Emerging from Crisis, Preventing the Next One
By Melanie Mayhew, World Bank Group
Every day for 27 years, in the early morning blackness that only fishermen know, John* and his crew dislodged their boat from Sierra Leone’s shore and paddled north toward Guinea, returning at sunset with nets flopping with fish.
Today John stands in a few inches of water in the port of Aberdeen, Sierra Leone, gazing at the colorful boats skirting the horizon, wishing he could return to the sea. It’s been a year since he captained a boat, a year since he fished.
“I would love to go fish but I can’t because I don’t have a boat,” John, 43, says.
John is landlocked by Ebola.
John doesn’t have a boat because the boats won’t hire an Ebola survivor—they’re afraid of contracting Ebola. Like the other former fisherman milling about the port, he is unemployed, unskilled to perform any job other than fishing. All are eager to work despite the blurry vision, body pain and headaches that they live with every day, reminders that they survived Ebola, but that Ebola never will go away for them.
The captains among them each made an average of $12 on a good fishing day. Now none of them can feed their families.
While much of the world has turned its attention away from Guinea, Liberia and Sierra Leone—which are just now emerging from the deadliest Ebola outbreak in history—the human and economic devastation endures. West Africa’s experience fighting Ebola is a lesson for the world, and for countries, as they prepare for the next pandemic.
With that lesson in mind, at the G7 later this month, world leaders will discuss a new mechanism, the Pandemic Emergency Financing Facility, which could help stop the next outbreak before it becomes the next Ebola crisis.
Rebuilding a life, block by block
Abdulai*, 34, sits in a flimsy plastic chair on the front porch of his home in Crab Town, Sierra Leone. He pushes his sunglasses to the top of his head so he can wipe tears from his eyes. Eight people in the house, including his parents, contracted Ebola. He was the only one to survive the disease.
Like John the fisherman, he was fired from his job when his boss learned that he was an Ebola survivor. He had a regular job in construction until late 2014, when he contracted Ebola. Now he lays concrete blocks, but the work is inconsistent. This week, he showed up for work five days, but was hired only one. He made $3 this week for a day’s work.
The family’s only other income is from his wife’s shop, which she runs from their home. She sells soap, cigarettes and garri. Sixteen cups of garri, a staple food that is made from cassava tubers, sells for about $4. The shop’s profits barely feed Abdulai, his wife and their children.
They haven’t paid rent in 18 months. They recently received a notice that they may be evicted from their home, which is made of concrete blocks, metal windows and doors, and a sturdy roof. If they’re evicted, they’ll move to a corrugated-metal shack with mud floors and no doors or windows. They say they’ll have to wash twice a night because of the heat. When the rains come, they’ll shiver when water streams through the roof and sides of the shack.
“We were not a wealthy family but we were coping,” Abdulai says. “Ebola was a setback for us.”
Stopping Ebola, and other diseases, at the source
The Ebola epidemic, which began in Guinea in December 2013, infected more than 28,000 people in Guinea, Liberia and Sierra Leone. It also rapidly exposed the paralyzing weaknesses in the countries’ health and public health systems.
Before Ebola, the countries were three of the poorest in the world, but had recently made significant health gains. However, when Ebola struck, the countries’ hospitals and clinics—overwhelmed by an influx of Ebola cases and the catastrophic loss of health workers to the disease— crumpled. Basic primary health care services, like maternal and child health care, were not available. A World Bank study found that the deaths of health workers may result in more than 4,000 deaths of women each yearacross the countries, as a result of complications in pregnancy and childbirth. These deaths are on top of the more than 11,000 people who died of Ebola.
The countries also had limited—and in some places, no—ability to detect and respond to infectious disease outbreaks as they spread in communities. Before Ebola, the country did not focus enough on disease surveillance and control, says Dr. Foday Daffae, the director for disease prevention and control for Sierra Leone.
If disease surveillance had been stronger, “we could have stopped Ebola,” Dr. Daffae says.
In addition to saving lives and building healthier communities, disease prevention and control efforts save the country money: Preventing diseases is much cheaper than caring for people when they get sick.
