(Formerly called IRIN) Journalism from the heart of crises

  • Opinion | Ebola responders must learn language lessons from the 2014 epidemic

    August 2014 was a scary time in West Africa. Ebola was spreading rapidly and the international community was waking up to a disaster that ultimately killed more than 11,000 people.

    In the midst of the epidemic, UNICEF and Catholic Relief Services published ominous survey results: In Sierra Leone, one of the hardest-hit countries, 30 percent of respondents believed Ebola was transmitted by mosquitoes; another 30 percent believed it was an airborne disease. Moreover, four out of 10 respondents (42 percent) believed hot salt-water baths were an effective cure.

    Many reports evaluating how different agencies responded to the epidemic pointed to a lack of community engagement or understanding of local culture as key early failures. A big part of that failure was the inability of aid workers to converse in local languages.

    In the three most affected countries – Guinea, Liberia, and Sierra Leone – people speak more than 90 languages. Literacy levels are low, especially in the official national languages (French and English), and yet Ebola-related materials were mostly in written form in those languages.

    This early shortage of information for non-literate people and speakers of minority languages left significant swathes of the population in deadly ignorance.

    ACAPS, a non-profit specialising in research and analysis of the humanitarian sector, found that in both Liberia and Sierra Leone women died in greater numbers than men at the beginning of the outbreak, in part because they had less access to information and communication channels.

    Four years on, we are again responding to Ebola outbreaks: this year there have been two in the Democratic Republic of Congo, one of the most linguistically diverse countries in the world.

    In the area affected by the latest outbreak, Beni Territory, the predominant languages are Swahili, Nande, and Mbuba. There are barely any trained translators for Nande and Mbuba, languages not supported by Google Translate, Microsoft Translator, Facebook, or Amazon.

    Community engagement is now a priority activity for some agencies. They write guideline documents and blogs about it, discuss local communication preferences, and make it very clear they are trying to learn the lessons of the past. Maps showing what languages are spoken where have proved useful to organisations working to curb the spread of the virus.

    The organisation I work for has helped provide local health workers and at-risk populations with localised translations of critical information. The International Federation of Red Cross and Red Crescent Societies and the World Health Organisation are coordinating closely with local organisations, national health service providers, and the DRC Red Cross to make sure people get timely information in a language and format they understand and trust.

    It’s heartening to see that, even in such a complex and difficult context, aid agencies can and are trying to communicate effectively.

    Still, some aid agencies rely on untrained and under-supported national staff or community leaders to interpret or translate for them. Our research in other contexts has found that even local aid workers don’t always understand what they are being asked to interpret. Comprehension rates among those carrying out field questionnaires, for example, are as low at 35 percent in some places.

    Too often responders use a national language or regional lingua franca (such as Swahili), assuming, sometimes incorrectly, that everyone will understand.

    Weak data on the languages people speak and understand means there is no evidence base for developing effective communication strategies. Language support is often absent from humanitarian budgets and programme plans, which leads to a lack of high-quality translation and interpreting services and an inability to mobilise such services early on in a response.

    Think of language as a factor of vulnerability: it intersects with everything we do. Meaningful two-way communication fulfils a vital function in an emergency response, as pivotal as providing food, water, or health services.

    To keep themselves and their families safe, people need critical information in a language they understand, such as, in the case of Ebola, how to best wash their hands or bury their loved ones. To be effective and accountable, responders need to be able to understand the needs and concerns of affected people.

    Opinion | Ebola responders must learn language lessons from the 2014 epidemic
  • “People’s science”: How West African communities fought the Ebola epidemic and won

    Three years on from the start of the West African Ebola epidemic, lessons are still being learned. And the most surprising are not coming from the scientists, but from the affected communities themselves; about how, with hardly any help, they tackled the virus and won.

    One of the curious aspects of the epidemic, which shook Guinea, Liberia, and Sierra Leone, was the way in which the number of cases started dropping before the main international response was in place. In one area after another, the infection arrived, spread rapidly, and then – apparently spontaneously – began to decline.

    Ebola first crossed over from Guinea into Liberia's Lofa County in March 2014. A rapidly erected treatment centre at Foya, on the border, was soon full to overflowing. In September, it was treating more than 70 patients at a time. But by late October, the centre was empty.

    People’s science

    Paul Richards, a veteran British anthropologist, now teaching at Njala University in Sierra Leone, has been worrying away at this phenomenon. He is convinced the main driver of the reduction was what he calls “People's Science”; the fact that people in the affected areas used their experience and common sense to figure out what was happening, and began to change their behaviour accordingly.

    He told a recent meeting at London's Chatham House: “One of the pieces of evidence which makes me think that local response was significant is that the decline first occurred where the epidemic began, so that the longer the experience you had of the disease, the more likely you are to see tumbling numbers. So, someone was learning… People ask me, 'How long does it take to learn?'  And we don't know, but on the basis of this case study, it's about six weeks.”

    A lot of national and international effort was put into public health education, and the messages broadcast on radio were very widely heard. But initially they were not very helpful, with a lot of emphasis on the origin of the disease, and warnings not to handle dead animals or eat bushmeat. 

    In fact, it now seems likely that only the very first case came from a wild animal; all subsequent cases were caused by human-to-human transmission.  

    The villagers interviewed by Richards and his team were sceptical about the government’s warnings: “If eating bushmeat is dangerous, why did no one get ill before”, was a typical question raised.

    He found the conclusions they drew from their own observation and experience were much nearer the mark. 

    “We know our own people,” they told him. “So, we know that it’s socially obligatory to wash the bodies of dead people and to attend their funerals. We monitor very closely who's not doing that, who's not paying attention to their social duties.  

    “So, it very quickly dawned on us that the people who were attending funerals were the ones that were dying, the good people, the ones that do their social duty,” Richards recounted. “So, from that we knew that it was something to do with funerals and we started modifying our behaviour.”

