November 20, 2014

Fighting the Ebola Virus Disease from a Seven (7) Way Angle in improving health delivery in Liberia

 - By Augustus J. Flomo

We met Augustus Flomo during the filming of our latest documentary in Liberia, in September 2013, a few months before the first cases of Ebola were reported. Augustus is Liberian, descendant of the first nations of Liberia before the country came to be called as such. He is Deputy Chief of Party at IESC - the International Executive Service Corps - a US-based not-for-profit with a focus on the support given to private enterprise in developing countries, and is Involved With His Whole Communities in the country through The Rotary Club of Sinkor whose he is Immediate President. His background in business, community development and aid work give him a profound understanding of economic and social development.

Deeply rooted in his culture and steeped in the history of his country, Augustus is one of the characters in Liberia: Emerging from the Shadows ?, our latest film released in October, and he agreed to give us his point of view on the current crisis occurring in his country.
This article is the first in our "Open Forum" series, a platform we chose to dedicate to those we met during our travels, those who have inspired us and continue to feed our thoughts and daily actions, and we hope that they will also bring you some of their humanity.

Maïlis Burgaud - Producer

Monrovia from Hotel Africa(c)Wayne Schoenfeld

Overview of the outbreak in Liberia
The deadly Ebola virus disease entry was announced in Liberia in March 2014 and said to have come from Guinea through family-friends who had gone to Guinea to attend funeral service of some love one.  According to specialists who had encounter with the Virus Disease, the one in Liberia is considered the most deadly in the history of the Existence of man. According to the Center for Disease Control – USA, the virus occurrence in the history of mankind was in 1976 when 318 people were infected with 280 deaths in the Democratic Republic of Congo which was then called Zaire. This deadly virus outbreak continued from 1976 into many countries and now seriously destroying lots of people in Liberia and its nearby neighboring Countries, Guinea and Sierra Leone in 2014.  

Liberia’s first infection in March was seem to have been fought seriously as the country health authority announced that the last suspected case was on April 4, 2014; This announcement was made on June 4, 2014 which reflected more than 21 days of window period, however with caution since our neighbors were still having the virus infection spreading in their countries. In no time after a few days, we again learned of a new outbreak in Monrovia and Lofa Respectively.   Before this outbreak, there was some time another outbreak of Lassa fever in 1972 that led to many deaths in Liberia before it was diagnosed.

Monrovia (c)Wayne Schoenfeld

Adequate and appropriate Leadership commitment in the fight against Ebola

John Maxwell said in his leadership theory that “everything rises and falls on leadership”. When the Ebola crisis first started, there seem to have been a lay-back attitude from the leadership. As mentioned earlier, the situation started in March 2014 in Lofa; at that time, senior officials of government particularly from the Liberian Senate denied that there was anything called Ebola in Liberia. Even on the part of the health authority in Liberia, there were not expressed comprehensive engagements of this Ebola Virus Disease. From reading about the behavior of the Ebola Virus outbreak, almost every country that have had such outbreak had received some re-occurrences. When there was a sign of a decline or elimination of the virus in May-June, everywhere in Liberia went back to normal activities without the necessary protocol put in place to continue to keep the Country on the alert of the deadly disease. 

The reoccurrence of the Ebola Virus Disease in June was the breaking of the entire Country and exposing of the kind of leadership we sometime provide in Liberia. There are lots of questions the Liberians were asking; like, why did we not stop the spreading of the virus when lots of grassroots citizens were dying? Why did the government of Liberia delay in response until high-profiled Liberians were succumbed to the deadly Ebola Virus Disease before trying to make issue of the health crisis? What was the intend of the pronouncement of a National Public Health Emergency on June 29, 2014 by the President of Liberia at the time number of death was 49 persons when there not corresponding actions (i.e. purchase of ambulances, deployment of health workers to other parts of the country there were not outbreak yet to train and set the necessary system in place) to tackle to Virus? Beyond the health emergency declaration, the response was very low and on August 6, another emergency was announced; “State of Emergency”.

Augustus Flomo with Antonio Rocha, Rotary International District Governor
 and Joseph Nyumah Boakai, Vice-President of Liberia

As we visited places and talked with people during these periods, a lot of people believed that there was no need pronouncing those emergencies in theory when in fact there were no responses as such from our National leadership. The citizens and residents got frustrated by the response strategy; they were watching to see concrete and visible actions that would reflect “EMERGENCY”. The level of response also had people wondering whether the Country did not have qualified health practitioners to share know and develop strategy for an urgent response in the country with population of about 4 million people. 

