I thought that in coming to Sierra Leone and working in an Ebola response, I would have a lot of thought as fodder to blog about. I couldn’t have been more wrong. It’s five months after and a massive case of writer’s block as I struggle with understanding enough of the complexities of this response to write something coherent about it.
In all the emergencies I’ve worked in, even the smaller ones, there was always something that stood out to me that made it important or urgent. For example, Haiyan meant understanding that the scale of typhoons had increased enormously, and preparation and response needed to scale up if we ever wanted to catch up to these changes. The Bohol earthquake helped me understand what an earthquake response needed to be, particularly if a big one hit Manila. Typhoon Ketsana was a wake-up call for how unprepared the Philippines was for a disaster and the importance, not just of preparedness, but of disaster risk reduction.
But this Ebola response will probably be one of the most significant responses I’ll ever work on, even if I get to respond to another one in the future. The last few months have been a trial and error of what worked and what didn’t work, keeping in mind the scale of the emergency, but also safety of the people involved. Remembering this will pave the way for a better and faster humanitarian response for a disease that still mystifies and terrifies most of the world. More importantly, this response is important to me, not just because the scale of the spread and number of casualties has been so large in comparison to previous outbreaks, but because of how important the humanitarian side of it is, in spite of this being thought of as predominantly medical.
Ebola is a terrifying disease. I remember getting off the plane in Lungi airport at 4am in the morning, with only the airport illuminated in the pitch dark. I was terrified to touch anything and anyone, and lingered at the hand washing station, wanting to get every nook and cranny of my hands clean as possible in the chlorine solution. A part of me was thinking “Well, you must be the biggest idiot in the world to choose to do this response. Do you have a death sentence???” I felt incredibly small, not just physically, but mentally. What could I contribute if all I had ever done were typhoons and floods and disasters? Looking back, I think part of my decision to respond was not thinking about the full ramifications of the disease. To think of the pain, the weakness, the bleeding for the more extreme cases… There is no cure, only palliative ones that buy you enough time and strength for your own body to kick in and start fighting back the disease. It’s a disease that is mystifying, even as there are sadly, more than enough cases to study of it.
It’s also an extremely isolating disease that hit a warm and friendly country. I remember the first few days in Sierra Leone where I would get chatted up by everyone telling me how much they love Philippine telenovelas and how I looked like Mara (but not Clara). Sierra Leoneans don’t do things by halves. I think they love their families and friends with abandon and they are passionate and extremely outgoing. When I see my staff interact with each other, the culture of togetherness seems very much in evidence. And they love their gatherings! I would come into the office on weekends and often find a busy place because it was the only place where they could come in, get out of their house and be with people. But then Ebola hit their country and suddenly, the culture seemed stifled. Everything was a don’t… avoid body contact, don’t go to public gatherings, avoid strangers in your villages. And when you get sick or someone in your household gets sick, you are isolated in your care and quarantined, where the people providing care are the very definition of strangers in that you can’t see their faces or feel a friendly touch. Everyone you encounter is encased in protective clothing and as soon as they leave you, wash themselves thoroughly with chlorine solution.
The combination of these two, being terrifying and isolating, as well as contagious when in contact with someone symptomatic, has led to a very specific type of response. To provide the best care and contain the spread, it is finding the source and going over their actions and belongings with a fine tooth comb. You need to backtrack to trace and list their contacts, go back to their homes and decontaminate their belongings, take the patient away and bring them to an Ebola Treatment Center where they are placed in red zones and given frequent care by professionals in suits, and their homes and families quarantined for 21 days. When I put myself in the place of someone from a rural section of the country, some of whom have never seen things like cars much less ambulances, it’s not a stretch to think witchcraft or aliens or something scary like that suddenly getting deeply involved in our life. When I put myself in the place of someone from my background with a lot more knowledge and access to information, I would imagine quarantine as a prison.
This is why it has been difficult to write about the response. While this should be thought of as a medical response, the humanitarian side of it should be just as strong. Because while quarantine and isolation of high risk individuals is what stops transmission, I personally feel that I can’t endorse quarantine. But at the same time, being no medical professional, I also don’t have the authority to give the best solution.
Why do I find quarantines tricky from a humanitarian point of view?
Imagine this scenario, your family is composed of a farmer father and a small petty trader wife with maybe 6 children. You were just gearing up to help your father harvest and prepare the seeds for the next harvest when someone in your family had direct contact with a positive Ebola case and your family was quarantined. In a very quick span of time, you had strangers come in to ask you questions for contact tracing and a team come into your house in suits to decontaminate your belongings. Some of these belongings are burned. All this is happening quickly and maybe you’re not too sure of what’s going on. Security is installed and a rope cordoned off around your house. A food pack is delivered to you with food like rice and oil. Maybe you get a few more food packs with a little more variety. Some other agencies come in and give you hygiene items.
