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Emergency Preparedness: Considerations for Ebola and Future Disease Outbreaks in Sierra Leone

22 August 2014 at 09:52 | 4118 views

Commentary

By Mohamed Kanu, PhD, USA.*

The magnitude of the current Ebola outbreak (largest recorded in the world so far) has left the Ministry of Health in Sierra Leone—and in other affected countries—scrambling for answers. To be clear, infectious diseases are not unique to developing countries, but the sometimes shaky public health systems in these countries make them claim more lives and reduce citizens’ quality of life more than they are supposed to. I have mentioned in a previous article that some public health problems are emerging ones while others have endured over time. Ebola is new to Sierra Leone, although it has appeared in other parts of Africa. Sierra Leone (and the other countries affected) is a Third World country and the task of managing especially infectious diseases is and will remain an on-going reality.

The current outbreak will eventually be fully contained. Furthermore, the question is not whether infectious diseases will emerge in the future. Even a re-emergence of Ebola is a strong possibility! What is most important now is to reexamine the role of the Ministry of Health and determine what physical structures, health policies, and human capacity need to be developed and implemented in anticipation of future outbreaks.

I offer the following recommendations, some, if not all, may have already been put forward and implemented. It is my hope; however, that my humble recommendations will be read by those directly involved in the handling of the outbreak and will help refocus attention on the crisis:

1. Perhaps the most important responsibility on the part of the government right now is information dissemination. The current level of misinformation about this epidemic is very scary – from suggestion of washing with salt as prophylactic to the outbreak being a political machination. We need an Information Center capable of providing programming of 24 hours a day and seven days a week. This can be a radio station able to reach citizens all around the country and in all languages and staffed with the country’s most effective communicators.

2. Continue efforts to cut Ebola transmission source through reduction of hospital-based transmission, community education and awareness, and Contact tracing.

3. Advocate for an increased role of the World Health Organization (WHO) and the Sierra Leone Medical and Dental Association (SLMDA). The WHO is the world’s international health police and its involvement in any health issue makes instant difference. Similarly, in a country without strong health research institutions, the SLMDA must play a leadership role in health-related emergency preparedness and disease management in Sierra Leone. A vocal SLMDA can provide guidelines that many people are likely to follow. At present, the role the WHO has played leaves much to be desired.

4. Maintain and sufficiently fund (with capable leadership) the recently established Presidential/National Task Force on Ebola. It does not matter what this task force is called as long as its mission and goals are clear – to develop a framework that will outline the nation’s response to the current and future health emergencies. When we lacked a similar set-up at the beginning of the current outbreak, we all saw the huge amount of time and other resources it took to assemble one.

5. Reconstitute some of the roles of the Presidential Task Force. The President does not have to be the Chairman of this group in order to demonstrate commitment to ending the ravages of Ebola. As busy as he already is, the President as Chief Executive must be relieved of that responsibility so as to allow him additional time to solicit and harness resources wherever they may come from. Another capable person can be put in that position and the President can receive daily briefing.

6. Use local channels of communication – for example, trained individuals with the correct prevention messages can visit villages and towns using loud speakers without people gathering in large numbers (since that has already been banned anyway). The use of mobile or cell phones is already playing a major role.

7. Solicit the additional support of those in the diaspora, especially health professionals through the Office of Diaspora Relations in Sierra Leone. Many Sierra Leonean health professionals want to provide help (equipment and training) if logistics are in place in the country (shipping, clearing at the quay etc.). Elected and government officials can make it less difficult for people to help.

8. Utilize trained personnel with the help of Muslim, Christian and other clergy to help explain to the public how to handle the dead in a time of crisis. It is nave to think that people will throw away cultural practices overnight. Giving “respect” to dead relatives through proper burial is a global practice and Sierra Leoneans will find it hard to treat lost loved ones with reckless abandon. With the correct approach, we can invoke a sense of remorse (and hopefully a change of attitude) in the public that harboring an infected person or improperly handling the dead is aiding and abetting the spread of the disease, thus indirectly contributing to the deaths of many more people.

9. Encourage hospitals in the country to collect health data. With such routine practice, even Contact tracing will be easier to do. The health system should not just treat patients without collecting even demographic/residential information (age, gender etc.). Such information, had it existed, would have been invaluable in the current epidemic.

10. We need mobile health units (with appropriate medical equipment). These are specially designed vehicles that can visit rural areas to screen and educate people whether or not they are suspected of carrying the virus. We can specifically request donor countries to provide such units.

11. Local health officials must be given additional incentives and become celebrated heroes and heroines, who are constantly praised on our local radio stations and other information channels. We will be surprised how praise and recognition can jolt people’s performance and perseverance.

12. Involve political and other role models (senior politicians, music stars) in information dissemination like never before. Senior politicians should continuously visit home constituencies to help in reducing fear and correcting misinformation. This is not reckless endangerment of people– it simply means getting the word out. The influence of a celebrity is worth many pamphlets of information, especially where many are illiterate.