The old sickness and virus of Liberia soon came into the picture when issue of accountability and transparency in the management of national resources resurfaced in the time when Liberians are dying. 5 Million Dollars approved by the government of Liberia could not be accounted for clearly. What was the point? Did we not have budget line items to spend money on? Did the health authority of Liberia not know what money should have been spent for? How did the request for 5 million come to being? Who were those considered to manage the emergency funds? What were the agreed frameworks in place? People were dying every minute every day; what were the priorities?  Did we not know health system was completely down before approving the US$ 5 million? Where people not aware that funds entrusted into their care would need accountability? What is the commitment level of the leadership to fight the Ebola Virus? These and many other questions were on the minds of a lot of us Liberians. 

Another issue that seem to have come back to haunt us as a Country is the fact that the leadership was not able to settle healthcare workers concerns raised about  two (2) years ago about working condition and appropriate compensation for their services. Benjamin Franklin once said “Don't put off until tomorrow what you can do today.” This statement actually caught the Government of Liberia when they had to be trying to resolve healthcare workers concerns at the time the Country is faced with an exponential growth of death of the people. From listening to a lot of the healthcare workers, especially those in clinical areas; they felt and continue to feel that they are working for a particular person instead of working for Country. I tried to follow the concerns and realize that they seem to have felt alienated by the system; disconnect between healthcare workers and the leadership; people having the feeling that others in the healthcare system are living better lives while others are left without attention; healthcare workers working vulnerably, no vaccinations to protect them from communicable diseases as they work in the facilities, no insurance plan, etc. When leaders do not make those that they lead to become owners (i.e. common interest) of whatever they are part of, those who see themselves are hired staff will demand for every bit of things, even if they what they are asking for seem difficult to receive. Leadership by example in countries like ours becomes very critical in transforming such environment.  

As we look ahead, proper system communication of salaries/benefits/ taxes on those help a whole lot to save time and resources and manage the issues that would have otherwise surfaced in the absent information dissemination to those who need to know. Assuming that a particular action or decision is understood without properly using the channel that should be used sometimes delay outcomes of intends or decisions.

There is a statement, when someone is helping to scrub your back, you should rub your stomach to reflect that you appreciate the person’s working and show also a capacity that you can do for yourself in some time. While is good to depend on others for help, it is equally good to show commitment to what you are to do.

Clinic (c)Wayne Schoenfeld

Training and capacity building of persons/staff/stakeholders in the fight against Ebola
There is evidently a great need to keep training of Healthcare givers (Nurses, Doctors, Midwives, Physician Assistants, Social workers, drivers, area attendants, etc.). We are aware that Liberia has one if not the least developed systems in the region and cannot or will not improve if we do not put resources into constant training of professional healthcare workers. With a Country of 1 doctor to about 14,000 people, we should not be moving at the rate of training as we are. 

We cannot have very minimal engagement of training or just a focus group or select number of people to train; even people at the community and town levels need regular training and follow up to ensure that there is enough education and awareness about Ebola and other health issues in Liberia. It is clear that we as a country must put resources into regular training of our healthcare worker even when we think we do not have an immediate need in this Country. You never tell what would be next health situation. Liberia needs a lot of training in the health sector more than ever before and these training initiatives must be effective with clearly defined deployment strategies after the training. I have been fortunate to come across people who were trained through Government programs and partnerships but have not had assignments all in the name of not having available area or need for deployment. I have always been left to ponder on the rationale of getting people trained and not utilizing the education for the purpose intended.  These training must continue and at the same time trained personnel must be utilized in the health system.

(c) European Commission DG ECHO

Treatment of the sick & Appropriate Burial of the Dead
You would not imagine how unprepared Liberia was when it got hit by this deadly virus. Our health system infrastructure did not have the appropriate structures, space, treatment units for case intake and management. There is a need for more sustainable construction of Treatment units and Management. The issue of the lack of such facilities actually created a situation where collection of suspected Ebola patients difficult. Even just the transportation to move staff around to respond to the cases as they were arising was not in place and everyone was wondering what was happening; imagine every day hearing people discussing how many dead bodies were in various communities and in homes without being picked up for over three days.

Was there a need for a holding center for suspected cases? That seems to have reflected clearly in order to help reduce the impact on a particular family or community. The construction and management of holding centers became evident and is still. There is a need for adequately designed and properly equipped holding centers in places in Liberia. There is a common saying, “time for war, prepare for peace” and “time for peace, prepare for war”. Liberia did not have this kind of preparation in place to enable the kind of response that was really needed from the beginning of the virus attack. At the centers, it is important to note that without the appropriate PPEs, it would also be difficult to prevent the spread amongst caregivers at those centers. 

