The Ebola crisis in Sierra Leone struck one of the world’s poorest countries, ranked 183 out of 187 in the United Nation’s Human Development Index. 1 Life expectancy is 45 years, 2 and Sierra Leone is “the third-most dangerous place on earth to have a baby.”Reference Nossiter 3 Established in 1787 by black former soldiers from the British army, Freetown (the capital) and the surrounding area became a Crown Colony of Britain in 1808. A succession of decentralized rule through inherited “chiefdoms” and political favoritism resulted in a legacy of competition, rivalry, and violence. Governance was characterized by economic inequality, forced labor, questionable land allocation, and the exclusion of women, youths, and the poor. Sierra Leone achieved its independence in 1961 only to suffer a succession of failures to reverse these conditions. Corruption, the withdrawal of large foreign firms, empty coffers, shrinking government services, and the marginalization of young generations with no access to schooling or jobs served as the breeding ground for the Revolutionary United Front. A brutal 11-year war that began on March 23, 1991, well financed by Sierra Leone’s rich mineral deposits and alluvial diamonds, was finally ended a decade later through United Nations and British intervention.Reference Jang 4
The results of the civil war in Sierra Leone included 70,000 dead, massive population displacement, a damaged health care infrastructure, widespread illiteracy, poverty, and high levels of infant and maternal mortality. 5 With only 40% of the population having access to safe drinking water (a situation that is worse in rural areas), the population struggles with malnutrition, diarrheal diseases, hepatitis A, cholera, and typhoid fever. A decentralized fee-for-service health infrastructure overseen by the Ministry of Health and Sanitation was augmented in 2010 by a program of free health care for pregnant and breast-feeding women and children under 5 years of age, funded primarily by the United Kingdom and the United Nations. 6 Traditional healers comprise an important component of the primary health care system in this country of almost 6.1 million people, 7 which is served by only 3 physicians per 100,000 population. 8 Despite steps taken to improve access to health care, Amnesty International notes, “Deficiencies in the monitoring and accountability system allow poor practice and mismanagement to go unchallenged, and have provided some people with opportunities to exploit the system and plunder valuable medicines.” 9 Absent a public health infrastructure comprising disease reporting and detection systems, medical treatment personnel and laboratory facilities, and effective strategies of risk communication to reduce disease spread, the government of Sierra Leone was not prepared to meet the challenges of the Ebola virus disease outbreak.
THE DE FACTO GOVERNMENTAL PUBLIC HEALTH ROLE OF NONGOVERNMENTAL ORGANIZATIONS DURING THE EBOLA OUTBREAK
An NGO is defined as “any non-profit, voluntary citizens’ group” that “perform[s] a variety of service and humanitarian functions, bring[s] citizen concerns to Governments, advocate[s] and monitor[s] policies.” 10 Over 100 NGOs (including large and well-known international NGOs such as Save the Children, the International Committee of the Red Cross, and the International Rescue Committee, along with many local religious and civil-based groups) operate in Sierra Leone, 11 and many have attempted to meet the needs of this vulnerable post-conflict state.
Large international NGOs such as Doctors Without Borders (Médecins Sans Frontières) immediately struggled to fill the void left by fragile and fragmented government health services, but their staff were overwhelmed and resources saturated by the continual spread of Ebola virus disease and the growing numbers of cases and deaths. Smaller NGOs, even those for which health is not the core of their mission, endeavored to assist as well. One such organization, Caritas, operates within the “social mission and core values of the Catholic Church.” 12 Father Peter Konteah, who is the Executive Director of Caritas Freetown, and Ishmeal Alfred Charles, who is a humanitarian aid worker and former conscripted child soldier now supporting Caritas Freetown through the Healey International Relief Foundation, provided insights into their Ebola efforts.
The early days of the Ebola outbreak in Sierra Leone brought confusion to those seeking care and those attempting to deliver it under austere circumstances. Mr. Charles told the following story: Mary was 23 in mid-September—4 months after Ebola hit Sierra Leone 13 and almost 2 months after the death of Dr. Sheik Umar Khan, the country’s renowned infectious disease physicianReference Fofana and Flynn 14 —when she was brought to the local hospital. Her chief complaint was a stomachache, and Mary’s relatives asked for a doctor. The nurses pointed. The doctor walked over, looked at Mary and denied he was a doctor. Relatives took her to another hospital, but Mary died while they were looking for another doctor (Ishmeal Alfred Charles, personal communication, September 29, 2014).
Caritas soon recognized the finite resources of Doctors Without Borders and others to handle the continuing (and increasing) onslaught of patients. Absent knowledge and formal training, Caritas personnel worked hard to access information about and to apply the basic tenets of public health. As Ebola began to overwhelm Sierra Leone, education regarding the elements of public health, such as what an “incubation period” is, were actively sought through Google searches and by logging on to the Centers for Disease Control and Prevention website. Local aid workers such as Mr. Charles of Caritas trained others down the chain, eventually ensuring that the 75-person Caritas Freetown office had the basic tools of disease control. Risk communication became the foundation of their efforts in parts of the country where disease transmission was dense: “You tell them, you tell them again, and then you tell them again” (Ishmeal Alfred Charles, personal communication, September 29, 2014).
Fear, lack of trust, and illiteracy among the population of Sierra Leone made the Ebola message difficult to communicate. In the early days of the current outbreak, “many people thought Ebola was God’s punishment” (Father Peter Alfred Konteah, personal communication, September 22, 2014). Guidance from government officials was deemed spurious at best, and admonishments to avoid handling dead bodies and to avoid engaging in practices that promoted disease transmission went unheeded. The spiritual commitment to the dead overtook concerns about disease exposure and risk. Caritas took to the streets and villages, the marketplaces, and police stations, using megaphones and brightly labeled t-shirts with warnings such as “Avoid touching dead bodies” and “Don’t touch.” Although risk messages from officials were often shunned, the words of religious leaders, such as Father Konteah, began to be followed, especially through collaboration with other faith leaders, including Muslims, Methodists, Pentecostals, and Seventh Day Adventists, to ensure consistent health and safety messages.
