Ebola Recovery: The Long View

[Written February 2015] While the Ebola crisis has quietly exited mainstream media and public interest (Figure 1), over 15,000, Ebola survivors [1], [2] struggle to regain a semblance of normalcy in a complex environment of pre-existing poverty and post-conflict dynamics. Each country heavily impacted by Ebola, Liberia, Sierra Leone, and Guinea has its own unique historical context which has influenced their ability respond to the Ebola crisis and plays an important role each country’s resiliency and recovery [3].

FIGURE 1

We are at a turning point in the Ebola epidemic in West Africa. With a steady downward trend of new cases (Figure 2) [4], and a current caseload of ~710 across all three countries (77% in Sierra Leone alone) , the situation is improving. The downward trend should not be interpreted to suggest that Ebola isn’t as deadly as it was before (it is), as the case fatality rate has not changed at all, remaining at an average of 60% across the three most impacted countries [5]. These data suggest it’s a time to not just continue the valiant effort of ending the epidemic but begin the process of recovery.

FIGURE 2

Recovery is a concept which at the very basic level gets us back to a baseline “normal”. However, recovery is often an afterthought – it is not on the agenda before and during an emergent event. Within most contexts, especially the developing world, “normal” isn’t good enough. Unlike a natural disaster, much of the damage in the context of Ebola Virus Disease, is not purely physical and visible in nature as we saw, for example, in the 2010 Haiti quake, 2014 Philippines tsunami, and the domestic impacts of Hurricane Katrina in 2005. That is not to say that these events did not have their own share of pre- and post- social inequities and poverty, but that we saw damage and could fix it by hauling off the rubble and making the “brick and mortar” repairs providing what amounted to an illusion of recovery. Ebola is fundamentally different.

Is disaster recovery on the agenda of Humanitarian Aid organizations and the affected governments? In a brief review of the allocation analysis from UNOCHA [6], out of a $3.2 billion budget of funded or allocated dollars for EVD, only $240,000 or 0.008% has been specifically set aside for recovery efforts. This is not to say that development and response dollars won’t be used for activities that may support recovery, but without the foresight, planning, and community involvement in how that money should be utilized, the recovery process will progress in a way that positively and productively impacts the regions which require the most assistance. Some good news - just recently the World Bank [7] pledged to contribute $650 million to the response and recovery efforts with goals of improving infrastructure, health systems, education, and agriculture. This dedicated funding stream is a step in the right direction.

Vulnerable populations are at a greater risk during this transition to recovery. According to UNICEF, more than 16,000 children lost their one or both of their parents or caregivers as a directly result of Ebola [8]. The pre-Ebola orphan population has increased by approximately 3,700 [9], under-utilization of pre- and post- natal care utilization has been noted and women and girls are subject to greater than normal violence and non-consensual sex. And with the economy devastated the underground transactions are likely to rise.

Disaster recovery planning should incorporate direct planning for the most vulnerable populations. Vulnerable populations, are often overlooked in recovery planning but require specific planning and accommodations for very specific needs. Children are vulnerable as a class but they are also powerful centers of action. If recovery planning is centered on children  community recovery will trickle up. Research has that a major predictor of community recovery is how soon children are able to return to school. Considering schools have been closed for an entire year in the country of Sierra Leone, we have yet to see how this will impact recovery and the long-term educational outcomes of this young population.

The central question to the issues presented is how do funders and disaster planners attend to and plan for the most vulnerable populations? The solution: support, fund, and bolster long-term programming by local grassroots organizations and the international organizations who had a strong in-country presence before the outbreak made the news. These organizations tend to have extensive local knowledge and experience which makes them agile, responsive, and culturally competent. They are able to navigate complex political relationships, work within social and cultural norms, which enables them to have a far greater impact. Funders and organizations on-the-ground need to focus on planning efforts which improve, above baseline, technological and social infrastructure, resilient communities, and continue to bolster local health systems.

Ebola and the Lost Children of Sierra Leone

Arriving at Port Loko, one of the largest towns in the north of Sierra Leone, is like reaching a country under siege. In the face of Ebola, the 500,000 inhabitants of this district have been sealed off from the world, stigmatized like a cellblock of criminals, and left largely to fend for themselves. Even to bring them food and schoolbooks, you need a government pass. And they are not alone. Counting other districts under quarantine, more than a third of the nation cannot move freely.

There is something chillingly familiar about the fear, suspicion and desperation I saw. The military checkpoints, the closing of schools and entire towns, people begging and queuing for scarce relief food all reminded me of a childhood in the 1990s I would rather forget — one of civil war, displacement and peril. Many people told me they thought today’s Ebola crisis was worse than the war, because at least we could see or hear the enemy then.

