El poder del tacto y la crueldad persistente del ébola
La epidemia de ébola es casi historia, pero su legado y sus lecciones reverberarán durante años. Margaret Batty, directora de Política y Campañas Globales de WaterAid, describe su experiencia de África Occidental con las cicatrices del Ébola y algunos de los titulares que no han salido a la noticia.
Do you know what your core body temperature is? Mine is 36.2°C, give or take minor fluctuations.
I know this not because I am a hypochondriac, but because it was taken countless times each day during my recent trip to Liberia and Sierra Leone – at army road blocks every few miles, at the entrance to every office or hotel, and at each stage of check-in for my flight – including the slightly daunting speedboat ride to Freetown’s waterside airport.
The number everyone dreads is 37.5°C, because that denotes fever – one of the symptoms of the Ebola virus.
Frequent handwashing has become second nature; hands are scrubbed raw by grainy sanitizer after every human contact. ‘Don’t touch. Minimize contact’ advisories are everywhere. People recoil involuntarily from handshakes. The insidious stress creeps up day by day under the monitoring, the curtailing of personal freedom in the interests of global health. Imagine this as your daily reality for nearly two years.
A physical barrier
While driving back to Monrovia airport at the end of my visit, which had stirred uncomfortable and raw emotions – empathy, fear, stigma, powerlessness, compassion, anger – my Liberian WaterAid colleague, Oretha, casually told me about an incident last summer, when she got a fever and was terrified that it might develop into Ebola.
As a precaution she had to tell her nine-year-old son that he could not come near or touch her. He had already been cooped up at home for months, because school closure and curfew measures were in force in attempt to contain the deadly epidemic. In his moment of anguish and terror, his mother could not console him with a hug or a cuddle. Imagine the torment for both mother and son. Words are a poor substitute indeed for the power of touch.
Liberia set back
The world has moved on, and Ebola may not now reach our headlines. Sierra Leone had its final Ebola quarantine lifted on 7 November. Liberia has been declared ‘Ebola free’ twice already, only to be set back again.
On 23 November 2015, 15-year-old Nathan Groote died in a Monrovian Ebola isolation ward – one more family tragedy to be endured, and a severe national blow. Nathan’s younger brother and father, both also initially feared infected, were released from the Ebola Treatment Centre on 3 December with a clean bill of health.
Liberia now enters its 42-day quarantine period yet again. Let us pray to whoever is listening that Nathan, the 11,315th life known to have been claimed by Ebola, is its last victim.
The longer-term effects of this epidemic are not yet well understood. There are more than 17,000 Ebola survivors, who face a new jeopardy – stigma and discrimination as they are shunned at work, school and in their communities, for fear they might still be infectious. Others are too afraid to use health services, afraid that they might still somehow catch the dreaded virus. Myths and rumours easily ignite in such a febrile atmosphere.
Another headline you may not have seen is that countless people died during the height of the epidemic not from Ebola but from treatable conditions such as diarrhoea, malaria, complications at births, and road traffic accidents. People were too afraid to present with Ebola symptoms such as diarrhoea in case they were quarantined; if they didn’t have the Ebola virus before quarantine, the chances of contracting it in a ward without rigorous infection control, or even running water or functioning toilets, were high. Additionally, health-care workers’ capacities were much-reduced, reducing quality of care.
A WaterAid-VSO report showed that maternal mortality increased by 30% during the epidemic as women actively avoided health centres for fear they might contract Ebola, and delivered their babies at home without clean water, good hygiene or skilled midwives, often with tragic results.
The health systems were weak to start with and Ebola stretched them beyond breaking point. Before the Ebola outbreak in Sierra Leone each woman had a shocking one in 21 chance of losing a baby in the days following birth because of sepsis, and in Liberia just 50 doctors served a population of 4 million people. As Liberian President Ellen Johnson Sirleaf has said: ‘we were utterly ill-equipped and unprepared for Ebola’.
Regression and recovery
Liberia, Sierra Leone and Guinea are experiencing development in reverse. Countries that were already among the poorest in the world (83% of Liberians live on less than $1.25 a day) had already endured the bitter legacy of brutal conflicts, and in recent months devastating heavy rains which have washed away roads. The Ebola epidemic has rolled back years of hard-won socio-economic gains. These are traumatised peoples and nations. The power of touch applies equally to relations between countries – ‘extending the hand of friendship’ has profound meaning indeed.
The recovery phase requires intense and sustained international support, in the form of health system strengthening, support for basic and essential services including water, sanitation and hygiene, psychological counselling expertise, open trade and investment, and much more.
Surely the case for investing in hygiene and sanitation couldn’t be more blindingly obvious – it played a critical role in the containment of and recovery from the Ebola epidemic. How can Liberia even contemplate resilience to another outbreak of disease when less than 2% of the population has handwashing facilities at home, and less than half of those with both soap and water.
The international response to the outbreak showed inadequacies. In particular, the disaster exposed inadequacies in institutional leadership, solidarity and systems failures.
Dangerously easy and glib talk abounds of ‘lessons learned’. A key lesson (re)learned was that the role of local communities and local leaders is the first critical interface for epidemic containment, which begs the question: why was this ever neglected? The concept of collective ‘health security’ has also regained fashion, along with awkward questions about the ethics of individual health security – whose security is most important? West Africans? Europeans? Mine? Yours? Nathan’s?
At the entrance to Kenema Hospital, the region of Sierra Leone worst affected by Ebola, I noticed a small memorial stone. I first assumed it was to remember the patients who had succumbed to Ebola there. But as I squinted at the small chiselled letters, I saw they read “doctor, midwife, hospital orderly”. The memorial honours the 37 staff who died of Ebola at this one district hospital, some of the more than 500 health workers who died of Ebola across West Africa. We owe it to these people to stop talking and start doing.
The human catastrophe of the Ebola epidemic that began on Christmas Eve 2013 –when Emile, a 2-year-old boy in a remote village in Guinea, was the first case identified – shocked the world’s conscience…for a while. Health is an essential facet of human and national security, and, as Amartya Sen said more than a decade ago, it is people-centred. Borders, money and international relations don’t matter. Ebola proved how interconnected the global community is; we are only as safe as the most fragile state, and we are all equally deserving of health security, underpinned by safe water, sanitation and hygiene. That includes all of our families: yours, mine, Emile’s and Nathan’s.