor being distributed. The focus is on establishing the CCCs and making them effective.

    I look forward to seeing you on LeaderNet again tomorrow as we discuss the role of strengthening Integrated Disease Surveillance and Response as well at the Framework for Ebola Response and Recovery at the Local Level.

    Many thanks for your input, please keep the good comments and ideas coming.

    Fred Hartman
  • Prof Lovemore gwanzura

    Prof Lovemore gwanzura

    30 October 2014 at 17:27 |
    I agree with your perception you outlined below. Here ( In Zimbabwe) some time everyone gets into a panic mood because someone will have been alarmist in their verbal discussion. we always note desperate measures being put up. I thus agree we should not allow fear, anxiety and of course avoid outright speculation to overpower scientific evidence. We are all risk because we are now living in a global world and our interaction is frequent. let us scientifically examine every situation we are before the press,radio, whatsupps are filled with speculations.

    Prof Lovemore gwanzura

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