You are told to sit tight for 21 days and hopefully, no one is symptomatic in your house during that time otherwise it gets extended. You might be lucky if your water well is next to your house but if it’s dry season, it might have dried up. Or if your water source is outside your quarantined home, then you have to rely on the kindness of your neighbors to bring about 20 liters of water for each member of your household a day. That’s a lot of water, considering their wells might also be drying up and they would probably prioritize their own families.
If you have your own toilet, great. If not, then you might be forced to escape quarantine to defecate in the bush or rely on someone to come in with a solution. Should you pee or poo in a plastic and throw it over the bush? Or should you just ignore security and break quarantine to do your business?
If you were fortunate, maybe you paid for your electricity top-up before the quarantine happened so you can listen to the radio to amuse yourself or even just have light! If you didn’t, then there is a possibility your electricity will run out. You don’t have a bank account or extra cash because you rely on daily work for money so you don’t have money to give a neighbor to top-up your electricity meter. And even then, can your money transfer hands? What about transmission risks? You have to rely on someone to come in and pay the bill, if their donor will allow it.
It’s day 10 and you’re missing some food items you’re not getting in your food pack. Maybe it’s groundnut, peppers, condiments, Maggi seasoning but you aren’t getting it. You also really miss fresh food. You have to rely on someone else to provide this for you because you’re still in quarantine.
You can see that your father is getting a bit worried about not tending to his fields. There is a small window of time in April where they have to harvest the seeds for the next planting season otherwise, they will be forced to eat what they have and worry about the next season. The fields are just past the bush, near your house, and your father is already thinking about escaping the quarantine in order to tend it. If he can’t, then you have to rely on someone to give additional support for the next planting season. Or maybe someone could prepare the field? But do you have money to pay daily workers? Or what if your entire village is quarantined and there's no other village for the next few kilometers?
You’ve just heard that school is starting in April, beginning with the exams for the baccalaureate. You’re worried about what will happen if you miss those exams. You need to rely on someone to come up with a solution for you not to miss this test. Do they delay it for you? Do they give you the test after?
I may have gotten one or two things wrong but based on my experience here, this happens quite a lot and without exaggeration. I can name laws to give a legal basis in humanitarian rules and conventions against imprisonment, etc. but to be honest, the easiest way of explaining the inhumane element of a quarantine for asymptomatic people is to imagine the living conditions and lack of choice that is taken away from quarantined households. In each basic right a person is entitled to, a quarantine becomes a problem when they run out of options, something very quick to happen when you are stuck in a place for 21 days relying on someone else for everything you need. And for an outbreak of this scale and for a disease still so mystifying, we must admit that we haven’t gotten the standards and rules of quarantines right. Human beings have so many different contexts that I’ve learned that if you think you’ve provided all the services and items needed in a quarantine, there is undoubtedly something else that will come out that you have not considered. It could be livelihoods, water, sanitation, education, medical needs. It could even be boredom. But there will always be something you missed out.
Personally for me, the part that would bother me the most about quarantine may not be even the essential services. It would be the fact that I could not decide or choose for myself how to provide what’s missing for my family. I would have to rely on others and the flexibility of their donors in providing it. And if I were a breadwinner in my family, this would challenge the dignity I possess in my role.
Now, I can’t comment on the medical side of things, I do believe that when it comes to positive or even negative cases, it is necessary for people to be treated in Ebola Treatment Units and in isolation. Sierra Leone and Liberia have lost too many health care professionals and people with incorrect procedures and precautions for infection prevention and control. And as an added disclaimer, again I’m not saying I have all the solutions to replace quarantines for asymptomatic households. What I can only do is give my thoughts based on what I’ve experienced, seen and heard in the last 5 months working this response and hope that more people will give more ideas so there are more choices in the next response.
What I feel are better alternatives to quarantining asymptomatic households:
Better access to information. Like most things, it starts with information. But it’s not just sharing information but looking at the whole package: how are you packaging the information? Is it contextualized? is it a form or medium people trust or recognize? who is sharing this information and do people trust them? I think we are inundated by messaging but people are intelligent and will challenge this information. The kind of information you need to give needs to also grow with time… for example, saying “avoid body contact!” was incredibly important a few months ago at the peak of the outbreak, but what about in my area now where there have been more than 60 days without cases? People ask me why they still can’t touch others when there’s no case in Bombali and when I tell them “well, there are still cases in Port Loko! Kambia! Western Urban!”, they look at me skeptically like “so what??? It’s xxx km away, how can I possibly be affected?” If these messages don’t develop or transition with the response, people get tired especially as they want to go back to their life as usual.