The Ebola crisis crippled the economies of Guinea, Liberia and Sierra Leone, costing them $2.8 billion in GDP losses, according to World Bank economists. Commodity prices collapsed; for example, the price of iron ore, which used to account for 60% of the Sierra Leone’s exports, crashed from $185/ton to $35/ton. Both of the country’s mines shut down and iron ore exports plummeted to zero. And donor funds, which helped the countries fight the Ebola crisis, now are drying up, leaving governments struggling to pay their bills and keep systems running.
Because of Ebola and its human and economic toll, countries like Sierra Leone are changing how they approach disease surveillance and control.
District surveillance officers now provide weekly and monthly reports on 47 diseases in communities, immediately reporting diseases like Ebola, Lassa Fever, Cholera and Measles. The country has focused on training health workers and surveillance officers, improving labs’ capacity to quickly test specimens, and collecting better data so they can analyze and address disease trends, Dr. Daffae says.
“This outbreak is over, but that doesn’t mean it won’t happen again,” says Dr. Daffae. “But we should detect it immediately and control it at the source the next time.”
The World Bank Group is working with nine countries in West Africa, including Guinea, Liberia and Sierra Leone, to improve surveillance and early reporting; strengthen laboratory capacity; bolster workforce training, deployment and retention; and enhance preparednes and rapid response. Because most contagious disease outbreaks cross borders, countries are working together to prevent and control diseases—no country can do this alone. This regional effort is part of the World Bank Group’s $1.62 billion commitment to help West Africa respond to and recover from Ebola.
In Liberia, the World Bank also is working with the Liberian government and many partners, including Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and USAID, with resources from the International Development Association and the Global Financing Facility Trust Fund, to reconstruct and strengthen its health system to increase the use of services and enhance its resilience to shocks. The effort emphasizes emergency preparedness, surveillance and response, with a special focus on maternal and neonatal death surveillance and response.
Counting every death to save lives
It’s mid-morning in Sierra Leone, and someone has called 117, the country’s emergency hotline, to report a death in Kissy Public Works Development. The call is routed to the Western Area district surveillance team, which dispatches Tomeh Bangura, 53, a disease investigator, and Gibrilla Kabba, 29, a swabber—someone who collects laboratory specimens—to the home. The disease investigator asks the family for details of the death, while the swabber pulls on personal protective equipment, including a face mask, gloves and scrubs from head to toe. He enters the home with a test tube and swab in hand.
The baby’s father pulls the curtain aside and illuminates the room with his cell phone. The swabber bends to open and swab the three-day-old baby’s mouth. He places the swab inside of the test tube. Later, he’ll send the specimen to a lab.
Outside, the baby’s mother is crying on the porch. This is her first child. Family members and neighbors have started to gather to mourn the baby’s passing.
Although the swabber and disease investigator do not suspect Ebola or another infectious disease as the cause of death, the country’s new policy is to swab every person who dies, even if they die, for example, in a car accident.
If the swabber and disease investigator had suspected that the baby died of an infectious disease, they would have called an ambulance. The team follows the same procedure when they receive reports of diseases among the living: They send a swabber and disease investigator and request an ambulance if the case is serious or if an infectious disease is suspected. If Ebola is suspected, the person is sent to a holding center to await lab results.
Community-based surveillance guides also routinely check in on people in their communities, to ensure that all diseases and deaths are reported, which helps the district management teams collect and analyze data. Each team meets every day, Monday through Friday, to discuss these diseases and deaths, and where they need to deploy resources.
“If anything happens now we’ll be in a position to combat it,” says Tomeh, who has investigated more than 100 deaths since 2014.
These enhanced disease surveillance and control efforts have helped control recent flare-ups of Ebola in the countries. During a recent flare-up in Liberia, a case was suspected to be malaria until a lab test confirmed that it was Ebola. This allowed the district team to quickly contain and limit Ebola’s spread, ultimately saving lives, says Dr. Yatta Wapoe, the community health officer for Monserrado County.
“If we hadn’t had surveillance with the latest cases, it would have led to a huge outbreak,” she says.
Although the countries have made great strides, challenges remain. Some specimens can’t be tested at hospitals and clinics, even if they have a lab on-site. The labs lack functioning equipment, reagents and trained staff to run the labs and return timely results. C.H. Rennie Hospital in Liberia’s Margibi County—one of the counties hardest hit by the Ebola crisis—sees 100 patients a day, but there is only one functioning microscope. It can take 24-28 hours to get a lab result for deadly diseases like malaria.
