By Sarah Ssali, Senior Lecturer, School of Women and Gender Studies, Makerere University
Diseases such as Ebola highlight the importance of a holistic focus on health systems, as opposed to assuming that health is the preserve and concern of health professionals alone. This was the lesson Uganda learnt very quickly in managing the Ebola outbreak in 2001. Until the current epidemic in West Africa, Uganda held the unfortunate record for the greatest number of infections, with 425 recorded cases of Ebola, of which 224 people sadly died (Omaswa 2014, Kinsman 2012).
Gulu district, in the north of the country, bore the greatest brunt of the epidemic, with 393 people falling ill and 203 deaths (Kinsman 2012). But it was not the only affected district. Mbarara district in the south west, recorded five cases of people contracting Ebola of whom four died and Masindi district in the west recorded 17 deaths.
Ebola causes community panic and mistrust in the health system
Initially, the epidemic caused a lot of fear, panic, and anger within communities. As is the case in West Africa now, communities: stigmatized the sick; stormed Ebola isolation units (in Masindi) causing the unit to seek another site; and scared off relief burial teams, forcing them to abandon work (Kinsman 2012). Elsewhere in the country, fear and stigmatization grew, causing those who suspected that they had Ebola to hide and patients to flee hospitals once they knew Ebola treatment was being carried out there. In Kampala, religious leaders held prayer rallies against the epidemic, while in nomadic Karamoja anti-Ebola rituals were carried out.
Very quickly, the Uganda Directorate of Health Services learnt that they needed to do something to restore community trust if they were going to tackle the epidemic. Treatment alone was not enough. They needed the community to understand that those treating Ebola patients and burying the dead meant well and needed the community’s support.
Seven measures taken to tackle Ebola in Uganda
Measures were undertaken to gain the trust of the community and help them fight the epidemic. Okware et al (2002) and Omaswa (2014) provide a list of the interventions undertaken by Uganda’s Ministry of Health, which included the following:
1. Partnerships with communities
Upon realizing that they could not do everything by themselves, the Ministry of Health decided to build partnerships with other actors within the community, such as non-governmental organisations like the Red Cross and World Vision. These partnerships were crucial for mobilizing communities, information dissemination, and early case detection. Okware et al (2002) even state that anti government rebels stopped fighting and supported the anti-Ebola efforts
2. Community-based disease surveillance
The Ministry of Health trained community members to provide a network for surveillance and public information. These community members rapidly reported suspected cases from households, who were rapidly assessed using history of contact and clinical assessment. This strategy was important in that it was not very costly to manage.
3. Work with the Media
Realising the role of the media in informing and misinforming the masses, given their previous role in propagating myths and rumours about Ebola, the Ministry of Health learnt very quickly that they needed to partner with the media to provide prompt and factual public information. Information dissemination could no longer be the preserve of health workers. The media was trained in Ebola and barrier nursing to protect themselves, after which they were charged with providing factual updates about the disease on a daily basis. This way, the media helped curb rumours, myths and risks associated with the disease.
4. Technology for quick field diagnosis of new infections
Because there was no special laboratory for testing Ebola in the country, a field laboratory for spot screening was provided with help from the Centre for Disease Control (CDC) and the World Health Organization. The South African Institute of Virus Research helped customize certain procedures to make them simpler and less costly. This helped with early detection, while those suspected but found to be negative were able to return to their normal lives. This helped reduce stigma and re-build trust between the communities and the health facilities managing Ebola.
5. Infection control and hospital waste management
While health facilities should routinely manage waste professionally, this is not the case, especially in rural communities. Moreover, no one had been prepared for the kind of waste management that accompanied an Ebola epidemic. Sometimes, health workers thought that ensuring that isolating people with Ebola was all they needed to do. In addition, there was need to protect non-health workers in the Ebola response, such as drivers. The Ministry of Health developed a programme to promote infection control in hospital and health facility settings. However, this training was not restricted to health workers, but to others such as drivers who transported people to referral centres.
6. Work on the legal, ethical and social issues
One of the biggest challenges in combating infectious diseases arises from people’s traditions and cultural norms. Such traditions, with respect to the Ebola epidemic, relate to burials in ancestral grounds, funeral ceremonies, and the handling of the dead. People were provided with information about the dangers of touching those who had died of Ebola and encouraged to leave burials to the specially trained burial committees.
In addition, there were issues of disclosure and confidentiality, which posed ethical challenges to medical workers, and the several children (about 500) orphaned by Ebola. To address these, the government enacted the Workman Compensation Act which entitled infected health workers and their close kin some form of compensation. Individual confidentiality was suspended for public information sharing and counseling services provided to the orphans. In addition, a Post-Ebola Association and a special clinic opened to provide services to survivors.
7. National and international collaborations
One thing that has been associated with Uganda’s success in combating epidemics such as HIV and Ebola is the leadership and commitment from government. With the suspicion of Ebola in Uganda, despite meager finances, the government embarked on a process of providing essential resources to help combat the epidemic. These essentials included but were not limited to; supplies, funding, expertise, communication, and information. Where resources became a challenge, the government called on the international community to help. Some of these, such as CDC, provided the expertise in field testing. All external actors were coordinated by the National Task Force. In addition, other tasks forces were established at the district (DTF) and between ministries (IMTF). These task forces included policy makers, such as district leaders, Members of Parliament, religious leaders, and the police along with people from the health sector.
Kinsman John (2012), “A Time of Fear”: Local, National, and International Responses to a Large Ebola Outbreak in Uganda, in Biomed Central 8 (15), Pgs 1-12
Okware S. I et al (2002), An Outbreak if Ebola in Uganda, Tropical Medicine and International Health, 7(12), Pgs. 1068-1075
Omaswa Francis (2014), Regaining Trust: An Essential Prerequisite for Controlling the Ebola Outbreak, The Lancet Global Health Blog, 11th August 2014
Photo courtesy of Josh Zakary https://www.flickr.com/photos/joshzakary/6864103297