    A healthcare worker stands next to a woman who had died of Ebola related symptoms. (Sep 2014)

    A healthcare worker stands next to a woman who had died of Ebola related symptoms. (Sep 2014)
    Kieran Kesner/IRIN
    A healthcare worker stands next to a woman overcome by Ebola

    Getting organised

    The areas where Richards was working in Sierra Leone had been badly affected by the civil war. But that period had taught them how to organise, and how to depend on their own resources. The Kamajor civil defence groups, which had protected villages from the notoriously brutal RUF rebels, were revived as taskforces to track cases, enforce quarantine, and bury bodies safely.

    Across the border in Liberia, the same thing was happening. Nyewolihun, a small village in the forest, not far from the original source of the outbreak, put itself into quarantine. 

    Matthew Ndorleh, the headmaster of the local school, told IRIN: “We didn't allow anyone to go and sleep in any other place, and we didn't allow anyone to come in. We set up a taskforce of young men to man checkpoints at all the entrances to the village, and everyone obeyed it.” 

    It was hard, and having to rely on its own resources meant the village ran short of rice, but although Ebola reached the nearby town of Kolahun, Nyewolihun stayed safe.

    It is clear that one of the missed opportunities in the outbreak was a failure to encourage these local initiatives and give local people the tools and techniques they needed to do the job. 

    Governments and aid agencies preferred to recruit and train official burial teams rather than teaching people how to bury their own dead safely. But there were numerous complaints about difficulties in contacting these teams, long delays, and disrespectful attitudes to the deceased. More isolated communities had no alternative but to take care of their own dead, whether they were trained and equipped or not.

    DIY response

    American anthropologists, who interviewed people in urban areas of Liberia during the outbreak, found a sense of frustration that the information campaigns told them about the origin of Ebola, how it was spread, but didn't give them practical advice on how to care for sick relatives, how to transport them safely to hospital, and what to do with corpses when the burial teams didn't arrive. 

    They wanted training, and they wanted access to protective equipment. “We have heard the messages,” said one interviewee, “but most people do not know how to practicalise them.”

    This was because Ebola is such a dangerous disease that home nursing, the transport of the sick, and do-it-yourself burials were being strongly discouraged. It took six months for Sierra Leone to finally produce a poster giving some advice on caring for the sick, and even then it was headlined, “Taking Care of Someone with Suspected Ebola: Be Safe While You Wait”. The clear message was that this was only a stopgap – professional care had to be the norm.

    And yet, in reality, people did have to take care of Ebola patients at home. The early stages of the disease are not obviously different from any other fever, and so would be nursed in the usual way. Once Ebola became obvious, patients were sometimes too sick to be safely moved, especially from off-road villages where the only form of patient transport was a hammock. 

    Richards met communities that had worked out the dangers of hammock transport for themselves, without it having been mentioned in official health messaging.

    Care in the community

    Some patients were kept at home because they and their families were terrified of the big Ebola treatment centres, where patients, once taken away, disappeared behind high fences and were often never seen again. 

    “They would transport you from your village to Freetown. You had never been to Freetown, never seen these town places,” explained Esther Mokuwa, who worked with Richards on his study. She was told by patients: “If you take me from my loved ones, even the discouragement would kill me.” 

    Mokuwa said the Community Care Centres that were eventually constructed in late 2014, although modest, were much more acceptable. 

    “People could go there; they had their colleagues working inside who could take messages; so they could relax. At the CCC, even though you were very safe, you could see them, and even stand talking. You could cook food and bring to them in the centre. Like pepper soup – pepper soup is very important in [West] Africa!”

    This was much more like normal care. People finally had a way to express their love and support, and do what they considered the proper thing for their loved ones. 

    The team investigating urban attitudes in Liberia met women who had planned in advance what they would do if anyone in their family became infected, and had worked out how they could nurse them as safely as possible. Many had seen the news reports of a student nurse who improvised protective kit from plastic bags and bin liners – and successfully nursed several family members without becoming sick herself – and were thinking how they might do the same. 

    With hindsight, it might have been wiser to acknowledge these powerful and understandable emotions, and the practical difficulties of providing professional Ebola services in remote areas, and to place more trust in the communities who wanted their own training and equipment. 

    But at the height of the epidemic there was no time to have a debate about community action and how best to harness it. The hope now is that the work being done can inform future policy, should another deadly epidemic emerge.

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    TOP PHOTO: Community volunteers in Liberia. CREDIT: Morgana Wingard/UNDP

    MAP SOURCE: Centers for Disease Control and Prevention/IRIN

    Three years on, lessons are still being learned from West Africa's Ebola outbreak
  • Five rare humanitarian success stories of 2016 (plus caveats)

    It’s hard to see the silver lining around a year as awful as 2016, but a few good news stories did emerge. Here are some recent successes from the humanitarian world, with our caveats:

    Paris Agreement enters into force

    Given that 2016 broke a number of unenviable global warming records, it seemed advisable that the Paris Agreement to combat climate change, adopted by 195 countries in the French capital in December 2015, should come into force and be implemented in good time. The first, easier part was achieved surprisingly quickly – enough parliaments had ratified it even before delegates gathered in November in Marrakesh for Paris’s follow-up meeting, COP22. But as for implementation, the devil is in the detail, and much will depend on whether countries live up to the nationally determined contributions that underpin the Paris accord. Plans are now in place for countries to sign off on a new rulebook that envisages them taking responsibility for their own progress from 2020.

    Parched earth following a drought in northern Afghanistan. The region has been hit by increasingly unpredictable weather, with most experts agreeing it is an effect of climate change.

    Parched earth following a drought in northern Afghanistan. The region has been hit by increasingly unpredictable weather, with most experts agreeing it is an effect of climate change.
    Joe Dyke/IRIN
    Parched earth following a drought in northern Afghanistan. The region has been hit by increasingly unpredictable weather, with most experts agreeing it is an effect of climate change.

