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.
My journey to Sierra Leone started from a gray and dreary Paris (I discovered that rain + winter makes Paris less romantic. Harrumph) through Casablanca, Morocco to Freetown, Sierra Leone. It was a lucky break I was in France because the Philippines discourages travelers from going to West Africa (really, my country needs to be a little less backward about things like this) and even blocks people from leaving if they find out that's your destination. (It's disappointing that the Philippines churns out thousands of medical professionals like doctors, nurses, and are known to be excellent caregivers. And yet, the government discourages them from going to West Africa to help in the response. But anyway).
When I think about what got me started in my career as a humanitarian worker, it’s the moment of clarity standing in front of the haunting photos of prisoners in Tuol Sleng on my birthday. The prickles in the back of my neck as the blank stares of the dead look though me, mixed with a strangely misplaced sense of frustration almost three decades after the fact. How could the world have just stood by as millions of Cambodians were massacred by the Khmer Rouge?
That sense of injustice disillusioned me straight through my first year of law school. Facing a long stretch of corporate work or slow moving human rights law, I took the deep breath I wanted and returned to Phnom Penh a year later to become a legal intern in the Center for Social Development and a researcher for the Orphans Class in the Khmer Rouge Tribunals. I came back to the Philippines that summer with more awareness of the atrocities of the world, a sense of responsibility that I felt owed to people in countries I’ve never had a connection to, and the certainty that I wasn’t in the path I wanted to take. Five years ago, with no real sense of what I wanted to do, I accidentally started my career as a humanitarian worker.
I’ve been based in Tacloban for barely a month now and walking around the city never ceases to amaze me at how devastated these areas have been, how much work has been put in to get to this state seven months after Supertyphoon Yolanda (internationally known as Haiyan), and how much more work is still left to do.
While walking back from the book launch of this beautifully moving book entitled “Agam: Filipino Narratives on Uncertainty and Climate Change”, a colleague was telling me of her experience doing the rapid assessment in Tacloban City only 3 days after Yolanda. Seven months ago, the road we were travelling in was strewn with debris. So much so, that she said you could barely walk on the road. In my month in Tacloban, I can imagine what this debris was like… trees, parts of homes, rocks, water from the sea… sometimes dead bodies. She told me that the communities along that road were in confusion and pointed out the little eskinita (alleyway) into one barangay where she was led to talk to some of the community members… the community where the barangay captain had broken down in tears in front of her and she didn’t know what to say or do.
Oxfam @ 25 Ebook: "Celebrate Change" (and my own article in it "What's on your mind: Forays into Social Media"
Oxfam celebrated 25 years of change in the Philippines last year and we came up with an ebook documenting stories of all those years. Check it out here!
(I also wrote an article on page 243 on social media!)
"What's on your mind?: Forays into Social Media"
My entry to Oxfam in 2009 was my first venture in the humanitarian field. Working in disasters was a huge wake-up call, and I needed to learn an entire language, culture and movement to be able to understand and respond to disasters. Eventually, I could connect the dots from different pieces of disasters to changes in the history of disaster management and disaster risk reduction. Typhoon Ondoy (Ketsana) in 2009, for example, became the impetus to pass the Philippine Disaster Risk Reduction and Management Law, which stagnated in Congress for the last two decades. As a new humanitarian practitioner, what amazed me the most was that every disaster, whether inside or outside the country, made little but smarter changes as to how we understand disasters. Responding to an emergency has gone beyond the provision of search-and-rescue assistance and food aid, to a complex set of interventions that respond to water, sanitation and hygiene needs; emergency food security and livelihoods; nutrition; humanitarian protection; advocacy; and shelter, on top of gender and many other considerations. A deeper understanding of disasters, on the other hand, strengthens the relationship between disaster risk management and development work as the focus zooms into forming resilient communities, rather than simply just responding to an emergency.
My previous blog "The Competition of Emergencies" was excerpted into an op-ed piece on Philippine Daily Inquirer on 19 December 2013.
BOHOL—With the recent spate of emergencies hitting the Philippines, there’s a need for it to be smarter and think more about how to approach the scale-breaking disasters we should come to expect. But we need to start thinking not just about what happens during a disaster but also the ramifications. A disaster doesn’t truly become a disaster unless the response falls short of what the affected people need.
Not being able to prepare and respond well to disasters actually causes another issue that hampersresponse and recovery. This is what I call a competition of emergencies. What we’re not realizing is that the inability to address the increasing frequency and scale of disasters is the perfect setup for disaster. That we’re not preparing on a scale proportionate to the disasters we are experiencing just means that we will continue to respond and play catch-up with the rotation of disasters.
The rush and panic of the first week of responding to a disaster has somewhat faded for TY Haiyan. Donations have poured in, aid is more firmly established, and a number of humanitarian agencies have set up camp for a good 3 months to a year (or even longer) to deal with the aftermath of this monster of a disaster. So what next? Well, now it's time to start talking to your communities again and in-depth.
