By Ezekiel Attuquaye Clottey
For three to four months in late-2013, Ebola cases went undetected in what would become the three most affected countries: Guinea, Liberia, and Sierra Leone. As of October 14, those initial undetected cases amounted to 8,914 confirmed infections and over 3,300 fatalities. It is estimated that by December 2014 the caseload could increase nearly 10,000 people per week, reaching a staggering 1.4 million by January 2015. Malfunctioning health systems and ad hoc, incoherent, policy responses are largely responsible for the failure to curb the West African Ebola epidemic. This issue was further exacerbated by the slowness with which affected countries recognized the weaknesses in their internal health systems and delayed requests for international support. The experiences of Ghana, however, can serve as an example of effective policy response.
Fragile Health Systems and Responses to Ebola Outbreak
Crucial to an effective response to Ebola is a well-functioning health system that is alert and organized at national, regional, district, community, and facility levels. The strategic deployment of highly trained medical practitioners—doctors, epidemiologists, clinicians, nurses, and community health nurses with resources for surveillance and monitoring of diseases are also required. At the government level, investment must be made in the maintenance of drug supplies and the supplying of medical facilities with modern laboratories, isolation wards, protective garments, and other logistical requisites for preventing and promoting health services delivery.
The health systems in Liberia, Sierra Leone, and Guinea all lacked these attributes largely due to low levels of investment in health and education and histories of political instability and civil conflict—resulting in high rates of illiteracy and a shortage of trained medical professionals.
In Sierra Leone, government and health authorities struggled to cope with the outbreak. Despite experiments with border closures and lockdowns, Ebola spread from the east toward the capital, Freetown, and north beyond Port Loko. At the isolation center in the east, there were only two clinicians working in the laboratory, while in Freetown, a single isolation center was available to support a city of over one million people. In Port Loko, where there was no treatment center, and patients were kept at the hospital for at least two days until the virus was confirmed. This turned the hospitals themselves into conduits for spreading the disease. In an attempt to allow health workers to better locate high infection areas, the government implemented a three-day lock down in mid-September.
After the lock down, a representative of Save the Children in Sierra Leone reported to the BBC that the scale of Ebola outbreak is ‘massively unreported’ as 765 new cases were reported in the last week of September in Sierra Leone alone. However, only 327 beds were available for the new patients.
In Liberia, Ebola has brought the already fragile health system to the brink of collapse. Years of civil war had reduced the number of doctors from 400 to 15 . By 2014, that number had rebounded somewhat with 155 doctors active in the country—roughly 1 per 100,000 people—assisted by roughly 500 community health volunteers. However, the isolation center in Monrovia opened for only 30 minutes each day and the overcrowded facility had to turn away new patients.
In Guinea, poor infrastructure led to remote rural areas being completely cut off from communications or treatment as heavy downpours swamped rural road networks. As a result, rural folks began losing trust in the health system, with some becoming openly hostile toward medical workers. Tragically, this hostility led to the deaths of eight health workers and journalists who were murdered and buried in Nzerekere, Guinea.
Preventing Ebola Outbreak in Ghana
Ghana, like many other West African countries, is at risk and needs to prevent or make preparations to tackle Ebola. According to Dr. Badu Sarkodie who heads Ghana Health Services’ National Disease Control Unit, preparedness is an on-going process. As part of that process, the country has put together an inter-sectoral committee headed by Dr. Kwaku Agyeman-Mensah, Ghana’s Minister of Health, to develop and execute Ebola response plans at national, regional, district, and community levels. Public education, randomized and purposive screening for early detection, and treatment are the committee’s main tasks.
With a doctor to patient ratio of 1:10,000 and a current nationwide outbreak of cholera with over 17,000 reported cases and about 150 fatalities, the health system in Ghana is already under some stress. Nonetheless, Ato Sarpong who represented President John Mahama at a recently organized BBC talk show on the outbreak, stated Ghana has taken delivery of 9000 personal protective equipment (PPE) kits to augment the 1000 already distributed throughout the country, and that surveillance systems have been set up at all ports of entry. Whether this is adequate to sure up Ghana’s very porous border is an open question as many can easily evade customs check even at these ports of entry. Aflao, on Ghana’s southeastern border with Togo, has a 16-bed isolation ward and 4 PPE suits. The plan is to alert the district capital, and more PPE and logistics will be made available. The main treatment centre for Accra-Tema metropolis is 90 percent complete and Dr. Kofi Bonney, Head of Virology Department, Noguchi Memorial Institute for Medical Research (NMIMR), University of Ghana, has reported that 98 test cases for Ebola virus have so far been all negative.
However, despite Ghana’s efficient technical response, there are still concerns about Ghana’s ability to respond should Ebola enter the country. Some medical officers are skeptical of Ghana’s preparedness and lack of PPEs remains a concern. In addition, many laboratories are not adequate, and it is takes a long time to test for the virus. Fear also remains an issue even within the medical community as some doctors have absconded from hospitals due to fear of infection. Others like Dr. Emmanuel Kwesi Aning, currently a member of the Economic Forum’s Council on Conflict Resolution he also advised the UN, AU, and ECOWAS, caution governments not to look at Ebola as only a public issue but also a security issue which requires both urgency innovation.
Malfunctioning health systems accounted for delayed response and early detection of Ebola in West Africa. But as demonstrated in Ghana, even where capacity is lacking, public education can play a key role in mitigating high levels of ignorance and hostility to health workers while promoting behavioral changes among large populations. In Ghana, Kojo Yankson of Ghana’s media house Joy FM Station, reported that public education about Ebola was extremely useful. Profuse and accurate dissemination of information empowered both public and health workers who volunteered to eradicate Ebola. Evidence abound as people refused to shake hands and washed and used sanitizers regularly. Traditional authorities and local opinion leaders have key roles to play in reaching out to remote areas. Medicine Sans Frontier and the Red Cross have used these means effectively, and both governments and other stakeholders can piggy-back on these strategies.
Ezekiel Attuquaye Clottey is a former research sssociate who has just completed a doctoral programme at the Institute of Statistical, Social and Economic Research (ISSER), University of Ghana.