A 3-day curfew or “lockdown” starting September 19 afforded the opportunity for aid workers to go house to house providing health information and education.Reference Roy-Macaulay and Corey-Boulet 15 Caritas brought 400 volunteers to this effort, which consisted of messages such as “Report sickness” and “Do not hide bodies.” This effort had mixed results. While many adhered to the lockdown and messaging, others perceived this as an economic hardship, a period when the leaves from backyard gardens would wither and die rather than be sold at the market to buy rice to feed families (Ishmeal Alfred Charles, personal communication, September 29, 2014).
Public gatherings, which could provide venues for disease exposure, were discouraged. Schools closed and church services were greatly modified. For example, rather than by shaking hands, the Catholic “sign of peace” was observed by placing a hand over one’s heart (Father Peter Alfred Konteah, personal communication, September 22, 2014). The use of herbalists and traditional healers, who some suspected may have played a role in spreading infection from village to village, was disparaged by many NGOs. Mr. Charles and Father Konteah, both of Caritas, along with many from the faith community, worked to change the beliefs that soap was poisoned and that salt baths could prevent and cure Ebola. Buckets and bleach were widely distributed along with instructions on handwashing (Ishmeal Alfred Charles, personal communication, September 29, 2014).
Fear and stigma were some of the greatest obstacles to overcome. People who worked with Ebola patients, “especially nurses,” were suspected of bringing the virus. Quarantine was rejected for fear that people would die of starvation, not of Ebola (Ishmeal Alfred Charles, personal communication, September 29, 2014).
Contact tracing was initiated by asking people who they knew who might be sick and whether they had any friends or relatives who they had not seen or heard from recently. Because the aid workers were part of the community fabric, trust was an established currency not available to either government representatives or “outside” disease responders.
DISCUSSION
Like the severe acute respiratory syndrome (SARS) virus outbreak in 2002 in Asia and the Middle East respiratory syndrome virus outbreak in 2012 in Saudi Arabia, the current Ebola virus outbreak in 3 West African nations illuminates the resounding global impact on travel, economies, and governance emanating from a regional public health crisis. Political conflicts, population dislocation, and climate-related disasters will both cause and result in large public health crises requiring NGOs—even those focused on social and political justice and non-health-related missions—to have a basic understanding of public health principles such as risk messaging, health education and behavior change, and contact tracing to contain disease spread. In West Africa, resources such as hospital beds and personal protective equipment may be limited, but NGOs such as Caritas have compensated by availing themselves of the knowledge they need, not to treat patients but rather to halt continued disease transmission. As Burkle pointed out, “public health containment challenges trump pure clinical responses in controlling the spread and overall outcomes in the Ebola epidemic.”Reference Burkle 16
Building a functional and sustainable governmental public health infrastructure in many developing countries will require strong and visionary leadership, political will, and substantial and prolonged investment in human capital. With growing recognition of the global threat from communicable diseases, initiatives such as the Global Health Security AgendaFootnote * may provide the framework for navigating countries such as Sierra Leone toward a sound public health infrastructure.
NGOs can serve as a bridge until that goal is achieved, but even they are re-evaluating the competencies required to address future health crises. The humanitarian enterprise has grown considerably over the past 3 decades, accompanied by increasing operational and funding complexities and commensurate with global unrest and fluctuating geopolitical forces. The Sphere Project—a movement to standardize and professionalize humanitarian effort and improve the quality and accountability of the actions of NGOs—was initiated in 1997. 17 Doctors Without Borders has described moving beyond its 40-year efforts of being a “collective of committed and idealistic volunteers” to adopting “standardized and evidence-based programs.”Reference Shanks 18 While larger NGOs may be sufficiently resourced to achieve the goal of standardized core competencies, this will be a much more difficult goal for smaller and less centrally organized humanitarian agencies. Although efforts to increase competency-based curriculum development have been robust, “the movement has lacked proper funding, legislations, and collective interest, especially from NGOs that generally prefer in-house training and evaluation.”Reference Gursky, Burkle and Hamon 19
CONCLUSIONS
As Mr. Charles of Caritas stated before a US Senate hearing on September 16, 2014, the role of NGOs in the fight against Ebola has been critical. “We work closely with the Ministry of Health and Sanitation, [the] Ministry of Social Welfare, [and] the emergency operation centers. What this essentially shows is that smaller organizations with lower human capacity and budgets are able to make impacts at the lowest community level, because they live within the community and they all [under]stand the reality on the ground.” 20 Eventually, however, there must be an investment in public health, noted Mr. Charles. “The country must be self-reliant so we do not have to depend on others.” 20
The Ebola outbreak ravaging West Africa—which then spread to Europe and North America 21 - 23 —has demonstrated the importance of having a prepared and coordinated international disease response. Ebola has jumped from isolated and remote villages to cities, a 21st-century trend in urbanization that inevitably will be replicated in many areas of the developing world consistent with expanding economies, transportation, and migration. Ebola, as well as other emerging pathogens will also spread, moving from less-resourced countries and threatening regions and continents because of a lack of clear policies, decisive strategies for international response, and strong public health infrastructure in disease-vulnerable nations. In the interim, much of the population health burden for acute and chronic health conditions will fall to NGOs, and all should have consistent and robust knowledge of and the ability to apply basic public health disease control principles.