    Caveats: There is the small matter of a climate change denier, namely Donald J. Trump, being elected president of the country that has been the driving force behind the Paris agreement. And, even if President Trump can’t (and/or doesn’t choose to) torpedo one of the last remaining planks of his predecessor’s legacy, the accord could still be too little too late. Analysis shows that even if national targets are fully implemented, the world will be 2.7 degrees warmer by the end of the century – a temperature rise that would have disastrous consequences.

    IS loses ground

    In a year of bad and worse news, the fact that so-called Islamic State is being forced off the land it controls is a chink of light for those civilians who have known the horror of its rule. The group has been kicked out of key holdings in Iraq – Ramadi and Fallujah – and lost al-Shaddadi in Syria’s Hassakah province, and Manbij near the Turkish border. Libyan forces backed by US airstrikes recently finished off the group in Sirte. It now holds no territory in the country, although members are still active. And the Iraqi army and its allies are now making slow progress towards Mosul, its last stronghold in Iraq – victory there would leave Raqqa in Syria as its major territorial holding, although it is resurgent in and around Palmyra.

    Caveats: We’re loath to call any military campaign ‘good’ – the Iraqi military’s assault against IS in Fallujah involved a punishing siege, and there have been many reported cases of retribution (often by allied militias) against civilians after liberation. And then there are the civilian casualties of course – those IS has been said to use as human shields or execute for attempting to flee, and those killed in coalition airstrikes, not to mention the innocent victims of the more relentless bombing campaigns ordered by the Russian and Syrian governments. There’s also growing concern that as IS-controlled territory shrinks, the group will increasingly turn its attention to sowing chaos in the sort of attacks regularly seen in Baghdad, and recently at a Christmas market in Berlin.

    That said, it’s hard to forget the jubilation of those liberated from IS rule – women smoking cigarettes, men cutting the beards they had forced upon them, and church bells ringing.

    Peace in Colombia?

    In November, Colombia’s Congress approved a peace deal with the FARC rebel group, bringing an end to more than half a century of fighting and – proponents hope – allowing the country to begin a process of healing. The deal will see FARC disarmed and demobilised, and its assets used for victim compensation. The group will form a political party, and have a guaranteed 10 seats in Congress. If the agreement, seen as tougher on FARC than the original version Colombians rejected in a plebiscite two months earlier, ends the bloodshed in Colombia, it’ll be a massive win for the country. More than 260,000 people have died in the conflict, mostly civilians, and nearly seven million people have been displaced.

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    Carlos Villalon/Redux/IRIN
    Celebrations in Bogota after the signing of a series of accords that paved the way for a permanent ceasefire between FARC and the Colombian government

    Caveats: While supporters waved flags as the deal was signed — and President Juan Manuel Santos won the Nobel Peace Prize before the “no” vote — not everyone is celebrating. Opposition leader and former president Alvaro Uribe argues Colombia is still letting the rebels get off easy. He walked out of Congress before the vote. Behind the politics, there are real concerns about justice: fighters who have confessed to war crimes will not serve time in prison. And with FARC promising to break its links with the drug trade, the country’s coca growers, who insist they are doing what they must to get by, are afraid their livelihoods are threatened. Plus, history in Colombia has shown that reintegration will be anything but easy.

    Canadians sponsor refugees

    In September 2015, the image of Aylan Kurdi, a dead Syrian toddler lying face down on a Turkish beach, galvanised the Canadian public. Canada has had a private sponsorship programme since 1979, allowing groups of individual Canadians to finance the resettlement of specific refugees. Besides making a financial commitment, sponsors provide practical and emotional support as the refugees settle into their new homes. In late 2015 and early 2016, the programme was scaled up to meet Prime Minister Justin Trudeau’s election promise to fast-track the resettlement of 25,000 Syrians to Canada by the end of February 2016. While Europe has shored up its borders and Trump has promised to reduce refugee resettlement to the United States, the Canadian government has struggled to find and screen sufficient numbers of eligible refugees to meet the demand of willing sponsors. Canada’s model of private sponsorship helped inspire a Global Refugee Sponsorship Initiative that launched in Ottawa in December. Several other countries, including the United Kingdom, Germany, Italy, and New Zealand are now implementing their own private refugee sponsorship programmes and interest in this approach continues to grow.

    Caveat: Funding for the refugees, whether privately- or government-sponsored, is only in place for one year, while many need longer to integrate and become self-sufficient. A Senate committee has called on Trudeau’s government to allocate more resources as a matter of priority.

    Ebola vaccine “100% effective”

    This came very late in the year, at the start of the holiday season, and was overshadowed by lots of headlines about celebrities dying, so you might have missed it. On 22 December, The Lancet medical journal published findings from the trial of an experimental Ebola vaccine involving 11,000 people in Guinea. Not a single person vaccinated contracted the Ebola virus and the vaccine was found to be well tolerated and to produce a rapid immune response after just a single dose. The study also highlighted the importance of discovering that trials such as this one, called “Ebola ça Suffit" (French for “Ebola that’s enough”), could be conducted in the challenging aftermath of epidemics and still be effective. The Ebola outbreak in West Africa claimed more than 11,300 lives, mainly in Liberia, Sierra Leone, and Guinea, between 2013 and 2016. “While these compelling results come too late for those who lost their lives during West Africa’s Ebola epidemic, they show that when the next Ebola outbreak hits, we will not be defenceless,” Marie-Paule Kieny, assistant director-general for health systems and innovation at the World Health Organization, and the study’s lead author, said in a statement.

    Caveats: Not required (Good news, no strings attached).

    (TOP PHOTO: Canadian Prime Minister Justin Trudeau and Ontario Premier Kathleen Wynne welcome Syrian refugees Kevork Jamkossian and his daughter Madeleine who were among 163 Syrians to arrive in Canada on 10 December 2015. PMO of Canada)

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    Five rare humanitarian success stories of 2016 (plus caveats)
  • Polio hopes and Zika fears in the vaccine race

    It’s busy times for the vaccine industry – a new vaccine against dengue fever has been deployed in the Philippines, research for a vaccine against Zika virus is gaining steam (although questions remain over the threat it poses), the Ebola outbreak refuses to go away, and a yellow fever outbreak in Angola has exposed an alarming lack of stockpiles.