Each country has just a few referral labs to test for Ebola, Lassa Fever, Measles, Rabies and Meningitis, but results are often delayed. However, there are signs of progress: In 2014, it took a week to get a result on an Ebola test, Dr. Wapoe says; now that test takes 24 hours. The previous weeklong delay thwarted health officials’ ability to prevent the spread of the disease.
“We were sitting on a time bomb,” Dr. Wapoe says.
Stopping diseases at the door
At C.H. Rennie Hospital in Margibi County, Liberia, construction workers sand and paint, in white and blue hues, cinder block walls. Days later, the hospital’s new triage unit will open, with sparkling white tile floors, two screening desks and a multi-bed isolation unit.
The new triage unit is meters from a memorial to the 14 health workers C.H. Rennie lost during the Ebola crisis.
During Ebola, infectious patients walked through the gates of the hospital with little or no screening. There was no area to keep them from infecting other patients, visitors and health workers. With the new triage unit, the hospital can immediately screen for infectious disease cases and then isolate people who may be contagious, ultimately delivering care more quickly to those who are infected, and decreasing the chance that they’ll infect others.
The triage unit is one of 27 that the United Nations Office for Project Service, with funding from the World Bank Group, is building in health facilities across Liberia.
Beyond these new triage units, health care workers are doing what they can to prevent the spread of disease, applying some of the infection prevention control measures they practiced at the height of the Ebola crisis, like wearing personal protective equipment and gloves, washing their hands and using hand sanitizer, and spacing hospital beds three feet apart to prevent the spread of disease.
Jackie*, a 41-year-old nurse midwife at Monserrado County’s Redemption Hospital, one of the busiest health facilities in the country, rolls an ultrasound cart through the hospital’s busy delivery ward, where five women are moaning as they wait to deliver their babies. After each ultrasound, she pulls sanitizer out of her pink fanny pack and squirts her hands.
Jackie has been working at Redemption Hospital for 25 years, first as a registrant, then as a nurse’s aide and now as a nurse midwife. She’s been delivering babies since eighth grade, when her midwife mother began training her.
“I love being a midwife,” she says. “I see the joy in the woman coming through labor and taking her baby home.”
Her job almost killed her. During the height of the Ebola crisis, Redemption Hospital was in the epidemic’s crosshairs. In September 2014 she was alone in the delivery ward, while other health workers stayed away, fearful of contracting Ebola.
A patient started bleeding. She didn’t stop until she was dead. The woman and two other patients died the next day of Ebola, and soon, Jackie learned that she had contracted Ebola from her patients. She was admitted to an Ebola treatment unit, and returned to work a few weeks later.
Although Jackie cheerfully says today that she no longer faces much stigma as an Ebola survivor, many are still struggling, like Lena*, 40, of Monrovia, Liberia. Despite great improvements in her life in the last year—she got married, was able to stay in her home despite a landlord threatening to evict her and is back in school—when she went to the hospital recently and disclosed that she was an Ebola survivor, the health workers refused to treat her.
“When you go to the hospital and they know you’re a survivor, no one is willing to touch you,” she says. Lena asked for water to brush her teeth and was given a bedpan filled with water.
Preparing for the next time
Everything Guinea, Liberia and Sierra Leone are doing to prevent the next outbreak is critical—however, infectious disease outbreaks are inevitable and can quickly overwhelm any health system, especially in the world’s most vulnerable countries.
The world sometimes comes to countries’ assistance only when a major outbreak, like the recent Ebola crisis, hits an explosive point. Without a strong system in place, the world will continue to move from crisis to crisis, killing thousands and destabilizing economies.
To respond to this, at the G7 later this month, leaders will discuss the Pandemic Emergency Financing Facility, a fast-disbursing financial mechanism that will make significant funds available the next time an epidemic hits. By stemming an outbreak before it reaches pandemic proportions, it could help save thousands of lives and keep the cost of outbreaks to millions, instead of billions or trillions, of dollars.
If Ebola had been stopped earlier, people like Umaru*, 39, who contracted Ebola in February 2015—14 months after the outbreak began—would still be fishing the seas of Sierra Leone.
“Things are pretty tough,” he says, “but I’m hopeful things will turn around. I’m a young man with a long life.”
*Ebola survivors have been identified only by their first names.
