The assigned case study is about Ebola control in Sierra Leone and Northern Uganda, which are two countries in Africa affected by civil war. McPake et al. (2015) describe how conflict and wars have made it difficult to have a strong health care system in the two nations, thereby making it difficult for them to have a rapid and effective response to global epidemics, such as Ebola. Evidence is given to show how Sierra Leone and Northern Uganda suffered civil strife in the 1990s and how the conflicts made them ill-prepared for managing the Ebola crisis when it occurred. The response and role of global health institutions are also analysed to understand how they influenced the response of these countries to such epidemics. Comparing the management of Ebola in Northern Uganda (in 2001) to the management of the same epidemic in Sierra Leone (in late 2015 to early 2016), we find that the two countries had different success rates. The case study also highlights how international global health institutions and different elements of conflict in the affected societies came together to contain the disease, as it happened in Uganda in a matter of days, or as was the case in Sierra Leone where it took months.
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This essay will provide a brief description of the case study and discuss different aspects of the health problem, including a succinct understanding of Ebola as a global epidemic, its transmission methods, and its preventive mechanisms. Backed by literature explaining how health agencies have controlled it in several conflict-affected areas, this essay will also highlight how different social, political and economic factors concerning conflict and wars affected Ebola control in Sierra Leone and Uganda. Lastly, this essay provides a conclusion and recommendation section, outlining the main points and solutions of our analysis.
Summary of the Case Study
Conflict and its aftermaths are some of the main reasons for the rapid spread of Ebola in Sierra Leone and Uganda, in 2001 and 2014/2015, respectively (McPake et al. 2015). The Sierra Leone conflict started in 1991 and lasted for 11 years. It left more than 50,000 people dead after opposing political and military forces fought for control of government (Ebenezer 2016). Affecting large swaths of territory to the northern and southern parts of the country, the civil war led to the collapse of the nation’s health infrastructure and the breakdown of health services in the country (O’Hare 2015). Many people fled their homes, livelihoods were disrupted, and sanitation services broke down (McPake et al. 2015). The same was true for Uganda because, for more than 20 years, the country suffered from a conflict, which saw many lives devastated, and the region’s health care system destroyed (IRIN 2017). More than 1.8 million people were displaced and tens of thousands mutilated, raped, or suffered other forms of travesty by the rag-tag militia group – Lord’s Resistance Army (LRA) (Jagielski 2012).
The conflict led to the outbreak of Ebola in Northern Uganda and Sierra Leone because the countries’ health care systems were too weak to detect, or even respond to the crisis (McPake et al. 2015). Furthermore, many of the residents in these countries were at risk of infection because their livelihoods were disrupted (Marc, Verjee & Mogaka 2015). The uncertainties associated with the 2001 case of Ebola in Northern Uganda highlight some of these problems because it was difficult to establish where the disease started, or who had been in contact with the affected persons in the first place (IRIN 2017). Lost records, a depleted workforce, poor health infrastructure and weak national and regional health governance systems are some of the problems associated with conflict that finally led to the rapid spread of the disease (O’Hare 2015).
Health reports show that Ebola-affected 425 people, but killed 224 in the 2001 Ugandan outbreak (McPake et al. 2015). Comparatively, there were 3,955 deaths in Sierra Leone, against a backdrop of more than 14,061 confirmed infections (Hoyt 2017). Based on the scale of infections and deaths in the two countries alone, we find that Northern Uganda contained the disease much better than Sierra Leone did. Part of the reason for this outcome is the existence of a functional government in the South of the country. In fact, IRIN (2017) says there was a well-coordinated response system at different levels of the country’s health care system that effectively managed the outbreak. Here, it is important to point out that Southern Uganda has not been affected by conflict. In fact, stable governance arrangements allowed effective coordination of international agencies to respond to the outbreak, thereby preventing the rapid spread of the disease (IRIN 2017).
Comparatively, aid-coordination problems affected the international response to Ebola in Sierra Leone. The West African country also lacked strong hospitals that would coordinate rapid response operations, thereby leading to the further spread of the disease (Hoyt 2017). In Uganda, there were non-governmental hospitals operating in the country, which could effectively respond to the outbreak (Namakula, Witter & Ssengooba 2016). For example, St. Mary’s Lacor Hospital, in Gulu, coordinated emergency efforts in Northern Uganda, thereby giving people an alternative to government hospitals, which were dilapidated and unable to contain the crisis (Namakula, Witter & Ssengooba 2016). Generally, the case study on Northern Uganda and Sierra Leone Ebola outbreaks have implications for the type of health investments that should be made towards responding to such health disasters at regional, national and international levels.
What is Ebola?
According to the Centres for Disease Control and Prevention (2016), Ebola is a haemorrhagic fever caused by a virus that goes by the same name. The virus mostly attacks human beings but can have adverse health effects on primates, such as monkeys and chimpanzees, as well. It is mostly concentrated in several African countries (the first known case of infection happened in 1976 in the Democratic Republic of Congo) (SF Dept of Public Health 2016). Since the first case was reported, the virus has caused several sporadic epidemics in different parts of the continent. The World Health Organization (2016) says that there had been 24 outbreaks from 1976 to 2013. These outbreaks led to 1,716 cases of confirmed Ebola infections. The largest outbreak occurred in 2013 and lasted up to 2016 (World Health Organization 2016). Concentrated in West Africa, the epidemic led to more than 11,000 deaths, against a backdrop of more than 23,000 cases of infections (Marc, Verjee & Mogaka 2015).