    Against this backdrop, the biggest-ever effort in human immunisation might finally be reaching the beginning of the end. Wild polio, once crippling hundreds of thousands a year, is found now in only two countries – Afghanistan and Pakistan. There have been just nine reported cases so far in 2016.

    If polio were in full retreat in 2017, it would mark 40 years since the last natural case of smallpox – the first disease to be completely wiped out in human history, in 1977.

    The multi-agency polio eradication programme led by the WHO since 1988 shows that the road to eradicating any disease is long and expensive, even one with relatively simple characteristics (unlike a number of other diseases on the global agenda, polio can only survive in humans; there’s no reservoir in animals or insects). The Polio Eradication Initiative has a budget of more than $1 billion per year.

    The research and development stages of any drug or vaccine take years, but that’s only one ingredient. Public education and mobilisation, funding, and, inevitably, tackling anti-vaccine suspicion and rumours, have all played their part in the twists and turns of the polio campaign. The same will surely be true of any future eradication programme.

    The next steps of the anti-polio drive require a synchronised switch in the type of vaccine, due between now and 1 May in 155 countries, and then, in the years to follow, a gradual transition to injectable vaccines to replace the oral drops so many countries are familiar with.

    Unintended consequences

    Until this year, the most common oral vaccine protected against all three types of polio. Since type two is now eradicated in the wild, the new version of the vaccine only protects against types one and three.

    Some surprising data is a factor behind this move.

    While the number of naturally-acquired cases of polio last year were 74, the total number was 106. How?

    In a tiny minority of cases – the WHO suggests it’s a 2.7 million to one chance – the oral polio vaccine backfires and causes paralysis: the signature symptom of polio.

    Given the right circumstances, both in the patient’s stomach and an unhygienic environment, the polio virus can further survive in faeces and be transmitted to others. This, circulating vaccine-derived polio virus (cVDPV) is most commonly a variant of type two, so it makes sense to remove the pathogen from the vaccine now if it’s not present in the wild.

    In 2015, 32 cVDPV cases were reported from Madagascar, Laos, Guinea, Myanmar, Nigeria and Ukraine.

    Therefore, the old oral polio vaccine was in fact the cause of about a third of cases of polio-related paralysis last year. Governments accept the rare incidents of vaccine-derived polio as an acceptable price to pay along the road to worldwide eradication. Using only the new bivalent (two-pronged) vaccine should reduce this unintended consequence significantly, while concentrating firepower on the remaining two types. Developed countries now tend to use the injectable polio vaccine, which carries no risk of vaccine-derived polio. The rest of the world should also graduate to the injectable model if the frontline battle against polio can be won by the oral vaccine.

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    Ben Parker/IRIN
    A Sanofi Pasteur employee visually checks a vial of vaccine. Manual and automated quality control is a significant part of the vaccine manufacturing process.

    What about Zika?

    Vaccine controversies, unfounded in science, have surfaced in Europe and the United States in recent years. There is no proof of a link between autism and vaccines, and a dropoff in vaccination rates has caused an upswing in cases of measles. Such scares and debates have always accompanied vaccines and are inevitable part of the public conversation, according to Sanofi Pasteur spokesman Alain Bernal.

    Much of the recent media hype involving vaccines has centred on the Zika virus, which has exploded in the Americas this year and has been categorised as a public health emergency of international concern by the World Health Organization.

    Sanofi Pasteur head of global research, Nick Jackson, told IRIN that in addition to being a major producer of polio and other vaccines it is among a number of bodies moving towards early-stage “wet experiments” on Zika.

    For Zika, there is a particular lack of data and research on the virus, its mosquito hosts and means of transmission. There’s also debate about the normal incidence of various congenital and neurological conditions that have so far been linked to it. Building baseline data will be critical both for researchers and for subsequent public confidence in any vaccine. A recent review of expert opinion by Scientific American explores a range of risks and complicating factors, all suggesting a quick win in vaccine research unlikely.

    One of the conditions that may be linked to Zika in adults is a severe neurological disorder called Guillain-Barré syndrome (GBS). “What is tricky is to be able to measure the level of GBS without vaccination… The background level exists naturally. It’s very important for a vaccine producer to demonstrate the level of these events before the vaccination, so that after the vaccination people don’t blame the vaccine,” Bernal told IRIN.

    Pressure for Zika treatment and prevention is an acute international priority according to the WHO – and the outbreak’s development in the Americas has triggered the early promise of US cash and research resources. At a recent consultation in the US, researchers, drug company officials, medical journals and public health officials compared notes. “Ebola’s scary because we know what it can do. Zika’s scary because we don’t know yet what it can do,” said Jackson.

    [Sanofi Pasteur provided travel expenses for IRIN's visit to its facilities in Lyon.]

     
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    Might this be the year polio is defeated?
    Polio hopes and Zika fears in the vaccine race
  • A look back at Ebola

    The past year has been a roller coaster ride for West Africa, with Ebola coming and going and coming and going, and then coming once again. But now, after nearly two years battling the deadly virus, the region finally seems to be Ebola-free. None of the three countries most affected – Guinea, Liberia and Sierra Leone – has had an active case since mid-November.

    Experts warn that there will likely be a re-emergence of Ebola at some point, but governments, health workers, communities and aid agencies all say they are now better prepared to stop any new flare-ups.

    The region may enter 2016 Ebola-free, but the impact of the outbreak is still being felt by many. More than 28,600 people were infected and 11,315 died. Hundreds of thousands more lost jobs or loved ones or had their lives in some way turned upside down. Economic losses totalled an estimated $1.6 billion in 2015 alone, according to the World Bank. Kids finally returned to school this year after months of disrupted classes, but the long-term impact on children and education won’t be known for years to come. And, despite waning stigma, not all survivors or Ebola workers have been accepted back into their communities.