During two weeks in late October I was on a mission to bring food and supplies to a Port Loko orphanage where 39 children and one teacher had just completed a 21-day quarantine. In those three weeks, the children received no outside help. No food. No visitors. No games. No real schooling, despite the teacher’s presence; her task was simply keeping them alive.

“I’ve got nothing for these kids,” she told me. “They have nowhere to go. There’s no food, nothing.”

It made me realize that what may be in the shortest supply in Sierra Leone is hope for the future. Each day further into the epidemic, it becomes harder to imagine how to recapture time lost — not just in the caring of parents who have died, but in education when schools are closed, in income when people can’t work, in food cultivation and road-building when cash itself has run dry.

Ebola is not just a health emergency. It is a tragedy that has swept away fragile new roots for a new society, put down after the decade of civil war. While a vast majority of Sierra Leone’s 6.1 million people have not been infected, Ebola has loosed many other threats that will linger long after the virus is quelled.

The orphanage and Port Loko are emblematic. Every place I visited felt locked down, even in the ways people showed emotion. When I reached my mother’s home, she kept her distance — no hug or touch. “For your protection,” she said.

Perhaps the most tragic challenge is what is happening to Sierra Leone’s children while schools across the country are closed — at least until March, the government says, but that seems optimistic. I can understand the logic of closing schools during an Ebola outbreak to lessen the chances of contact with others. Still, I can’t help but wonder whether, in the short run, Sierra Leone’s children would be safer in schools than languishing at home, with very little food and almost no mental stimulation.

It is not as if they are safely alone. In fact, there can be as many as two dozen people — relatives, neighbors — sheltering together in a small house. And contagion from them is not the only danger. There are also widespread and sickening reports that girls, cooped up for weeks at a time, are being raped. This points toward a surge of pregnant teenagers, whose hope of reaching their intellectual potential by staying in school will be dashed. My mother, an elementary school teacher in Freetown, knows of at least four of her sixth graders who are pregnant. When she is outside and recognizes any of the girls she teaches, she worries they will be attacked sexually or exposed to the virus: girls especially, because their families are likely to press them into taking care of someone sick with Ebola.

The streets are not the place for girls, she says. They should be in school. But Ebola has killed many qualified teachers, who were in desperately short supply even before the epidemic. And the teachers who remain are forbidden to hold informal learning sessions because the government has prohibited gatherings of more than five people. (Curiously, though, authorities have allowed large groups of worshipers to go to churches and mosques.)

This presents a grave contrast to almost any other type of humanitarian crisis — even most wars. In those, one strategy is to keep children in school when possible; there, children have some protection from the turmoil outside, are cared for by responsible adults, and can be helped to build resilience against hardship.

Closed schools also mean more children will fall into illiteracy, which is already too high, and leave the society more vulnerable to future health crises. Sierra Leone’s Ebola victims include a disproportionate share who could not read the billboards and other public messages advising them how to stay safe.

The government is making some effort to broadcast lesson plans over the radio, but those boring programs don’t distinguish among grade levels or ignite a child’s spirit of inquiry. And, of course, the poorest families don’t own a radio.

Still, children instinctively crave learning, and I met many even under these awful circumstances. One group of girls, on their own initiative, had arranged a study club that met in order, as one girl said, to keep their minds alive.

At an official discharge ceremony of 41 patients who had been treated for Ebola, I asked two children what they most wanted now. First, they said, food. Then school.

I handed them a couple of bags, holding pencils, pens, paper, crayons and books. They were grateful. In those simple items, they saw hope.

Ebola and Women: Chernor Bah on the Impact on Girls in Sierra Leone

Chernor Bah, a global youth advocate and education activist from Sierra Leone, recently returned from a visit to his home country. He discussed his findings with Judith Bruce.

Judith Bruce is a policy analyst at the Population Council, whose work helps build the health, social and cognitive assets of girls in the poorest communities in the developing world. Bah was one of the founders of the Sierra Leone Adolescent Girls Network, designed to reach vulnerable girls throughout the country.

Bruce: You have recently returned from Sierra Leone. In the course of your visit you focused on the impact on girls, and you also met with political leaders and those who control important policy decisions related to the national response to Ebola. How did you explain to them that we should also be focusing on girls at this time?