Causes of Ebola
Ebola infections in human beings stem from four of the five strains of the virus. The four strains are Bundibugyo virus (BDBV), Sudan virus (SUDV), Taï Forest virus (TAFV) and Ebola virus (EBOV) (Centres for Disease Control and Prevention 2016). EBOV is known as the most deadly strain of the virus. In fact, experts attribute most of the outbreaks reported in Africa to the strain (SF Dept of Public Health 2016). The Reston virus is known as the least harmful strain because it mostly causes diseases in other primates, but not to human beings. The virus is transmitted through contact with fluids from an infected person. It would ordinarily enter a person’s body through broken skin and membranes in the eyes, nose or mouth (World Health Organization 2016).
Ebola Prevention and Control
Ebola is a deadly disease because it kills people quickly and there is no vaccine available to treat it. Therefore, the focus of all health agencies is to prevent transmission through quarantining infected patients and preventing uninfected people from getting into contact with fluids from infected parties (Hoyt 2017). The preventive measures also include restricting travel to affected areas. This precautionary measure was applied by many western countries during the 2016 Ebola outbreak by cautioning their citizens from travelling to West Africa. The precaution was also given to health care personnel to wear protective clothing, such as gloves, gowns and goggles when treating Ebola patients (Ellis 2015).
Using infection-control measures is a standard procedure for medical personnel operating in the affected zones. However, the availability of such equipment, or even citizen education about such practices, is a daunting task in countries ravaged by war and affected by health care system underfunding, as was the case in Sierra Leone and Northern Uganda (Hoyt 2017). International organizations often come to supplement health efforts whenever there are such inadequacies. However, even with such goodwill, there needs to be sufficient, steady and steadfast government support and health infrastructure to accommodate or absorb, such inputs from the international community (O’Hare 2015).
One factor that confounded Ebola management efforts in Sierra Leone was insufficient government goodwill. Bureaucratic red tape also failed to facilitate the integration of international help in the country’s Ebola control plan. For example, Nossiter (2014) reports that international well-wishers sent $140,000 worth of equipment (gowns, gloves and other protective equipment) to Sierra Leone at the height of the crisis. However, because of government ineffectiveness, they were left unused at the port for more than three months because of delays in cargo clearing. Ironically, reports showed that Sierra Leone health workers suffered severe shortages in equipment supply (Nossiter 2014). In fact, some reports show that some nurses had to wear street clothes (Nossiter 2014). This challenge showed weaknesses in the government’s ability to integrate international help in its Ebola management plan.
Education and Empowerment
Education and people empowerment are at the centre of many epidemics (Ness & Lin 2015). The same is true for Ebola, as was witnessed in Sierra Leone and Northern Uganda. For example, evidence from Sierra Leone showed that high levels of illiteracy were problematic for health workers and authorities when managing the disease because they could not effectively get the required health information needed from local populations to manage the crisis (Ness & Lin 2015). Conspiracy theories helped to fuel the spread of the disease because some locals thought that the disease was caused by witchcraft. Others believed that local remedies could help cure it, while their proponents thought that Ebola was a product of “bad spirits” (Kuriansky 2016). Some of them refused to acknowledge its existence and went on with their lives, as if nothing was happening, thereby aiding in its spread (Ellis 2015). Most of these problems are caused by high illiteracy levels that stem from a country that has a broken education system. A holistic view of this issue reveals that during the civil war, the country’s education system was broken, exposing a generation of people to illiteracy.
Reports by international observers show an even greater impact of the civil war on Sierra Leone’s education system, because, in 2001, close to 70% of children who were supposed to be in school could not get an education (Ness & Lin 2015). This situation explains the low literacy levels among adults in Sierra Leone, which is only pegged at a paltry 39.1% (Ebenezer 2016). Broadly, these statistics show that the civil war had a big impact on the education standards of Sierra Leone, thereby creating a fertile ground for the growth of conspiracy theories about Ebola. The war also undercut the potential talent the country had to offer in terms of educating and training health care service providers who would have helped improve the country’s health care response to the disaster. The situation is the same in northern Uganda because education standards are relatively low, compared to the Southern parts of the country where there are law and order (Namakula, Witter & Ssengooba 2016). However, what is unique to this region is not only the breakdown of education services but also the use of child soldiers to fight wars in the region. Jagielski (2012) says that 28,000 children were kidnapped to fight in the civil war. In fact, Independent reports show that 80% of the fighters in the LRA army were children (Jagielski 2012). With such statistics abound, there were minimal investments made in the health or education sectors in both countries. This reason mostly explains why populations were unable, or unwilling, to collaborate with authorities to control Ebola.
Northern Uganda managed to contain the 2001 Ebola epidemic better than Sierra Leone did, despite having the same conflict dynamics as the West African nation. The services offered to the citizens were cost-effective, relative to the resources, inadequacies and limited government support available to the region. Nonetheless, the cost of preventing an outbreak in Sierra Leone and Northern Nigeria should not be high if the right investments are made in the right areas, or in critical areas of education and health infrastructure. More importantly, the need for making proper investments in health services cannot be overemphasized.
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In this paper, we have shown that Sierra Leone and Northern Uganda have been victims of Ebola outbreaks because they have weak health infrastructures and poor education systems that prevent them from detecting the disease early, or even containing it before it spreads. These problems come from decades of underinvestment in health care services, brought about by war and civil conflict. To address these challenges, both countries need to invest in their health infrastructure and possibly educate their citizens about Ebola and its prevention. The latter approach mostly means a greater investment in the education system. Sierra Leone needs to pay close attention to its bureaucratic policies for aid delivery and integrated health because international health agencies cannot supplement the government’s health response to future epidemics without political goodwill, or with the existing bureaucratic “red tape” in place. Broadly, Ebola control requires a concerted effort by all parties involved to manage future crises. However, this strategy needs to occur against a backdrop of proper investments in health and education.
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