    IRIN has covered the ups and downs of the outbreak from the start, as far back as March 2014. Here’s a look back at a selection of our Ebola stories from the past year:

    The good

    Before the Ebola outbreak, many Guineans used to rely solely on local medicine men or “féticheurs” to treat their various ailments and illnesses. But as local communities watched both their people and traditional healers die from Ebola – their powers apparently not strong enough to combat the virus – more and more of the sick began taking the advice of health workers and seeking out care from licensed doctors and nurses. 

    See: Ebola's silver lining: Guineans learn to have faith in hospitals 

    For a long time after the outbreak began, families were forbidden from holding traditional funerals, due to fears the events would help spread the virus. They thought they’d never be able to give their loved ones a proper goodbye. But as more and more communities were declared Ebola-free this year, and public gatherings resumed, many finally got that chance.

    See:  A year on, Guineans finally lay Ebola souls to rest

    A great number of Ebola survivors, particularly early on in the outbreak, lost their jobs, were excluded from community events, and were often even shunned by their own families. But thanks to large-scale education campaigns, many are now being welcomed back home. 

    See: Liberia Ebola survivors find unexpected hope

    The bad

    West Africa is known for its friendly, personal interactions – even among strangers. But Ebola, which is transmitted through bodily contact, changed all that. Too afraid to get too close to anyone, many people gave up their most common practice: the handshake.

    See: Guinea Ebola diary: In the land of lost handshakes

    Guinea’s Gueckedou region, where the outbreak began, was declared Ebola-free in January 2015. But this photo feature and reportage from IRIN West Africa Editor Jennifer Lazuta show how, months later, the extent of the damage was only just starting to be realised.

    See: Photo feature: Ebola and me: Tales from Guinea
    See: The pain of the new normal: Guinea after Ebola

    Things in Sierra Leone and Liberia were looking up mid-year: unemployment was down for the first time since the outbreak began and schools had reopened after nine months of closure. But many families said they still didn’t have enough to eat and malnutrition rates among children under the age of five remained high. Just 10 percent of students initially returned to class, according to Save the Children. Many were too afraid; others had already turned to selling goods on the street, in order to support their families. 

    See: Ebola in Sierra Leone: A long way to go
    See: Schools reopen but Ebola keeps pupils on the streets 
    See: Ebola effect ripples on in Liberian schools 

    The ugly

    Some 17,000 people are believed to have survived Ebola in West Africa. But their ordeal is far from over. More than half say they are suffering from debilitating joint pain, headaches, and fatigue, and at least 25 percent have experienced some degree of change in vision, with many now close to being blind, according to the World Health Organization. Their healthcare options remain limited. 

    See: Post-Ebola Syndrome: It's not over for Ebola survivors 

    More than 20,000 Liberians risked their lives to bury the dead during the Ebola outbreak. Many left their former jobs to help contain the virus. Others simply volunteered their time. Now, due to ongoing stigma, they are unable to find new work. Burial workers in Sierra Leone faced a similar fate: months after the last Ebola case was found, volunteers were still being shunned by their families and communities.

    See: Stigma leaves Ebola burial workers high and dry  
    See: Photo feature: After Ebola: Sierra Leone's burial workers fear their future

    Nearly 6,000 children in Liberia lost either one or both parents to Ebola. While many found loving homes with friends, family or neighbors, not all were so lucky.

    See: What happened to Liberia's Ebola orphans?

    Liberia was in dire need of doctors and nurses before the Ebola outbreak began. Then, more than 200 health workers died from Ebola. Now, at a time when the country needs new staff at clinics more than ever, many Liberians say they are too afraid to enter medicine. In Sierra Leone, where more than 220 health workers died from Ebola, many worry about the impact on pregnant women. The World Bank has warned that the country’s maternity mortality rate could increase by up to 74 percent because of the Ebola crisis.

    See: Ebola scares off trainee nurses in Liberia
    See: Ebola's victims of the future: Pregnant women

    Looking forward

    The WHO has vowed to reform following widespread criticism of its delayed and “inadequate” response to the Ebola outbreak. WHO’s newly appointed regional director for Africa, Matshidiso Moeti, says the organisation has learnt lessons and become stronger after making changes, but health experts say there is still a long way to go.

    See: Can WHO learn the lessons from Ebola? 

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    A look back at Ebola
  • Ebola: Where are we now?

    For the first time in more than a year, no one in either Sierra Leone or Liberia is being treated for Ebola, raising hopes that after more than 11,000 deaths and 28,000 infections throughout West Africa, the epidemic could finally be winding down.

    But 18 months after the World Health Organization (WHO) formally announced the beginning of the Ebola outbreak in March 2014, the last thing the region needs is another false dawn. Three months ago, Liberia was declared free of the virus only for new cases to emerge.

    See: Bush meat trade roaring again despite Ebola ban

    Although there are just three known cases left in the region and just 629 potential contacts still under observation, the epidemic isn’t yet over.

    Here is where things stand:

    Guinea
    Cases: 3,792
    Deaths: 2,527

    Guinea is where the outbreak started in December 2013 with the death of a two-year-old boy. Now, 20 months on, much of the country is Ebola-free, including the southeastern forest region where the index case originated. But there remain a few pockets of resistance, particularly in and around the capital Conakry, where the only three current cases in the entire region were recorded during the week ending 23 August. Approximately 600 people are still under observation in Guinea and WHO warns that “there remains a significant risk of further transmission,” particularly because one of the positive cases – a taxi driver who was not previously on any contact lists – could have spread the virus to his passengers. Guinea is also the site of the first health worker infection in more than one month. 

