Ebola does not stop at the border!



A closer look at the UNOCHA situation report maps reveals that the outbreak is concentrated in the cross-border areas of three Mano River Union countries; half of all victims are Liberians. There is no operational health system in place in these rural areas traversing three countries. The origin of the Ebola outbreak makes it fundamentally a cross-border concern. Nevertheless, the calls for help and the responses primarily take a country-by-country approach. Ebola does not stop at the border - the response must therefore take into account the regional dimension. 

It is also important to invest in capacity-building initiatives, in order to build African organisations that are able to effectively respond to this type of crises and more importantly, to anticipate them. ECOWAS needs to further develop its strategic planning capacity to co-ordinate a timely regional response and convince member countries to think and act regionally.

by Julia Wanjiru, 29 September 2014

also read: Ten facts about Ebola


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Ebola, a regional challenge

With the world preoccupied with the Gaza crisis, air strikes against ISIS in Iraq, conflict in Ukraine, there is little time to focus on the major public health crisis the West African region is currently experiencing in its desperate fight against the worst Ebola virus outbreak in history. Yet US President Obama took time to record a short video to deliver his message directly to West Africans: “Stopping this disease won’t be easy but we know how to do it; you are not alone.”

With his decision to send medical equipment and establish a 3 000 troops military command centre in Liberia, he sent a sign of hope to many West Africans who feel desperate about the world’s timid reaction to the crisis. As of 20 September, 2 900 people have died since the beginning of the Ebola outbreak and the epidemic is still far from being under control.


Ebola is not just a national tragedy for Liberia, Sierra Leone and Guinea; the crisis also heavily affects the whole West African region. It will pay a heavy price, not only through the death toll, significant economic loss and the impact on food security. The Ebola epidemic also adds to the list of negative “events” for which the region is sadly making headlines and which are damaging the region’ s reputation: Boko Haram, Al Qaeda, Islamist insurgency in the Sahel, criminal networks, human trafficking, piracy in the Gulf of Guinea, etc;

Despite these challenges, West Africa is a region with a lot of potential; a region that is spearheading the regional integration agenda on the African continent; a region that could further capitalise on its economic powers, with Nigeria being the continent’s largest economy and Côte d’Ivoire and Ghana positioning themselves to become emerging economies.

The Ebola outbreak is a significant setback. However, the epidemic should help the region to boost its solidarity and act united as a group.



Why is Ebola so difficult to contain? 

The first cases of Ebola can be tracked back to as early as December 2013, but the beginning of the epidemic is often traced back to 23 March 2014, when the Guinean authorities confirmed a local outbreak of the Ebola Virus Disease (EVD). Six months into the outbreak, isolation centres and hospitals are overwhelmed and the already fragile public health services have completely collapsed.

Doctors Without Borders (MSF) in Sierra Leone reports that they have to turn away Ebola patients simply because they do not have sufficient bed capacity. Health workers at a state-run Ebola treatment facility who risk their lives every day – have gone on strike to claim the payment of their wages: USD 50 per week. However, providing funds is clearly not enough. “We need urgent medical equipment, not in a month or so but in the days to come”, says a MSF health worker on the ground.

Following a decade of conflict, Liberia and Sierra Leone have the weakest health sectors on the African continent. The two countries have just 0.2 and 0.1 doctors per 10 000 people respectively (compared to the average 2.6 in West Africa and 240 times that number in the United States – source: MSF). Life expectancy at birth in Sierra Leone is just above 45 years; 182 out of 1 000 children die before reaching the age of five. 36% of under-five-year old children are stunted; and 21% are underweight. People die of diseases which could be easily treated, simply because they cannot afford proper treatment. A country that is not able to provide basic health services to its citizens in “normal” times can hardly be expected to perform better when fighting against the deadly virus of the world‘s worst Ebola outbreak. 


Due to the lack of basic response capacities, a local epidemic which could have been quite easily confined to a restricted area - has now evolved into a global health emergency.

In her state of nation address of 30 July, Liberian President Ellen Johnson Sirleaf declared the state of national emergency and presented a national action plan to cope with the crisis.

Furthermore, in a CNN interview, she called upon the international community to help Liberia address its “national tragedy”: “We need everything. We need preventive care, we need ambulances; more importantly, we need human assistance; we need technical assistance, doctors, nurses, experts who can train our own people. […] We have already taken a lot of preventive measures: we have quarantined places. We have closed schools; we have closed our borders, we have closed markets; we have done everything we can but what we have done is just not enough. […] This is an international crisis and I hope that the international community will respond to it.” 

Estimates of future causalities vary between 20 000 to up to 1.4 million new infections by end January 2015. According to the UN, the outbreak has moved from rural to urban areas, doubling the number of cases within three weeks.

