AMNESTY INTERNATIONAL
PUBLIC STATEMENT
AI Index: AFR 01/013/2014
22 September 2014
International assistance and human rights protections vital for Ebola-stricken countries
As the Ebola epidemic spreads and the death toll rises, Amnesty International underscores the legal obligation of the international community to provide assistance to the affected countries.
In addition to the need to mobilize the necessary financial and technical resources, the organisation is highlighting the following issues as requiring particular attention, both within domestic response plans and as part of the international assistance effort:
Protect health care workers and service providers
Address the disproportionate impact on women
Apply a human rights framework to protect the safety, dignity and freedoms of affected communities
Guarantee support for long-term recovery of affected states
Cases of Ebola have been reported in the West African states of Guinea, Sierra Leone, Liberia, Nigeria and Senegal, as well as the Democratic Republic of the Congo. Fourteen of Liberia’s 15 counties have now reported confirmed cases. Current data show that at least 2,600 people have died from Ebola and more than 5,000 are infected. However, data collection is weak and the Director-General of the World Health Organization has stated that these figures are “vast underestimates”.
The World Health Organization has warned of an exponential rise in the number of people infected with the disease in West Africa and the need to significantly scale up the international response. Reports indicate that health centres are overflowing with patients, and that people suffering from the disease are having to move around to seek treatment or are returning to their homes and communities, increasing the risk of spreading the infection further. On 18 September the UN Security Council declared the Ebola outbreak in West Africa a threat to peace and security.
The international response
Human rights cannot be fully realised without international cooperation and assistance. This is reflected by the fact that the vast majority of the world’s states have recognised that human rights obligations include the obligation of international cooperation and assistance, including with respect to the right to health. In the context of a health emergency, such as the Ebola crisis, this obligation is triggered by the appeals of the affected countries or the United Nations (UN) for help. All countries that can respond must do so as swiftly as possible. The response must itself be rights-respecting and should take account of long-term as well as immediate needs.
While recent weeks have seen greater international focus on the situation West Africa, too many aspects of the crises are yet to be addressed. On 5 September the UN Secretary-General, Ban Ki Moon, made an international rescue call, saying the next weeks were “crucial” in the fight against the disease. Since then, although some resources have been mobilised, this has largely been insufficient to meet the needs of the crisis-affected countries. On 16 September Doctors without Borders warned that the world was losing the battle to contain Ebola and that the response continued “to fall dangerously behind” what was needed. On the same day, the UN Secretary-General called for US$1 billion for the response effort.
Mobilizing financial and technical resources is vital; in addition, the following issues should be given attention, both within domestic response plans and in international financial and technical assistance.
Protection of health care workers and service providers
At the frontline of this epidemic are health workers, burial personnel and community workers who are courageously continuing to deliver services despite the personal risks, and despite having lost colleagues, relatives and friends.
Over 300 health workers have been infected, according to the World Health Organization, and at least 144 have so far died of the disease. On 14 September a fourth doctor died in Sierra Leone after contracting the disease in the course of carrying out her professional duties.
Liberia and Sierra Leone, whose health systems were already crippled by years of conflict, struggled to provide health care services at the best of times; they are now collapsing under the strain of responding to the epidemic. There are insufficient personnel to cope with the number of patients. While many health workers heroically continue to work, they are doing so – in some cases – without personal protective equipment or are having to recycle the little protective clothing they have.
The support of the international medical community is vital and foreign medics have joined their colleagues on the frontline, sometimes at great personal cost. However, much more is needed to support national and international medical response teams.
Personal protective equipment, information, training and psychosocial support are all necessary to support nurses, doctors and other response staff. Increased efforts are required to get equipment and technical support to where it is needed. States must also ensure there are mechanisms in place to guarantee support for the families of health workers and others who have died or become ill as a consequence of caring for Ebola victims.
While international assistance should prioritise urgent needs, it must also be forthcoming for long-term rebuilding of health systems. The health communities of the affected countries need to know they will be supported to rebuild their health care systems when the crisis has passed.
Addressing the impact on women
Women appear to be at disproportionate risk of contracting Ebola. According to UNICEF women comprise over 50% of the total number of those dying from this outbreak of Ebola, children 22% and men around 25%. In Liberia, reports attributed to the government claim that between 55% and 75% of those who have died in that country are women.
There are a number of reasons why women are more vulnerable to contracting the disease; in many of the affected areas it is women and girls who shoulder the burden of caring for sick relatives and washing the bodies for traditional burials. Most nurses in the region are women and nursing staff make up the majority of medical staff in most facilities.
