Seven things we can learn from the Ebola epidemic in Uganda in 2000 – 2001

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.

References:

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

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Gendered Health Care Coping in Northern Uganda: A quick update from Cape Town

By Sally Theobald,

Sarah Ssali from ReBUILD and Women and Gender Studies at Makerere University, Uganda, presented her poster on “Gendered Health Care Coping in Northern Uganda: What are the gender and equity considerations in post conflict health systems strengthening” at the Health Systems Conference in Cape Town. In discussion with poster Judge, and Emerging Voices presenter, Angelia Rawat, Sarah eloquently explained why gender needs to be taken into consideration in post-conflict reconstruction of health systems in northern Uganda. Health services are geared towards women as mothers, but in reality women have “lives beyond being mothers of babies” they have multiple identities and stages of their life cycle and many women are sadly widowed. In the post-conflict context, private providers flourish and people often have to pay for medicines. For women ability to pay is a big challenge and the choices they make are navigated by livelihoods, which in turn are shaped by access to land and animals where it is not an even playing field. Women have duties but no capital to fulfil them. Sarah concluded by arguing that gender matters in post-conflict reconstruction and needs to be taken into account in and beyond the health sector.

How to protect health workers in conflicts and crisis

Recruiting health workers with high levels of internal motivation is critical for work in difficult conditions, where their personal security and health might be compromised, according to new research published today in Health Policy and Planning.

Health workers often witness the deaths of friends and colleagues during conflict situations and also face abduction, injury and death, themselves. Life history interviews with 26 health workers who lived through conflict in Northern Uganda reveal their resilience and how they coped by building trusting relationships with the community, seeking support from managers and elders, and finding strength from their faith and commitment to serve their community.

Namakula and Witter propose the following solutions to help protect and keep staff motivated during and after times of crisis, when they are likely to feel disconnected from social and professional support systems, lack supplies and face an increased work load with limited pay and personal insecurity:

* Community support

* Appreciation by supervisors

* Effective working conditions

* The opportunity to learn and develop new skills

* Formal promotion and recognition of their contributions in a dangerous situation

* Employment benefits such as food, accommodation, transport and free healthcare

* Good leadership and communication in the workplace

* Regular and adequate pay

* Flexible working and inclusive management

This research was carried out at Makerere University and Queen Margaret University with support from the UK Department for International Development through the ReBUILD Consortium. Justine Namakula, ReBUILD Research Fellow at the School of Public Health, Makerere: “This research helps us to understand the lived experience of health workers during and after conflict in Northern Uganda and how policy-makers can protect and motivate them”

The study is part of the ReBUILD health worker incentives research project, which aims to understand the evolution of incentives for health workers after conflict and propose policy recommendations to improve health worker retention. Recruitment, retention and management of health workers can be challenging worldwide but is exacerbated in conflict situations and fragile states. In previous research on conflict and fragile states the perspectives of health workers on the front-line has often been overlooked but they are crucial to improving policies and providing effective health services. The Acholi sub-region of Northern Uganda experienced violent conflict as a result of fighting between the government and the Lord’s Resistance Army for 20 years, between 1986 and 2006. During the conflict, the health system was split into two, a camp-based system run by international agencies and NGOs, and a health service provided by the government in towns.

This article describes the experience of health workers who had lived through the conflict in the Acholi sub-region, explaining how they coped and what motivated them to stay. It is published as part of a special supplement on the ‘science and practice of people-centred health systems’, the theme of the Third Global Symposium on Health Systems Research, currently taking place in Cape Town, South Africa.

Notes Health Policy and Planning is a peer reviewed, optional open access journal publishing high quality research and original ideas relevant to the design, implementation and evaluation of health policies in low and middle-income countries. The Journal is jointly published by the London School of Hygiene and Tropical Medicine and Oxford University Press.

For more information or to request interviews contact Mandip Aujla, mandip.aujla@lshtm.ac.uk If you wish to provide a link to the free abstract of this paper for your readers, please use the following, http://heapol.oxfordjournals.org/content/supplemental

Full reference: 1. Namakula, J. and Witter, S. Living through conflict and post-conflict: experiences of health workers in northern Uganda and lessons for people-centred health systems. Health Policy and Planning 2014; 29: ii6-ii14. 2. This research was carried out with the support of the ReBUILD Consortium and was published as part of a supplement launching on Thursday 2nd October at the Third Global Symposium on Health Systems Research, Cape Town.