THE UNDETECTED SPREAD AND MEASURES OF CONTAINMENT OF EBOLA IN WEST AFRICA
The Ebola virus first appeared in the countries of Sudan and Zaire (what is now known as the Democratic Republic of Congo) in 1976, but the largest outbreak in history recently took place in West Africa in 2014. Since the flare-up of this disease, the governments of Liberia, Guinea, and Sierra Leone have faced continuous obstacles in their efforts of containing it.
Background
Due to its lethal nature, the Ebola virus has caught traction in the media in recent years, but few people understand how the disease actually affects the human body. Ebola is known as a hemorrhagic fever virus because of the problems it causes with blood clotting, leading to internal bleeding, inflammation, and tissue damage. Symptoms of the disease include fevers, severe headaches, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, and unexplained hemorrhages. In previous outbreaks, the fatality rate has ranged from anywhere from 25 to 90 percent, but on average it is approximately 50 percent (Johns Hopkins Medicine, 2016).
Scientists still have yet to officially identify where the Ebola virus originates from, but by studying similar diseases they believe that it is animal-borne —most likely carried by bats, that then transmit it to other organisms such as apes, monkeys, duikers, and humans. The Ebola virus spreads through the direct contact of the bodily fluids of someone who is infected or has died from the disease (by entering through broken skin or mucous membranes in the eyes, nose, or mouth). Transmission can also occur through sexual intercourse, exposure to objects contaminated with bodily fluids (such as needles), and through direct contact with the bodily secretions or tissues of infected primates and fruit bats (Center of Disease Control, 2014).
There has yet to be an FDA approved vaccine or treatment for the Ebola virus (see the STRIVE section for details on the Sierra Leone Trial to Introduce a Vaccine against Ebola), but preventative measures can be taken when traveling into areas where the disease is prevalent. It is important to practice good hygiene, avoid contact with potentially contaminated items, refrain from attending funerals and burial rituals of those who were infected, stay away from facilities where Ebola patients are being treated, and avoid sexual contact with anyone who has been infected. Once a patient has been infected with the virus, his or her symptoms are treated as they appear. The most common methods of treatment are the use of intravenous fluids (IV), balancing electrolytes, maintaining oxygen status and blood pressure, and treating other infections if they occur (Center of Disease Control, 2014).
AN ADVANCED DISEASE IN A NEW ENVIRONMENT
Having experienced the disease for nearly four decades, several states in equatorial Africa were already extremely familiar with the Ebola virus prior to the outbreaks in Sierra Leone, Guinea, and Liberia. Although the equatorial region also has rather weak health systems, through its struggles it earned the advantages of previous experience and acquired knowledge that aided its combat with the endemic. In contrast, when the Ebola virus struck West Africa the outcome was much more severe resulting in far more casualties.
A key difference in the spread of the Ebola virus in equatorial Africa in comparison to the spread in West Africa is the distinctness of the geographical landscapes of the regions. In the preceding outbreaks that occurred in equatorial Africa, the disease was often isolated in secluded rural areas, while the capital cities of Guinea, Sierra Leone, and Liberia have become hubs of Ebola transmission. Once the virus gained traction in less sanitary and densely populated urban areas, it began to spread like wildfire throughout the population. In addition to this, health care facilities were the primary locations in which the virus spread in equatorial Africa, while explosive flare-ups in West Africa are characterized by rapid community-wide infection (World Health Organization, 2015).
AN INADEQUATELY PREPARED REGION
All ranking within the 21 countries with the lowest GDP per capita in the world (CIA World Fact Book, 2018) Guinea, Sierra Leone, and Liberia were already not in perfect condition when the Ebola virus struck. All three states had just emerged from years of civil wars and public unrest that left most of their public health infrastructures in irreparable conditions. The three states also suffer from their inadequate road systems, transportation services, and telecommunications networks (especially in rural regions). These insufficient systems prevent the necessary swiftness required to transport patients to treatment centers, make calls for help, and broadcast emergency alerts (World Health Organization, 2014).
Much like the cities of Memphis and Savannah during their yellow fever outbreaks, the states of Sierra Leone and Liberia were forced to endure the detrimental effects of poor sanitation during the Ebola crisis. The vast majority of the population in both states (86.7% of people in Sierra Leone and just over 83% of people in Liberia) live without access to basic water sanitation (WaterAid, 2016). The incidences of open defecation (resulting from this lack of essential sanitation) are a collective action problem because they occur without regard for the consequences (the transmission of Ebola through fecal water contamination) on the rest of the population. In other words, very many people are contributing to the sanitation dilemma, but very few are making the effort to improve it.
In addition to the issues with public infrastructure and sanitation, the three countries suffered from a severe shortage of healthcare workers prior to and during this critical time. Before the Ebola outbreak even struck, Guinea, Sierra Leone, and Liberia all had an extremely low ratio of only one to two doctors per nearly 100,000 people. That miniscule workforce has been further reduced due to an unparalleled amount of healthcare workers being infected during the outbreaks. Almost 700 were infected by the end of the year and more than half of them did not survive (World Health Organization, 2015).