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The West African response

Neighbouring countries first adopted protectionist measures by closing their borders with Guinea, Liberia and Sierra Leone. Some African airline companies shut down their flight connections with Ebola-affected countries. After the initial panic, preventive measures have been put in place in many West African countries: systematic screening procedures at airports and land entries; information flyers, TV spots and radio broadcasts dedicated to Ebola preventive measures. Many major cultural events such as the Panafrican Film and Television Festival of Ouagadougou (FESPACO) or the International Art and Craft Fair (SIAO) have been postponed. The government of Ghana decided not to host any meetings for a three-month period.

Despite these preventive measures, “fear is spreading even more quickly than the virus itself.” West Africa is living a collective psychosis; people avoid travelling and refrain from shaking hands, attending public meetings or cultural events. Sometimes simple rumours undermine medical support and can even lead to deadly consequences. Many people are now dying in countries not affected by Ebola, because they no longer seek treatment in hospitals out of fear of getting infected with Ebola.

ECOWAS Commission President Ouédraogo recalled:"The spirit of oneness and solidarity is the essence of ECOWAS and we should not lose the very foundation of our community because of this epidemic."

The initial response to the Ebola crisis was largely West Africa-driven.

The West African Health Organisation (WAHO) was the first to hold an experts committee meeting on Ebola and its impact for the region. Ebola was on the top of the agenda of all ECOWAS Heads of State summits, health ministerial and defence chiefs meetings, etc. ECOWAS leaders decided on 10 July to set up a Regional Solidarity Fund to raise money for a regional Ebola response. Nigeria contributed USD 3 million to Guinea (USD 500 000), Liberia (USD 500 000), Sierra Leone (USD 500 000), WAHO (USD 500 000) and to the ECOWAS Pool Fund for Ebola (USD 1 million). The government of Ghana has offered to the WHO and international partners to become the logistic hub for the dissemination of medical equipment in the sub-region. Ghana’s Minister of Health, Dr Kwaku Agyemang-Mensah, called for harmonisation of individual country’s efforts to avoid panicking. ECOWAS Health Ministers are currently finalising an Ebola Regional Operation Plan, calling for the implementation of humanitarian, economic and health corridors, adequate financial incentives for health workers and harmonised sensitisation and information messages. The UEMOA Commission has granted on 25 September for each of its member countries a subsidy of 60 million CFA francs (EUR 0.9 million) to boost preventive measures. CILSS is planning to assess the impact of Ebola on the region's fragile food security situation. 


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The international response

Doctors without borders (MSF) repeatedly warned the UN and Western powers about the risk of spill over to other African countries and regions, and ultimately to other continents. Further international attention was drawn to the Ebola crisis when two American health workers received experimental treatment in the US and survived the disease.

On 8 August, WHO Director General Dr Margaret Chan declared the current outbreak of the Ebola Virus Disease a “public health emergency of international concern”. The WHO acknowledges the “serious and unusual nature of the outbreak and the potential for further international spread, but also the need for strong international co-ordination of the response.” 

Fear is rising that Ebola could potentially reach European or American shores. "Could the Ebola outbreak spread to Europe or the U.S.?"“Should we be worried about the Ebola outbreak?”, are the typical questions answered by specialised Western agencies responsible for disease control and prevention which all highlight: The risk to the general public from Ebola remains very low; Western countries have generally good diagnostic and isolation facilities.

The Ebola epidemic is no longer a West African problem but considered to be a global scourge that must be addressed through a swift, well-co-ordinated international response.

Altogether more than USD 1 billion is being channelled into one of the world’s poorest regions. But it is not all about money: “Human resources are clearly our most important need", the WHO has noted. It remains difficult to mobilise well-trained human resources for such a scary disease in a region that is already suffering from a lack of medical staff. Despite all efforts, the WHO warned on 12 September that “the disease is still outpacing the international response to contain it”.