    Liberia
    Cases: 10,672
    Deaths: 4,808

    Last month, Liberia began a 42-day countdown to being Ebola-free, but not for the first time. The outbreak was previously declared over in the country on 9 May. But on 30 June, the Ministry of Health announced that a teenaged boy had tested positive in a small town on the outskirts of Monrovia. Over the next two weeks, five more cases were confirmed. The source of the second outbreak is still unknown, but Ebola response teams were able to quickly contain the flare-up. The last patient was discharged on 23 July and all potential contacts have since passed the 21-day incubation period. Liberia could once again be declared Ebola-free on 3 September.

    Sierra Leone
    Cases: 13,541
    Deaths: 3,952

    Sierra Leone has now gone two consecutive weeks without any new cases being reported. The last patients were sent home as survivors on 24 August. Just 29 contacts are still under a 21-day surveillance period, which is set to end on Saturday. If no new cases surface, Sierra Leone will be declared free of Ebola on 5 October.

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    Ebola: Where are we now?
  • Post-Ebola Syndrome: It's not over for Ebola survivors

    West Africa’s Ebola outbreak might be winding down, but the struggles facing survivors in Guinea, Liberia and Sierra Leone are far from over.

    Beyond psycho-social problems related to stigma and post-traumatic stress disorder, more than half of survivors say they are suffering from debilitating joint pain, headaches, and fatigue. At least 25 percent have experienced some degree of change in vision, with many now close to being blind, according the World Health Organization (WHO).

    “I was cured from Ebola last October, but since then I have been suffering from severe pain in my joints,” 45-year-old Kebeh Jomah, who lives in Monrovia, told IRIN. “Sometimes it is so serious that I don’t walk around… I hardly visit people anymore. All day I am sitting home crying from joint pain.”

    Chris Tuan, 18, said his vision has been getting increasingly worse since he was discharged from an Ebola Treatment Unit (ETU) in Liberia in November.

    “I hardly see from a far distance anymore,” he said. “I am gradually losing my eyesight. I am worried. Sometimes I can’t walk alone. Someone has to help me to move around…This is no joke.”

    Medical mystery

    Doctors and other Ebola specialists say they are still unsure exactly why recovered Ebola patients, months later, are still suffering from these lingering side-effects, which many refer to as “post-Ebola syndrome." It is also unclear why the symptoms manifest themselves in so many ways in different people and to varying degrees.

    “We have very preliminary data – and I will again stress it is very preliminary – that suggests that patients who may have had more severe, acute disease may have more severe chronic disease after the initial recovery,” said Doctor Daniel Bausch, a clinical infection control specialist for WHO.

    But while studies from previous outbreaks have shown that the virus can survive in certain parts of the body, where the immune system does not reach, such as the eyes and testes, even for months after recovery, Bausch said nobody knows why patients are experiencing other physical problems, such as headaches and joint pains, in places where the immune system can reach.

    “That’s really one of the big knowledge gaps in which we need more research,” Bausch said.

    During past outbreaks, the number of people infected was always much smaller and so was the number of survivors, making it difficult to perform studies on a largescale.

    Now, there are more than 13,000 survivors across the three most-affected countries, giving experts a chance to have a more comprehensive look at the various long-lasting effects of Ebola.

    Even that, however, may be difficult, as the testing requires special biosafety facilities and can sometimes be invasive for the survivor.

    “It would be difficult… to really do studies that would measure, for example, cleaning the virus out of the eye, because that requires a relatively complicated procedure of tapping [and] putting a needle in someone’s eye – that’s [something] not too many of you would probably like to volunteer for,” Bausch explained.

    A need for care

    Beyond the need to better understand the long-lasting effects of Ebola, the more immediate need for these survivors is care.

    “When you say joint pain, it sounds like a minor thing, [but] it can be quite a major thing for many people,” Bausch said, explaining that many people in these three countries rely on farming and other manual labour for their survival, but are now unable to go back to work and provide for their families.

    For eye problems, in particular, if the inflammation, which causes vision problems, is left untreated, the person can go completely blind, according to WHO.

    There are no known treatments for any of these ailments, however, and trained eye specialists are rare. In Sierra Leone, for example, there are just two ophthalmologists for the entire country.

    Doctors say they are currently treating people’s symptoms on a case-to-case basis, using general medications, such as steroid eye drops or arthritis pain relievers.

    To reach survivors in other areas of the country, WHO is now working with local governments and organisations in all three countries to create mobile eye clinics, as well as offer other treatment for the various ailments facing survivors.

    In Liberia, the country’s first Ebola Survivor Clinic was opened earlier this year at the ELWA Hospital on the outskirts of Monrovia. A second recently became operational in Paynesville. The clinics offer free consultations, care and medications to survivors.

    According to Doctor John Fankhauser, the deputy medical director at the ELWA Hospital, they see more than two dozen patients each day.

    “We see a lot of muscular problems, people who come in with very severe pains in their hips, in their joints and in their knees,” Fankhauser said. “Some of them even have a hard time shuffling into clinic. And these are patients who have been suffering from this for months [without care].”

    Many people hope the clinic will finally offer some relief.

    “My little baby you see here is an Ebola survivor,” said Morris Kollie, inside the Survivor Clinic.“By the special grace of God, he survived and just turned five [years old] this year. But he continues to complain of severe headaches and pains. We have taken him all over the place, but no cure yet.”

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    Ebola survivors still suffering
  • Ebola vaccine: reason to be hopeful?

    News that an Ebola vaccine trialled in Guinea has proved 100 percent effective has elicited both excitement and caution from a range of actors closely involved in the outbreak, which also struck Liberia and Sierra Leone and has claimed more than 11,000 lives since March 2014.

    Some 1,200 frontline workers and 4,000 others who came in contact with the virus were vaccinated between 23 March and 26 July in Guinea, as part of a trial run by the World Health Organization (WHO), Médecins Sans Frontières (MSF) and the governments of Canada, Norway and Guinea. Research published today in The Lancet found that the vaccine, known as rSVS-EBOV, protected 100 percent of participants who were treated immediately after exposure. 