STRIVE
The Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) is a clinical trial that was launched in April 2015 by The College of Medicine and Allied Health Sciences, University of Sierra Leone, the Sierra Leone Ministry of Health and Sanitation, and the U.S. Center for Disease Control and Prevention. The unblinded and individually randomized study utilizes the rVSV-ZEBOV, or recombinant Vesicular Stomatitis Virus Zaire ebolavirus vaccine.
In class we discussed how the elimination of a disease is a public good and how that would be defined. In this case, the public good is the potential herd immunity/the elimination of Ebola that could come from the population receiving this vaccination. The elimination of a disease can be described as achieving zero new cases within a territory over a set period of time. In this case, the disease is Ebola and the territory is Sierra Leone. Public goods are known as being non-rivalrous and non-exclusive within limits, but in the case of the Ebola vaccination clinical trial, I do not believe that the statement of non-exclusivity holds to be true.
The STRIVE clinical trial was not non-exclusive because it was only offered in Sierra Leone and not the other countries that were extremely affected by this outbreak: Guinea and Liberia. The vaccination was also exclusive within the country of Sierra Leone by only being available in five regions: Western Area Rural, Western Area Urban (containing Freetown), Port Loko (three chiefdoms), Bombali (three chiefdoms), and Tonkolili (one chiefdom) (Goldstein, 2016). Even within these regions, only people of the age of 18 years or older were allowed to participate. Pregnant women, breastfeeding women, and people with weakened immune systems were not permitted to participate in the clinical trial (Center of Disease Control, 2016).
COMMUNITY RESISTANCE
Efforts of containment have been met with profound community resistance in all three states. The fundamental driving factors behind this opposition are the lack of trust in authority (whether it be the state governments or non-governmental organizations) and the people’s unfamiliarity with the disease. This situation is very similar to what occurred in Haiti during its Cholera outbreak. During this time of crisis, the Haitian people didn’t know where the disease originated from and began to blame peace keepers and those who practiced voodoo for the spread (there is evidence that suggests the disease was brought from Nepal by peace keepers who were not tested for Cholera prior to coming to Haiti). The distrust in the peace keepers and aid workers, who were supposed to be relieving the critical situation, resulted in infected people refraining from seeking treatment (Frerichs, 2016).
Many inhabitants of Sierra Leone, Liberia, and Guinea refused to believe that Ebola was real. These people and their ancestors had walked the land for hundreds of years and had never seen anything like it. Then all of a sudden their loved ones started falling ill and foreign men in haphazard suits started taking them to hospitals and barricaded tents from which they seldom returned. Resistance also stemmed from the government’s (and non-governmental organization’s) inability to provide ambulances and burial teams with efficient response times. Dead bodies were often left in communities for as long as eight days (World Health Organization, 2015). International organizations such as the Red Cross were in charge of securely removing and handling the infected bodies of the deceased, but their methods interfered with native practices. Friends and family of the deceased were not even able to view the burial from a distance, and initially there wasn’t even a system in place to track where the bodies had been buried. The phenomenon was especially upsetting to a culture that places a large amount of emphasis on its burial rituals and believes that these practices affect the spirit of the deceased. The local populations held the belief that if their loved ones were not buried according to ritual, the deceased would become phantoms instead of ancestors. In fear of this, people continued on with their burial customs and were exposed to the Ebola virus (ACAPS, 2015).
In addition to the fear brought upon these people by response efforts, poorly constructed public health messages contributed to the widespread panic. Initially, these campaigns focused on making the public aware of the severity and high mortality rate of the Ebola virus. The goal of the messages was to draw out the sick to health care facilities so they could be isolated and tended to. They included statements such as ‘neither treatment, nor a vaccine exists for this disease’ and ‘the sick should be isolated to prevent contagion’. As a result, the campaign had the opposite effect of its intentions as people decided that since they were going to die anyway, they would rather have it happen in the comfort of their own homes. Very few people sought medical attention once they fell ill and the disease continued to spread (ACAPS, 2015).
In response to the fear and confusion, the three states of West Africa saw extended episodes of strikes, riots, and violence. Control efforts were even more so disrupted due to burial teams and health care workers going on strike as a result of not being paid for weeks, and even months on end. Protesters took to streets and began to stone cars in Sierra Leone. The demonstrations became lethal when eight outreach workers (September 2014) and two police officers (January 2015) were murdered on the streets Guinea (Wilkinson and Fairhead, 2016). As a result of these acts of violence and several more like them, military forces were deployed to Womey, Nzerekore in September 2014. It has been recorded that numerous gross human rights violations were committed during this time.
Two months later, politicians, civil activists, and several other figures went on a hunger strike, demanding the withdrawal of troops in the area and the safety of the local people (who had been seeing refuge in the forest for over a month to escape the conflict). In January 2015, President Alpha Condé of Guinea authorized state forces to arrest those who were being uncooperative to the Ebola response protocols. Records state that warning shots were fired, tear gas was thrown, people were beaten, belongings were stolen, and infected people were taken to health care facilities by force. In response, hospitals were vandalized and many people fled their communities in fear (ACAPS, 2015).
THE ROLES OF INTERNATIONAL ORGANIZATIONS
After seeing the death toll of the Ebola pandemic rise exponentially, the world knew that the states of Sierra Leone, Liberia, and Guinea were not equipped to deal with such a crisis. International and nongovernmental organizations began to step in and take over responsibilities that were previously handled by the state governments.
The United Nations Population Fund (UNFPA
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