Another thing that killed us was the issue of timely testing and confirmation of sick persons and the dead during the outbreak. How could someone know that a particular headache was not Ebola? How family members could determine that a particular family member that died was not due to Ebola. I know of a particular family that lost three very important persons in their family because they were sure that the first person who got sick and died in their family did not die of Ebola. 

The first person was a granddaughter of a woman who started caring for her granddaughter in the name that it was some other sickness especially where the granddaughter in question was a healthcare worker who had thought that they were suffering from some other common illness.  While the grandmother was caring for the granddaughter, the biological mother of the girl arrived to join the team of care givers. They jointly took her to one of the few facilities that were conducting Ebola test to confirm the status of the girl since the girls was now presenting signs (weakness and change in temperature). They remained at the health facility for more than 9 hours asking for help but there was no help available for them until the girl died. Not testing the dead to confirm the status, the family when home and after a short time, the grandmother died, still without test to know the cause of death. The last person to die was now the biological mother of the girl who started showing signs exactly 21 day after the death of her daughter. After many calls for almost a whole day, she was taken to again one of the facilities that finally confirmed that she had Ebola; anyway, the lady died. It was the confirmation and death of the third person in the family that made others to have avoided contacts. 

Considering the story above, we can see clearly that early testing and confirmation of deaths would have helped save probably the lives of the grandmother and mother respectively.  

The issue of burial was another one that drew attention of the public. We had lot of call in on radio stations in particularly Monrovia about the way the dead were burry in certain communities. Liberians have a culture in burying their love ones in places where they could remember and be able to sometime in the future go to remember. First, it was about burying Ebola dead in the communities where people believe it should not have had such burial. The other related burial issue that became a concern is cremating bodies. Culture and practices creating problems, burial teams were attacked in some instances. It is important to consider the societal norms in issues that may appear to be traumatizing for them in these kinds of situations with reference to families and communities concerns.    

In street (c)Wayne Schoenfeld

Community Mobilization/Prevention Services/Contact Tracing
The best way to fight Ebola is by getting the communities engaged properly especially putting serious resources into prevention programs. Creating the awareness in every city, town and village is critical because a case of Ebola anywhere is many cases everywhere. For example, people quickly listen to their community members who are equipped with the necessary and right preventive messages; such people would share with their communities and regularly make follow up on the implementation. They can re-enforce easily based on what they see the community members practicing. 

For a setting like ours, using teachers, youth leaders, women leaders, opinion leaders (i.e. elders, political leaders, business people), who live in a community could help impact the transfer of messages very quickly and help improve the understanding of the residents. 

You will notice that since the outbreak, there were a couple of attack on healthcare workers in Liberia, Guinea and Sierra Leone. I believe strongly that if the community leaders were among those who were trained and send back to their own community to share the messages, they would have prevented a lot of the attacks. The primary reason why communities attacked healthcare worker was due to lack adequate information and belief that healthcare workers were transporting Ebola to non- affected areas to increase the spread. 
So sad, but I think they saw themselves as separate people from the healthcare workers and if we can manage to get the most difficult to deal with people in towns and villages to be community mobilizers and awareness agents, they would see themselves as owners and help to prevent their community from being affected. Along the preventive messages, there is a great need to intervene with preventive support materials such as disinfectants, buckets, chlorine/bleach, soap, etc. 

Another key component of effective prevention is a robust contact tracing program that considers primary, secondary, and tertiary contacts with a full database and regular follow-up plan. It is glaring that we played around with our contact racing program and did not h;8ave any effective implementation and that hurt Liberia so much and is still affecting us holistically. Due to the lack of adequate contact tracing program, Liberia became mode of infecting other countries like Nigeria, in the case of Patrick Sawyer and the United States in the case of Thomas Eric Duncan. From this indication, contact tracing must be a well-planned and setup program that would help track every incidences and movements; with the right kind of information being shared with relevant stakeholders such as air and sea ports authorities to avoid transporting the virus to others and also reduce the negative image of Liberia in the Virus outbreak.  

A properly designed communication framework must have been considered. It would amaze anyone to hear state own broadcaster was struggling with keeping on during such critical in the history of the Country. We monitored many days when we were told they could go off the air because of lack of fuel (in my opinion, the least). It became a concern of all as we saw various organizations, institutions and individuals donating to keep the station up. We all were concerned of what was going on with the messenger of the Government of Liberia. The importance of communication cannot be overly stressed as it is critical in the spread of the message. 