International commitments in the fight against Ebola

Indicative, non-exhaustive information as of 29 September 2014

  • The EU reaffirmed its “partnership and solidarity with West Africa” within its Europe-wide response to the Ebola epidemic”, including  EUR 181 million in financial commitments. 
  • In the US, the White House published on 16 September its four goal strategy. U.S. Africa Command will set up a 3 000 troop-strong Joint Force Command headquartered in Monrovia; re-programming of USD 500 million + additional USD 88 million from Congress for the fight against Ebola, including USD 58 million for the development of experimental treatments; plans to create 17 health-care facilities with roughly 100 beds each; training for 500 health care workers per week.
  • The World Bank Group is mobilising a USD 230 million financing package for Liberia,  Sierra Leone and Guinea, including a USD 117 million emergency response. The aid package was upgraded to USD 400 million on 25 September 2014. > fact sheet
  • The African Development Bank Group (AfDB) approved on 18 August a USD 60 million grant investment as part of a USD 210 million package for immediate implementation to “help strengthen West Africa’s public health systems in response to the Ebola crisis”.
  • Canada’s initial financial contribution totaled USD 2.5 million in support of humanitarian and security interventions in Guinea, Liberia, and Sierra Leone. Canada has also sent a mobile lab to Sierra Leone to do rapid testing, as well as donated 800-1000 doses of an experimental vaccine for the Ebola virus or "VSV-EBOV". > fact sheet | Le Monde announced that Canada's support totals CAD 27 million.
  • China intends to set up a mobile laboratory composed of 59 experts in Sierra Leone and has already shipped medical equipment to Guinea.
  • Cuba is preparing  to send a 165-strong medical team to affected countries, now enlarged to 461 medics.
  • France announced plans to set  up a military hospital in Guinea in addition to its EUR 9 million support for Guinea. Le Monde announced that France's support totals EUR 70 million.
  • Germany announced logistical help for Liberia. According to Spiegel, as of 10 September 2014, Germany's support was scaled-up to EUR 10 million
  • Japan has extended USD 5 million in emergency aid grants and intends to send up to 23  Japanese medical experts to affected countries. Its support totals USD 40 million. 
  • Switzerland’s total contribution since the first Ebola outbreak in March 2014 stands at CHF 3.65 million. > fact sheet
  • The UK is setting up an Ebola Treatment Centre in Sierra Leone which is part of a £ 5 million  package of assistance for humanitarian actions + £ 20 million structural support via multilateral agencies.
  • The Bill Gates Foundation announced on 10 September that it will commit USD 50 million “to support the scale up of emergency efforts to contain the Ebola outbreak in West Africa and interrupt transmission of the virus”.

Ebola survivor Dr Kent Brantl openly charged that the response to the Ebola crisis “remained sluggish”. “The World Health Organization has laid out a roadmap […], but they are so bound up by bureaucracy that they have been painfully slow and ineffective in this response”, he said.  

For World Bank President Jim Yong Kim, the world's "disastrously inadequate response" to West Africa's Ebola outbreak means many people are dying needlessly”.

“Everyone underestimated this disease from the very beginning; the crisis has been minimised, considered to be a local problem, and the international response has been slow and inadequate", said AfDB President Donald Kaberuka in an interview with the French newspaper Le Monde in September. "If the epidemic was declared as a humanitarian crisis at the beginning of the outbreak, as was the case for example, after the earthquake in Haiti in 2010, the situation would be different. Today, international awareness is being raised, countries respond to the crisis but we need to further mobilise”, he added.

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Looking ahead

Ebola has evolved from a local cross-border crisis into a regional and now global health emergency. It is more effective and less costly to act in time on the right scale. In the aftermath of the crisis, it is important to analyse the structural deficiencies in the most severely affected countries: Why have the states failed to provide basic health services for all their citizens? How has past development aid been spent in the health sector? How can trust between citizens and the political elite be effectively rebuilt? It is much more cost-efficient to invest in prevention; making sure that minimum standards are met; building local capacity to provide basic health services, etc. rather than spending billions of dollars to tackle structural problems once they run out of control.

Ebola does not stop at the border; the response must therefore take into account the regional dimension. It is important to invest in capacity-building initiatives, in order to build African organisations that are able to effectively respond to this type of crises and more importantly, to anticipate them. ECOWAS needs to further develop its strategic planning capacity to co-ordinate a timely regional response and convince member countries to think and act regionally. For example, WAHO should play a much stronger co-ordination role which must be better visible to  ECOWAS citizens and also on the international scene. National action plans, preventive measures and Ebola treatment centres must include nearby located border communities. Information campaigns must also promote regional solidarity with affected countries, in order to effectively calm fear and prevent discrimination and collateral damage. Public awareness building must be adapted to the cultural context: “When people were told at hospitals that no vaccine or medication could protect them from Ebola, they preferred to visit traditional healers", reported Guinea's health minister. 

As long as there is no cure or safe vaccine, the key focus must of course remain on saving lives and preventing new infections, including in cross-border areas. After six months of talk, there is still little concrete support implemented on the ground. Health workers confront immense challenges: Fighting Ebola is like “fighting a forest fire with spray bottles", says a health worker of Doctors Without Borders. Nevertheless, they pursue their fight against time on the frontlines under often very basic conditions, true heroes of this health emergency. One can only hope that once the Ebola outbreak is under control, tangible lessons will be learned from this crisis, and there will be no return to business as usual. Otherwise, "Ebola will simply come back." 


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