Bah: Here’s why we should be focusing on girls at this time: Dorcas is 17 years old. Her mom contracted Ebola when treating a patient in the clinic where she was a nurse. Dorcas took care of her mom when she was sick at home. Her dad, her elder sister and her mom were all infected and admitted. At the hospital, after her mom and elder sister died, Dorcas was helping to take care of her dad – even in the ward where they were both sick. Her father eventually died. Dorcas survived. She is left with her two younger siblings, who have become her primary responsibility. She is now the breadwinner and without support might be forced to engage in risky behaviors to fend for herself and her family. She is also unsure of returning to school, as there is no one to take care of her or pay her [tuition] fees.

"Girls, who bear the biggest burdens, are the last to get anything."

Unfortunately, her story is not unique. Many of the 30-plus girl survivors of Ebola told me varying versions of a similar story. Girls in Sierra Leone are typically the primary caregivers in the home and in the community, especially for sick relatives.

Despite being primary caregivers, girls typically have less education and even lesser access to scientifically based information. And, despite carrying provisioning responsibility, they have less access to public services.

When emergency distributions are done in communities ... girls, who bear the biggest burden, are the last to get anything.

If we don’t begin with the girls, we won't get to them.

Bruce: We hear that there is a 70 percent mortality rate, but that also means 30 percent survive. How are female survivors being treated?

Bah: Girls who have survived Ebola are super girls. They are celebrated publicly for defeating the virus, but in their communities they have less social capital. They are stigmatized and have fewer friends; they might have lost parents, loved ones or benefactors, and have very little – if any – help from the government.

Fortunately, we mostly know who they are. If they have survived Ebola, it means they have been in a health clinic, where their data was recorded. Figuring out a way of first creating a support system for these girls will be crucial. Connecting them with each other in potential Ebola survivors’ clubs could be one way. It would provide social assets and capital, provide platforms to share their stories and support. They could also be powerful role models for girls, in a society where those are few and far between.

"As one girl put it to me, it’s not a very safe time to be a girl."

Bruce: Before Ebola, there was already a long-standing culture of sexual exploitation; that is, some girls depended on sexual exchange for basic necessities for themselves and their families. What is the situation now?

Bah: Every girl I spoke to expressed concerns about the increase in transactional sexual exploitation. In fact, girls in Port Loko, north of the country, which has been badly hit by the virus and is now under quarantine, told me that they have friends who are now pregnant and will never return to school. We have received reports of police officers – assigned to enforce the quarantine of households – sexually molesting young females. Bear in mind that typically during school holidays, when girls are at home, there is normally a spike in sexual abuse and exploitation and early marriage. Now you have communities that are shut down or economically depressed, men and young girls are home all day and no one knows when it’s all going to end. As one girl put it to me, it’s not a very safe time to be a girl.

Bruce: We’ve heard that many of the groups originally working on programs for girls have left the country or shut down their operations. Is that true?

Bah: Amid the shock of the epidemic, the government and the donors basically instructed that all programs that were not directly dealing with Ebola be shut down, and that funds all be redirected to fighting the epidemic. So these groups have, for the most part, been on the sidelines, watching helplessly as they see girls falling further behind. I worked with UNFPA (the United Nations Population Fund) to pull together a major meeting with the members of the network, and the first thing I should say was the sense of relief and excitement that they could come together to discuss how the virus was affecting girls and their programs. They were disappointed that their programs have generally been shut down, and many have been told they can’t proceed with their normal activities, including community outreach and other alternative social safety-net programs that they say are critical for the poorest girls they serve.

"Girls will drop out of school permanently during this long break in education."

Some fear a spike in sexual violence and the exploitation of young girls, an increase in teenage pregnancy and forced marriages, an increase in fistula, an increase in maternal mortality and, of course, more girls will drop out of school permanently during this long, unprecedented break in education.

Bruce: How has the emergency affected policies and programs designed to reach girls and young women?

Bah: One of the critical challenges we often face in Sierra Leone is the invisibility of girls in national policies and programs. Youth programs, government policy and interventions – under normal circumstances – typically exclude girls. It gets worse in an emergency. As the president of the country told me in a private conversation, the government was shocked and overwhelmed by this epidemic, and has been playing catch-up ever since.

While in Sierra Leone I was able to review the Reproductive Health Strategy that was being proposed by the government and its partners to respond to the sharp decline in the availability of reproductive services during the outbreak. In some cases, there had been up to a 100 percent drop in the provision of basic contraceptive services for women and girls. The core concept of the strategy was to be the creation of 17 dedicated Reproductive Health Service Centers in each of the districts across the country, but it barely referenced the unique needs of girls or had mechanisms to foster their use of these services. Thankfully, working with the partners, especially UNFPA, we were able to review the proposal to include a stand-alone adolescent girls pillar. This will increase girls’ access to these services.