13. All Sierra Leoneans must remember that this is our problem and that many of the solutions have to be Sierra Leonean solutions (e.g. revisiting our cultural practices, investing more in our health, changing our health-related behaviors etc.). Although the international community has a human and moral responsibility to help with what has now become a global threat, it is still those who “feel it that know it” best.

14. Sierra Leoneans (at home and abroad) must exercise patience and objectivity regarding the outbreak. This is a tough moment for everybody, more so for those who have lost loved ones and the political leadership. The frustration is fueled by individuals who spread misinformation and/or deliberately help to hide persons suspected of carrying the virus. Eluding authorities by sick individuals in order not to be discovered is not a new phenomenon in human history. Interested readers can read the story of Mary Mallon (nicknamed Typhoid Mary) who, infected with typhoid fever in the United States, eluded authorities and refused medical tests while spreading the disease until authorities finally arrested and incarcerated her. In Sierra Leone some people are afraid of the stigma associated with Ebola and it will take time and education to make people do the right thing.

Long-term Policy Recommendations

While we are scrambling to assemble structures to address the current die-or-live situation in our country, we need to look beyond the current epidemic through policies. Polices are rules and regulations. They become health policies when they relate to matters of health. Sierra Leone’s national health policy developed by esteemed experts could be expanded. In health policy, three things need to happen before a window of opportunity opens for the development of new policies: 1) the existence of a problem, 2) the availability of a solution to the problem, and 3) the political circumstances or willingness to do something about the problem. At this time in Sierra Leone all these three conditions are met and the time is ripe to undertake new policy initiatives to improve our public health infrastructure – both in terms of material and human capacity. Below are suggestions for long-term solutions.

Improve or Establish Structures within the Ministry of Health

The Ministry of Health should establish (if it has not already done so) and/or strengthen an Epidemiology Department with a strong focus on infectious diseases. Epidemiology is the study of the cause and distribution of diseases in human populations; which is why many of the experts now sent to Sierra Leone from other countries are epidemiologists and disease prevention specialists. A well- resourced department of epidemiology will conduct disease outbreak investigations in the country and will routinely collect pertinent health data. Such data are crucial even for those experts who come to the country to assist during health emergencies. During this crisis, the Ministry of Health has made reasonable efforts in reporting new and existing cases of Ebola infections but few can disagree that data gathering efforts can be further enhanced.

Furthermore, an effective department of epidemiology (with surveillance capabilities) will foster collaboration with medical doctors in the country (foreign and native born) to practice evidence-based medicine. Evidence based-medicine is the use of proven research to treat patients. The fight against Ebola would probably have been less difficult if we had local research that is focused on infectious disease prevention that incorporates local realities, such as cultural practices, poverty and other factors.

Develop Academic Programs of Public Health in the Country

These programs can be newly developed ones or improvement of existing ones. Academic programs in public health will train Biostatisticians (specialists in collecting and analyzing health data), Behavioral Scientists (experts in health-related human behavior), Health Policy experts (developers of health-related policies), Environmental Health professionals (who specialize in the impact of the physical and social environment on health) and Epidemiologists (already defined above). Having strong local academic programs in public health will continuously train sons and daughter of the soil, many of whom will always be there to help during emergencies, and train future generations.

I am convinced, although I stand to be corrected, that Sierra Leone has more nurses, doctors and pharmacists that public health professionals with advanced training. A country with limited clinical or therapeutic capabilities must improve its structures on health promotion and disease prevention. I maintain that public health is the “weakest link” in our health system.

Encourage Interdepartmental Collaboration

Encourage a continuous interdepartmental, inter-agency and inter-ministerial collaboration to address new and existing health problems. Even the private sector cannot be left out. Effective interface between and among departments will prevent key ministries from working in silos and hence encourage “systems thinking.” Again, this cooperation must not end with the containment of the current Ebola outbreak. For most of the recommendations about establishing departments and health promotion units, it will be a grave mistake to concentrate all of them in the nation’s capital – Freetown. Many of these structures must be replicated in provincial headquarter towns.

Increase Funding for the Health Sector in the National Budget

Currently, the budget for the Health Ministry is inadequate – some might even say it is pitiful. Granted that the government has competing demands, but some government ministries are more important than others. Health is one of the very important ones! When the health ministry is underfunded, lives are endangered.
This epidemic has tested the resolve of our nation, the credibility of our leaders (political or not), our collective conscience, as well as how best our public health infrastructure is working. There is a lot of blame to go around but we must put that aside for now and find workable solutions.

In the past few weeks, we have seen how a country that pulls together can mobilize resources even under challenging circumstances. As much as the government, private individuals, organizations and society at large have tried to address this problem, it will seem as if nothing is working. That is not the case. Actually, many of the structures now in place (quarantine, declaration of a state of emergency, establishment of a task force headed by the president, prayers, financial and other contributions etc.) are having an effect, but as long as people are dying and new cases of infection continue to emerge, no one can claim victory.

*Mohamed Kanu is an Associate Professor of Public Health and Director of the Master of Public Health Program at Tennessee State University in the United States of America: Email: Mkanu@tnstate.edu. Tel: (615) 963 7326.

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