    Experts warn that more data and research is needed to determine how much of a game-changer the vaccine is. It is unclear how soon the vaccine protects those inoculated against Ebola, how long the protection lasts, what side-effects the vaccine may have, especially on high-risk groups such as pregnant women and children. 

    IRIN asked some key Ebola-response players about their reaction to the news.

    Dr. Unni Krishnan, Plan International’s Head of Disaster Preparedness and Response

    “The early results offer a ray of hope. However, this development shouldn’t take the attention away from building strong public health systems, which is a key antidote for all health emergencies.” 

    Martha Paulson, Ebola widow and mother-of-three from Monrovia, Liberia

    “This is the best news I have heard since 2014. I am really afraid of that disease. I lost my husband to Ebola…. I wish he was still alive before the discovery of the Ebola vaccine. But thank God…. We just want to tell the researchers that we are grateful. Liberia is [waiting] for it.” 

    Dr. Bertrand Draguez, Medical Director for MSF

    “These results are promising and we should definitely make this vaccine available to at-risk groups as soon as possible. But it is also of crucial importance to keep working on all the pillars of an Ebola response including contact tracing, health promotion and isolation of infected patients.” 

    Margaret Harris, WHO spokesperson

    “It’s very good news, but… at this stage, it’s a vaccine only used for high-risk groups…. It’s very important to understand it’s a tool for prevention, but it’s not something that can cure Ebola and it’s important to understand that all the other things used to prevent Ebola must continue.” 

    Guinea’s national regulatory authority and ethics review committee says it plans to continue the trial based on these preliminary results, but it is still unclear what should happen next.

    “To say exactly when and where [the vaccine will be used next] would be jumping the gun, because you need to look at who would benefit, who would provide it, cost and so on,” Harris said. “Those are not decisions that can be made overnight. All the pieces of the puzzle are now being brought together, but to put a timeline on it would be misleading.”

    Many people simple expressed excitement at the breakthrough:

    Joy Coleman, Liberian nurse

    “I just heard the news and I am here shouting in my office. We are so happy as a nation to hear this good news. A lot of people died in this country. I even lost six of my colleagues who were nurses…. Although it’s coming late, it’s better late than never…. We hope they can immediately send it to Liberia so all our citizens can be vaccinated against Ebola virus disease.” 

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    Ebola vaccine: reason to be hopeful?
  • Can WHO learn the lessons from Ebola?

    An independent panel described the response of the World Health Organization (WHO) to the Ebola outbreak in West Africa as “delayed” and “inadequate,” so what systemic changes need to be made to ensure future crises are handled better?

    Barbara Stocking, who chaired the panel, called it a “defining moment,” not just for WHO but also for member states, who have just pledged an additional $3.4 billion to boost recovery efforts in Guinea, Liberia and Sierra Leone over the next two years.

    WHO has declared the rebuilding of health systems in Guinea, Liberia and Sierra Leone a “critical priority” and announced plans to help make them more resilient, but the recommendations last week of Starking and her colleagues went much further.

    WHO must: devise a system that would allow the alarm bell to be rung sooner; create a new body combining emergency response and humanitarian need; and generally cooperate and coordinate more efficiently with its health and humanitarian partners, the panel said.

    Matshidiso Rebecca Moeti, WHO regional director for Africa, told IRIN that the world health body welcomes the recommendations and has already begun moving forward on some, including the development of a global health emergency workforce and a contingency fund.

    “The report stated quite strongly that WHO did not have the resources, even now, to adequately respond to an epidemic, to emergencies,” Moeti said.

    “It’s clear that the capacity of WHO over the years has been taken away as resources become less and less available...The organization needs to do better. We know that… and I think we learned our lesson… I’m quite confident that WHO can do the job effectively in the future.”

    But the road to change won’t be easy. There are a number of deeply entrenched systems within WHO that will have to be overhauled and other new components that will have to be implemented. 

    IRIN spoke with five health experts about what needs to come next.

    Rebecca Sutton, campaign manager for Oxfam UK’s Ebola Response and Recovery programme

    “We are pleased to see that WHO will continue to be the lead agency responding… but a significant overhaul is needed in terms of culture… WHO needs to be much less bureaucratic and much more able to respond quickly and in a coordinated and fast and effective way, because that was not the case with Ebola.”

    “Community engagement has been crucial to dealing with Ebola so far and it’s crucial going forward with recovery and dealing with a broader range of diseases… [Interagency cooperation] is also very important and I think the key here is to have better coordination at the district level, which needs a lot more capacity building. It’s at that levels that agencies need to come together.”

    Ilona Kickbusch, director of the global health programme at the Graduate Institute of International and Development Studies in Geneva and panel member of the WHO assessment report

    “The WHO is as strong as three key dimensions: how strong it is in its technical excellence, how strong the support of its member states is – in terms of both political and financial support – and, thirdly, the strength and determination of the director general.”

    “We need a strong WHO… We need an organisation that can respond to the health challenges of 21st century and is truly accountable for that. And that means leadership by the director general and member states.”

    “Internally, the WHO secretariat needs to make clear and tough decisions on how International Health Regulations and humanitarian sections of the secretariat are now brought together… it should have a board that does independent oversight… it also need to address staffing, organisational culture… and the issue of financing.”

    Philip Ireland, emergency medical physician at the John F. Kennedy Medical Centre in Monrovia, Liberia, and Ebola survivor 

    “For the most part, I agree with the critics: The response of the international community was not as fast as it should have been because there were was a lag time. If they [WHO] had come in a little earlier and provided all the stuff that they provided later on, we might not have the epidemic we have now, it might have not been as bad as it was.”

    Ireland said training doctors and nurses and growing local capacity would be key to rebuilding West Africa’s health systems.

    “If WHO and other NGOs just continue to come in and do quick fixes, at the end of the day it won’t be sustainable. It’s like having a cancer on your foot ¬– if you put a plaster over it to cover it, that wouldn’t work for very long time because the underlying condition hasn’t been dealt with.”