It's not uncommon for aid workers and agencies to have the mentality that they are 'swooping in to save the day' and fall back on arrogance that because we've done this several times, we know what the affected populations need." No worries, we got this in the bag." Hang on and hold up. Sure, aid workers get the general outline right but you can never say you know what an affected population needs until you actually pause and take a second to talk to them.
It's happened before that humanitarian agencies have not done well by the people they're trying to serve. In 1994, there was pretty strong criticism for the NGO community responding to the Great Lakes Refugee crisis (aftermath of the Rwandan genocide) and there was a move to create a set of international minimum standards called the Sphere Project that should be achieved for each response. By minimum standards, it's basically the very least that you can do... but feel free to do much better than that if you want to really launch a great response. (To read up an article that can break it down, here's Rodolfo Ticao's article entitled "Guide for aid-givers: Beyond good intentions you must do no harm"). There are also other great standards you can check out, like the Humanitarian Accountability Partnership (HAP).
Also published on Oxfam's blog here.
When our rapid assessment teams came back from Leyte and Eastern Samar, they came from a total information blackout into a storm of angry and combative debate on the efficiency of government response to supertyphoon Haiyan victims. A couple of my colleagues marveled at how negative the atmosphere was and admittedly, the debate has gotten pretty exhausting and polarizing. Everywhere I go, whether it's a dinner, a team meeting, an email exchange or social media, the conversations run along the same questions. Why is government response so slow? With so many donations pouring in, why are people still saying they aren't being served? Where are our donations going to if we're still not moving fast enough? Why should we give it to the government when they are moving so slowly?
It's interesting to be in the position I find myself in, working for a humanitarian agency and having relationships with government and other aid agencies, while at the same time being as involved in the public's reaction as you inevitably find yourself in when you're using social media. Early on in the week, when I could tell that the general feeling towards this response to Haiyan was going to get very heated, I made the conscious decision to step back and not get involved in these debates. But there is a lot of context in what's happening now that I feel is not explained comprehensively enough to understand why we're not moving as quickly as we should.
A few days ago, I was asked to be on the panel of BBC World Have Your Say (BBC Why) on the Analysis of an Aid Mission with representatives from some of the larger aid agencies all around the world. In spite of it being at 2AM in the morning, it was an interesting conversation because it was a rehash that a lot of the problems we're currently encountering were also experienced in a few of the larger disasters in recent years. The Haiti Earthquake and Hurricane Katrina are two such disasters frequently mentioned in line with Supertyphoon Haiyan, and from the aid workers on the panel, there was a sense of "well, we're not learning from our mistakes if the same situations keep happening!"
With the goodwill pouring in from literally all corners of the globe, the relief goods are coming together more and more quickly (while unfortunately, aid is not keeping up pace -- but that's another blog for the next time). I find it amusing (in an "awwwww" sort of way) that people are packing massive gymnasiums... and then slowly edging themselves out of the building as the food packs begin to take over. In the US, my uncle sent word that Americans curious about the commotions around huge Fil-Am communities are stopping their cars to ask what's happening and then handing over fistfuls of cash when they find out what for. These are truly Christmas stories in the making (oh yes! It's Christmas season!).
But before the well of generosity runs out (after all, we're not limitless pools of cash), let me put out there the idea of alternative kinds of relief. These may not be answering to the basic needs of food, water and shelter, but supports families in very convenient ways. There is such a thing as volunteer fatigue (which thankfully, hasn't seem to have started yet) but there might be such a thing as volunteer boredom also. And so here's a list of alternative relief items that might peak your interest to give. (P.S. This post may grow, especially if ideas are shared!)
Earlier in the afternoon, while stuck in the constant Manila traffic, I was (as always) scrolling through my phone and monitoring what was coming out of Yolanda. In the middle of the rants, complaints and doubts, I came upon a post about positive stories that grew out of the concern for Yolanda victims.
What struck me the most was a photo of a half-full bag of Bear Brand milk and the story of the elderly laundrywoman who gave it to a man asking for donations for Yolanda victims. The genuine heartfelt donation came with the explanation that the half bag of milk was all she had to give because she had absolutely nothing... but if you mixed it with water and gave it to the children, it would make them happy because it was Bear Brand milk. Tears welled up in the eyes of the man as he thanked her and walked away, dissolving into tears as soon as he got to the privacy of his home.
So did I, man. So did I. Stuck in the normalcy of Metro Manila traffic and the world moving forward as it must do, I scrunched down in my seat so the cabbie couldn’t see me surreptitiously wipe my tears. I continue to be floored by people who think they have nothing still coming up with something for people who have lost everything.
Abbi is a petite human, blogger, amateur photographer, permanent humanitarian, avid traveller, culture addict, giant bookworm and impossible foodie.