It’s also not just that people get tired of hearing the same thing over and over again (and I’m one such person). But it’s also building people’s capacity on how to use that information. I’ve been to quarantines where people say, well if they understood the information better, they would have preferred to go to the holding center on their own rather than put their entire family under quarantine. If given the chance, I believe people who are at risk, would rather take themselves away rather than put their entire family under quarantine. Wouldn’t you? If I were sick and I knew the limitations of a quarantine, I would willingly go to the treatment center or a holding center rather than risk my father not being able to work for 21 days and lose his salary, or have my little brother miss important school exams because of me.
Community members as messengers. I really believe social mobilization is one of the key reasons we are succeeding in this fight. A heavy-handed approach to beating Ebola, using strict quarantines and punitive measures, will not work, especially when you have a disease that seems to attack even the culture of people, from their traditional healing, their community gatherings, even their affection for others. You need to work with people they trust, people who have always been there in their lives. I was in a community where a pregnant women was telling me she didn't get any aid because she hadn't registered. So I asked her "well, why didn't you get registered?" She said it was because a strange man had knocked on her door and she was afraid to come out. Well... makes sense to me why she didn't come out (especially after meeting that intimidating man)! We should be using people straight from the community, people of influence who can convince them why they need to cut down on their traditions for now so that they can keep Ebola from entering their areas.
Community preparedness. Now that we know more about how to respond to Ebola, it's time to build the community's capacity. NGOs and the government have trained thousands of people to be community health volunteers. Now that there will always be Ebola in these countries, along with other big illnesses like cholera and malaria, these people shouldn't just be ad hoc volunteers but attached to the government healthcare system. In the Philippines, I've found that barangay (village) health workers are usually the first people that are approached for healthcare in rural areas. They trust these people and they are in the community already. They get a small stipend from the government but in many cases, barangay health workers are practically full time jobs. I believe that Sierra Leone should institute a similar system, where community health workers are attached to peripheral health units and report to their community health officers. As you build their training over time, community health workers become more equipped and more trusted and more knowledgeable about how to work in the community.
I also believe that with such serious illnesses in this country, the community, not just health workers, needs to know symptoms and triggers and what not to do for various diseases. People from the village, who know everyone and who care about what goes on in their area, will be the best people to ask sensitive information, like "is there anyone sick in your home?" or to say that a stranger has suspicious symptoms, without alarming people. This kind of active case finding for diseases like Ebola or malaria can be referred to community health workers, who can start the proper referral process. And in times where there isn't any case, then developing contingency plans at community level, with activities like simulations from triggers to referral processes, can go a long way to building people's confidence and knowledge about the long process to treatment.
It's also a way for to ask the community their ideas. I've found that people are half-hearted about recommending quarantines because they don't know any other alternative that is better (although to be frank, neither do I). They say it was good but they aren't excited about recommending it. But after a year of dealing with Ebola, I'm sure there are good ideas out there. Someone asked me "can we set up an isolation tent and so if someone gets sick, the chief can set it up and we can put them there with water and ORS until an ambulance comes along?" Well... that kind of sounds like a decent idea to me. So how do we give them information and materials to set that up safely???
Exploring the idea of quarantines again. In some places, people do like quarantines. Before I came to my district, there was a village in my district where they got tired of being quarantined over and over again so they set up their own community quarantine with a checkpoint. They limited movement outside their village, but also prevented strangers from coming in. But my favorite part of this is that they decided on it. It wasn't imposed and it was successful.
There was also a quarantined village that I worked in where I was seriously worried about their livelihoods and their water. It was planting season and they needed to harvest but the quarantine was only around the close proximity of their village. Their fields, however, were close by that you could see them from the village. So were the water sources. And we tried to get them to redraw the line around their villages to allow people to till their fields but still stay within the designated area. It was an issue of capacity of security, it was too big, etc. etc. but long story short, it didn't happen. I believe though, that with community agreement and with the right information, people would not have left quarantine. They only left the taped grounds because of water or because they wanted to work their fields. Simple things like these need to be explored so when it is possible to make a quarantine less restrictive and more contained, you can greatly improve their quality of life.
Again, I am no expert and in fact, these are only my opinions and not my organization. But I do believe that before the next big Ebola outbreak, these conversations about how to improve quarantine, how to develop what work and how to set standards need to happen. These ethical and humane discussions are not just to make life difficult but I strongly believe will make getting to zero cases so much faster in the next round. I do strongly believe that for a disease whose care is so isolated, can be built around a community to make them part of the solution.
Disclaimer: this blog represents only my views and not that of my organization. Again, I am not a medical professional nor do I claim to be. If there are any suggestions I brought up that are not safe, then please do challenge it! I would love to hear more ideas about how to make this response better.
Abbi is a petite human, blogger, amateur photographer, permanent humanitarian, avid traveller, culture addict, giant bookworm and impossible foodie.