    Franklin Gregory, head of the West and Central Africa office for UN emergency aid coordination body OCHA

    “[We] subscribe to the recommendation for establishing more clarity [as to] how a public health emergency fits into the wider humanitarian system and at what point an outbreak becomes a humanitarian emergency that requires a broader United Nations-wide response, as highlighted in the July 2015 Ebola Interim Assessment Panel report.”

    “There is, at the same time, the need [for] a better understanding by health organisations [in] the humanitarian system, with enough investment in operational capacity and crisis coordination skills in health emergency response and preparedness to ensure a better collaboration with humanitarian partners.”

    Unni Krishnan, head of Plan International’s Disaster Preparedness and Response program

    “During a big crisis, someone needs to be in charge and act as an authority, and that’s what WHO needs to demonstrate that it can do, before, during and after outbreaks… We also need to recognise the need for speed and flexibility. During an emergency, it’s about moving from first gear to top gear very quickly and if that ability is lost then it won’t be able to deliver.”

    “There needs to be continuous dialogue between WHO and the UN and non-UN agencies… to galvanise that collective capacity that is crucial. Coordination is not easy, but cooperation is possible and the first step is information-sharing.”

    “There is no question that the 11,000 lives that have been lost should be a constant reminder for WHO and the global health community to reform and perform better in the future. WHO isn’t the only agency responsible for what happened… but transformative changes are clearly needed within WHO.”

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    Can WHO learn the lessons from Ebola?
  • Turn on the taps to defeat the next Ebola

    It is a cruel irony that many of the top doctors and nurses in Guinea, Liberia and Sierra Leone will not be around to help rebuild their health systems in the wake of Ebola, having succumbed themselves to the virus. For those that are, the biggest challenges are likely to be electricity, sanitation, and, most of all, water.

    “How is it possible to build, or rebuild, as you may call it, a health institution or hospital without [access to] water, which serves as a major catalyst to run the facility?” asked Moses Tamba, a spokesperson for Liberia’s Ministry of Public Works. “It is not possible. You need water.”

    With the head of one international aid organisation warning in recent days that if the Ebola epidemic was to flare up again, health authorities in West Africa would be no better off to deal with it than they were a year ago, it is time to focus urgently on what can be done.

    Even before the outbreak began in December 2013, the three countries that were to become worst affected had some of the weakest health systems in the world. Frequent power cuts and water shortages afflicted even the most-developed clinics and hospitals in Guinea, Liberia and Sierra Leone on a near-daily basis.

    During the Ebola outbreak, which has killed more than 11,150 people in the region and is still rife in Guinea and Sierra Leone, a lack of access to water both in private households and public health clinics meant that the virus, which is passed on through contact with infected individuals or soiled materials, continued to spread.

    Many people were unaware or unable to properly disinfect their homes and belongings.

    “You need water to boil to wash bedding, clothes, cooking utensils, equipment and so forth,” Tamba said. “You need water to drink, both for hospital staff and the patents. Electricity is also essential to operate our health facilities. This is serious and every health facility needs these [basic necessities].”

    Lessons learned

    Worldwide, more than 2.5 billion people still don’t have access to proper sanitation facilities, including toilets, according to a 12 June joint report by the World Bank and World Health Organization.

    In Guinea, a quarter of the population has no access to potable water, according to the international development organisation WaterAid. In Sierra Leone and Liberia, 40 percent and 25 percent of people, respectively, don’t have sustainable access to safe drinking water. 

    “If you really look at these figures, they can help to explain some issues around hygiene attitude and the context that has caused Ebola to spread,” head of WaterAid’s West Africa region Mariame Dem told IRIN.  “If you have health centres where you can’t ensure proper hygiene practices, supported by the availability of toilets… and if you can’t ensure 24-hour access to safe water… it will really have a bad impact on [people’s] health and hygiene.”

    Moving forward

    All three countries, backed by their international partners, have pledged to improve their public health systems despite the fact that the Ebola outbreak has strained their already limited resources.

    In Guinea, the government has allocated more than $200 million to modernise and equip Conakry’s Donka hospital with better access to water and sanitation facilities.  Across the country, 3,000 hand pumps will be installed outside hospitals and health clinics so that “patients can stay clean,” Health Minister Remy Lamah told IRIN.

    The Guinean government has also just completed a new dam that will supply hospitals and clinics in and around Conakry with “constant power.”  The government says it is also in the process of installing generators in many of these facilities in case of power failures.

    But, for many, it’s a question of too little too late.

    “If the government had previously taken the initiative to improve the Guinean health care system… Ebola could have been detected and eradicated long ago,” said Mohamed Toure, an epidemiologist at Donka hospital, which now contains the country’s largest Ebola treatment centre.

    In Sierra Leone, Jonathon Abass Kamara, a public liaison officer at the Ministry of Health, told IRIN that the government was, “working very hard to ensure that public health services are improved beyond what they used to be.”

    He warned, however, that funding would be a problem.

    Sierra Leone spends just 1.7 percent of GDP on public health expenditures, according to the World Bank.

    But Dem warned that fixing the problem would require a lot more than just money.

    “It’s obvious that funding, or rather, a lack of funding, is one of the reasons [why water and sanitation remain poor] in these countries,” she said. “But we also need to go beyond that because… the most important thing is political will – not only by the government of the country, but also at the global level.”

    The world has already met the Millennium Development Goal of halving the number of people who don’t have sustainable access to safe drinking water by 2015, but Dem said even that wasn’t adequate for the fight against Ebola.

    “We need to go beyond these commitments,” she said. “If you invest in water and sanitation systems, you will not only give better quality health services, but also lessen the burden, lessen the impact, in terms of financial cost and human cost, of Ebola and these other diseases, during times of crisis.”

    (With contributions from Prince Collins in Liberia, Karim Kamara in Guinea and John Sahr in Sierra Leone)

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    Water key to Ebola fight

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