Augustus Flomo convincing Liberians that Ebola is real (c)Alison -
Psycho-social and affected homes and families support Programs
The need for rigorous psycho-social programs cannot be overly emphasized. Imagine living in a home where you lost family members in just a few days after they encounter Ebola. I particularly remember a family that lost their only daughter who was a nurse to the disease in less than 10 days after she was confirmed positive. The father and mother were extremely hit with trauma and after a few days, I saw the mother of the late nurse and she had lost weight more than 45% and the father who himself is a nurse could not easily talk with friends and even up to present cannot afford to see the photograph of his daughter; he would stop everything and appear to be confused. 

Let also look at even those who work at the treatment centers, I have heard a number of them mentioned the number of deaths that occur at those centers. According to them, they have not experience those kinds of situation in their career practice. For example, have more than ten – fifteen people died on the same day and in the same treatment units. This is really traumatizing and must have a serious and rigorous counseling program for homes, families, communities, school workers and healthcare workers. This kind of psycho-social program must be comprehensive enough professional psychologists and religious counselors. 

In continuation of the intervention, it is also important to note that appropriate support programs for children who lost their parents to the Ebola is key and must not be overlooked. Children became orphans due to the fact that they lost their both parents and are currently hopeless and have not direction for their lives; such people need serious attention while the fight against Ebola continues. Properly disinfecting and rehabilitating or replacing household materials and supplies in homes where confirmed person (s) were removed is a great idea to avoid the re-use of contaminated things; in other words, survivor kits will be helpful to get families back to normal activities in their homes. Ebola fight must extend to all fronts to get the country become normal again. 

Social Welfare program for the Disabled – normally vulnerable, the death of the disabled man in his wheelchair in the street – on broad street – movement during crisis – firestone movement during the civil war with our father in the rubber bushes… 
Health workers being asked to leave house because they are working at Treatment Units

Nurses and patients (c)Wayne Schoenfeld

Regular Health services to cater to Non-Ebola related health cases
The Ebola outbreak confirmed a lot of us comments that we had made before the attack of the virus that Liberia had a very poor health system. Liberia health system had over 98% closure of its health facilities for more than 60days, I personally know of families who lost their family members who were pregnant and needed hospital attention for delivery but could not get those services and at the result they had to die. We had many of such cases all over the country. I know of a friend who lost his life to asthmatic attack because the family could not get a single health facility to cater to him. We live in a country that we know is a death trap; if anyone gets seriously sick of any other disease even at present and needs other medical intervention beside Ebola care, that person will surely die due to the total breakdown in the provision of health services,

Liberia must build and strengthen its health infrastructural framework; the signs are visible, clear, and transparent. We cannot afford to continue to live in country that appears to be a grave site; we must do something now! Supporting the full operations of Hospitals and clinics is critical to the survivor of all residents of Liberia and must not be downplayed by stakeholders in the decision making areas.  I had the opportunity to talk with some senior healthcare workers in the health system; they believe that the system proper and sustainable diagnostic centers included into our health system delivery framework.  In strengthening the health system, the regulatory systems in the health framework must be supported to do what is appropriate in enhancing and maintaining best practices. The health system cannot be left without regular policy enforcement. The enacted health regulatory agencies and institutions must be supported to their work by following up and re-enforcing best practicing and retraining of healthcare workers.

Economic Issues and Considerations
The Liberia Economic has been classified as a donor driver Economic since the Civil war that started in December 1989.  The Ebola situation even made the case worse as the country was in the economic recovery stages where new concessions were granted to foreign companies with some level of impact to the Economy. Businesses were at the stages of improvement and building institutional systems and frameworks and also building records and relationships with both financial institutions and other partners. 

With the Ebola outbreak, a number of businesses closed their operations thereby leading to lots of Jobs.  Further, the closure of schools also made a lot of teachers lost their income sources especially those working for private schools due to the fact that private schools rely on the payment of tuition and fees to pay employees.

Hotel Africa after the Civil war (c)Wayne Schoenfeld

Other areas of the economy affected include the transport sector where there was increased transport cost based on the fact that Government of Liberia passed a regulation that compared vehicles owners to reduce the number of passengers that could be on board at any one time; for example, a taxi was required to take not more than 4 passengers. Prices of commodities changed including the Nation stapled food which eventually increased the hardship on the ordinary Liberians as the fight against Ebola continues.  

It is general said that the Liberian economic is having a very serious decline in the economy and by the time the Ebola fight is over the country may have a decline of more than 5% from where the economy was when the Ebola outbreak started.

We cannot fight Ebola efficiently without considering the protection of the economy or finding a way to keep the economy running or planning effectively to engage the potential decline by the time we are done with the fight.

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