In addition, women are particularly vulnerable to infection during pregnancy because, amongst other things, they have more contact with health facilities. They may also lack relevant information on how to protect themselves. For example, men who have recovered from Ebola continue to secrete the virus in their semen for up to several weeks after recovery. However, medical experts have noted that this fact is not well known.
Proper assessments are needed to identify the particular gender dimensions of this epidemic. Women should be engaged in strategy development and assisted in addressing any particular obstacles they face in adhering to protective procedures, due to prevailing attitudes about gender roles, lack of access to information or other pre-existing inequality.
The international community has an important role to play in ensuring that considerations are given to gender, and that they involve women and women’s rights experts in the design of both their short- and longer-term programmes to respond to the epidemic. Specific action plans should be developed to address gender-related risks, and resources provided to implement action. International cooperation and assistance will be vital in this regard.
Using a human rights framework to protect the safety, dignity and freedoms of affected communities
Containing and controlling the spread of Ebola is vital and the affected countries face significant challenges in doing so. While recognising the complexity of the challenges, certain containment measures are of concern.
For example, in Sierra Leone, the 2014 Bye-laws for the Prevention of Ebola and Other Diseases introduces prison sentences of up to six months for anyone harbouring a person who has, or may have, contracted Ebola. Such uses of criminal law may be counter-productive, increasing fear and suspicion within communities and between communities and the authorities.
Medical professionals have raised similar concerns about some of the quarantine measures that have been used. Sierra Leone’s three-day “lock-down” from 19 to 21 September was criticised by Medecins Sans Frontieres. The organization stated: “it has been our experience that lockdowns and quarantines do not help control Ebola as they end up driving people underground and jeopardizing the trust between people and health providers."
Quarantines, which restrict the right to freedom of movement, may be justified under international law only if they are proportionate, time bound, undertaken for legitimate aims, strictly necessary, voluntary wherever possible and applied in a non-discriminatory way. Such an approach is needed to maintain the trust of the population – an essential part of a successful response to infectious diseases.
There have also been reports of people in quarantine being left without food and other basic necessities and use of force by police in enforcing quarantines. The international community must assist affected states to ensure that where quarantine and isolation measures are being implemented, they are done so in a safe and respectful manner and the rights of those under quarantine are respected and protected.
The police have an important role to play in controlling the spread of the disease and ensuring public safety. Policing of quarantine and other containment measures must be in line with international standards on policing, including the UN Code of Conduct for Law Enforcement Officials and the UN Basic Principles on the Use of Force and Firearms by Law Enforcement Officials. These principles, which apply at all times, including during times of public emergency, stipulate that law enforcement officials may use force only when strictly necessary and to the extent required for the performance of their duty, and that as far as possible, they should use non-violent means before resorting to the use of force, which should only be used if other means are ineffective. Firearms must not be used except in self-defence or defence of others against the imminent threat of death or serious injury.
Guaranteeing support for long-term recovery
In addition to medical support the international community must make a commitment to support the Ebola-affected countries’ longer-term recover and to look at the wider impacts. The World Bank has noted, for example, that Ebola-related restrictions on people’s movements are “leading to food crises in the quarantined and most affected areas … and that: “1 million people in the region are facing a food crisis in the coming months.” The Bank has also warned that the disease will have a potentially “catastrophic” impact on the already fragile economies of Guinea, Liberia, and Sierra Leone.
As vital as international support for the medical response is, the wider impacts on the economies and development of the affected countries must also be addressed. This means new resources must be forthcoming from the international community - through the UN agencies and well-coordinated donor engagement – and not only a reallocation of existing aid funding. When the crisis is past, those who survive must not be left to endure grinding poverty and hardship as international attention moves on: commitments to ongoing support should be made now in line with States’ legal obligations.
See: http://www.who.int/mediacentre/news/ebola/8-september-2014/en/
See speech made by Dr Margaret Chan, Director General of the World Health Organisation to the Security Council made on 18 September 2014, available at: http://www.who.int/dg/speeches/2014/security-council-ebola/en/
WHO Director-General addresses UN Security Council on Ebola, 18 September 2014. See: http://www.who.int/dg/speeches/2014/security-council-ebola/en/
See: http://www.who.int/mediacentre/news/statements/2014/ebola-roadmap/en/
See for example, http://www.who.int/mediacentre/news/ebola/overview-august-2014/en/
See http://www.who.int/mediacentre/news/ebola/8-september-2014/en/
See: UN News Centre, http://www.un.org/apps/news/story.asp?NewsID=48746
Article 2(1) of the International Covenant on Economic Social and Cultural Rights provides that “Each State Party to the present Covenant undertakes to take steps, individually and through international assistance and co-operation, especially economic and technical, to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant by all appropriate means”. Article 12 of the Covenant guarantees the right to health for everybody within a State party. The Covenant has been ratified by 162 states.
http://www.un.org/sg/offthecuff/index.asp?nid=3531
For example, China and the USA have made contributions http://www.who.int/mediacentre/news/statements/2014/chinese-ebola-contri...http://www.who.int/mediacentre/news/statements/2014/usa-ebola-support/en/
http://www.who.int/dg/speeches/2014/security-council-ebola/en/
http://www.nytimes.com/2014/09/18/world/africa/ebola-world-bank-west-afr...
WHO: Ebola Response Roadmap Situation Report 3, 12 September 2014 See pages 4 and the table on page 5.
http://www.theguardian.com/society/2014/sep/14/ebola-outbreak-fourth-doc...
WHO, ‘Unprecedented number of medical staff infected with Ebola’, 25 August 2014. See: http://www.who.int/mediacentre/news/ebola/25-august-2014/en/
The WHO Ebola Response Roadmap makes many suggestions along these lines, including on remuneration, training, equipment and medical care for health workers, and the need for personal protective equipment. See pages 10 & 11, http://apps.who.int/iris/bitstream/10665/131596/1/EbolaResponseRoadmap.p...
See: VOA News, ‘Ebola Has Devastating Impact on Children in Liberia’, 12 September 2014, at http://www.voanews.com/content/ebola-has-devastating-impact-on-children-...
The figure of 75% is attributed to the Liberian Ministry of Health,. See: VOA News, ‘Ebola Has Devastating Impact on Children in Liberia’, 12 September 2014, at http://www.voanews.com/content/ebola-has-devastating-impact-on-children-... A report by UN Women noted that the Liberian Ministry of Health and Social Welfare had put the figure at between 55 and 60% See: http://www.unwomenwestandcentralafrica.com/news1/ebola-toll-on-women-app.... The different percentages were given at different times, with 75% referred to in an early August briefing and the lower percentages (but still majority of those affected) referenced by officials in September. http://www.unwomen.org/en/news/stories/2014/9/ebola-outbreak-takes-its-t... This statement by UN women puts the figure of women dying in Sierra Leone at 59% http://www.independent.co.uk/news/world/africa/ebola-virus-outbreak-this...
There is little data available for the current crisis. The gendered vulnerabilities to infectious diseases, including Ebola, are discussed in World Health Organization, Addressing sex and gender in epidemic-prone infectious diseases’, 2007, ISBN 978 92 4 159534 6.
World Health Organization, Addressing sex and gender in epidemic-prone infectious diseases’, 2007, ISBN 978 92 4 159534 6.
See: http://www.parliament.gov.sl/Portals/0/BILLS/PUBLIC%20EMERGENCY%20REGULA... %20AUGUST%202014.pdf
http://www.dw.de/msf-sierra-leone-lockdown-will-not-stem-ebola-spread/a-...
See ICESCR General Comment 14 which describes the legitimate contexts in which states can take measures which may limit the exercise of other fundamental rights. “Issues of public health are sometimes used by States as grounds for limiting the exercise of other fundamental rights. The Committee wishes to emphasize that the Covenant’s limitation clause, article 4, is primarily intended to protect the rights of individuals rather than to permit the imposition of limitations by States. Consequently a State party which, for example, restricts the movement of, or incarcerates, persons with transmissible diseases such as HIV/AIDS, refuses to allow doctors to treat persons believed to be opposed to a government, or fails to provide immunization against the community’s major infectious diseases, on grounds such as national security or the preservation of public order, has the burden of justifying such serious measures in relation to each of the elements identified in article 4. Such restrictions must be in accordance with the law, including international human rights standards, compatible with the nature of the rights protected by the Covenant, in the interest of legitimate aims pursued, and strictly necessary for the promotion of the general welfare in a democratic society.”
http://allafrica.com/stories/201408151535.html
UN Code of Conduct for Law Enforcement Officials, Adopted by General Assembly resolution 34/169 of 17 December 1979, Article 3
UN Basic Principles on the Use of Force and Firearms, principles 5 and 9.
http://www.worldbank.org/en/news/press-release/2014/09/16/ebola-world-ba...
http://www.worldbank.org/en/news/press-release/2014/09/17/ebola-economic...
This has been emphasised by the UN Committee on Economic, Social and Cultural Rights in its General Comment 3 on the nature of States Parties Obligations when it notes in particular the importance of the Declaration on the Right to Development adopted by the General Assembly in its resolution 41/128 of 4 December 1986 and the need for States parties to take full account of all of the principles recognized therein. It emphasizes that, in the absence of an active programme of international assistance and cooperation on the part of all those States that are in a position to undertake one, the full realization of economic, social and cultural rights will remain an unfulfilled aspiration in many countries.