DRC Ebola Outbreak: Lessons from West Africa

SATURDAY INSIGHTS

By Terence Gibson

With a new outbreak of Ebola cases being announced last week in the Democratic Republic of Congo, I am reminded of early 2014 when I took up a position as a consultant physician in the largest hospital in Freetown. I was a volunteer member of the Kings Sierra Leone Partnership, dedicated to supporting the development of clinical services and both undergraduate and postgraduate education.

 In a country of just over six million people, there was an acute shortage of health workers and just 150 doctors nationally. For two months the pattern of my professional life was familiar; a mix of daily ward rounds, teaching and organizing seminars for house officers. The diagnostic facilities were poor and treatment options limited by availability and patients’ ability to pay.

In neighboring Guinea, an outbreak of Ebola erupted in March and cast a shadow over Sierra Leone. Ebola had never been seen in the region and the country and health infrastructure was not prepared for the seismic shock that was about to come.

Public posters did appear in May advocating that those with blood stained vomiting or diarrhea report to a hospital. These symptoms were amongst the least likely early symptoms of Ebola.

As cases trickled into the East of the country, to many in Freetown it seemed too distant to cause an immediate worry. Denial of the disease led to inaction. Amongst the first practical moves of preparedness in Freetown, the Kings Partnership, in collaboration with the hospital authority, converted a surgical observation area into an isolation unit, a step emulated throughout the city and neighboring districts much later.

By summer, denial was overtaken by panic as deaths mounted. NGOs packed up and left, schools and colleges were closed, airlines withdrew services. There was a shock when the national clinical lead against Ebola died of the disease, followed soon by one of my two physician colleagues. Health workers around the country began dying in disproportionate numbers despite increasing availability of protective garments.

The house officers at my hospital went on strike and many deserted. For the next several months the local medical workforce continued to decline until bolstered by clinicians from elsewhere. Ebola treatment centres began to appear run by international volunteers and supported by outside agencies and governments. But it was too late to avoid the spectacle of corpses lying outside and within the hospital as remaining staff bravely maintained an inpatient service for all the other diseases.

Separating and isolating suspected Ebola from the main body of patients was a risky priority and more doctors and nurses were to die while performing their duty. The isolation unit at the hospital where I worked was staffed by volunteer Sierra Leone nurses and health workers from the UK and elsewhere, sponsored by the Kings Sierra Leone Partnership. When cases were confirmed they were transferred to treatment centres of which there was only one in the first few months and that was a five-hour drive from Freetown.

By the end of 2014 the number of Ebola cases appeared to be reaching a plateau at the same time as isolation and treatment centres were expanding. As the number of beds grew so did the admission of suspects who proved not to have Ebola.

Throughout the epidemic, the many diseases sharing characteristics of Ebola such as fever, delirium or diarrhea were denied best treatment until cleared of Ebola. Many of those that died are not included in the official statistics, because they were hidden cases that involved secret burials.

Weak leadership and fear of offending the national pride of the Sierra Leone government may or may not have accounted for the invisibility of the WHO on the ground during this period. As a clinician who was there at the beginning and at the end, I was puzzled by the slow response of the WHO.

My only personal interaction with the organization was as the disease frequency was in decline and the number of WHO officials was increasing. A policy of quarantining all those who had contact with initially unsuspected positive cases unless wearing full personal protective clothing was introduced by WHO and enforced by the suddenly numerous and zealous officers on site.

Those of us who had been exposed inadvertently on several occasions survived because of simple infection control precautions and the monitoring of body temperature. We wished that they had been present six months earlier when the disease was running rampant. Then, strict quarantine and monitoring would have been sensible but now the measures were seen as too late to make any real impact.

For those of us involved in clinical care during this period, the role of WHO in leading the effort to contain and manage Ebola seemed chaotic from start to finish.

Ebola exposed a systemic failure at the highest level of the organization. Now that there is going to be a fresh head of the organization, there is an opportunity to ensure that such dilatory and inept behavior are not repeated should similar circumstances such as the Ebola pandemic recur.

To this end, a candidate with personal experience of clinical medicine and its challenges, who can translate this into policy across continents and who is unafraid of confronting national governments when appropriate should be appointed. As far as I can see, Dr. Sania Nishtar is the standout candidate that matches this criteria and would be an effective leader to deal with future Ebola outbreaks.

As well as accelerating the reforms within WHO, it is critical that we learn the lessons of past outbreaks and move quickly to stop the DRC outbreak and save lives.

––Dr. Terence Gibson is a Physician at Guys and St Thomas NHS Foundation Trust, London and was a Consultant Physician at Connaught Hospital in Freetown, Sierra Leone between 2014-16   

QUOTE:   By summer, denial was overtaken by panic as deaths mounted. NGOs packed up and left, schools and colleges were closed, airlines withdrew services. There was a shock when the national clinical lead against Ebola died of the disease, followed soon by one of my two physician colleagues. Health workers around the country began dying in disproportionate numbers despite increasing availability of protective garments. The house officers at my hospital went on strike and many deserted. For the next several months the local medical workforce continued to decline until bolstered by clinicians from elsewhere. Ebola treatment centres began to appear run by international volunteers and supported by outside agencies and governments. But it was too late to avoid the spectacle of corpses lying outside and within the hospital as remaining staff bravely maintained an inpatient service for all the other diseases

Amina Mohammed: Education, Right Skill, Key Ingredients for Closing Gender Gap in Work Places  

Despite many countries passing equal opportunity laws and adopting UN resolutions on women empowerment, education, access to finance, security, healthy environment, discriminatory pay packages, Kasie Abone, who just returned from World Bank-IMF Spring Meeting held in Washington DC, USA reports that until certain barriers are pulled down, achieving comprehensive economic development will remain a mirage

G

ender equity and its economic implications was one of the key topics that engaged delegates at the recently concluded World Bank IMF spring Meeting held in Washington DC, United States of America. The global issues which came under the theme “Gender and Macroeconomics: What Next?” had a team of high profile panelists that brought different countries and institutions perspectives on the causes and solutions to gender issues in work places. Among the panelists were former Nigerian Minister and now United Nations Deputy Secretary General, Amina Mohammed, IMF Managing Director, Christine Lagarde, Oxfam International Executive Director, Winnie Byanyima, Norway Minister of Finance, Siv Jensen and Coca Cola CEO, Muhtar Kent.

In their individual contributions, the panelists shared their experiences on the causes of gender inequality in work places and its dire implications on economies of nations while proffering solutions on ways to have more women engage in productive ventures with equal pay, security, equal education and access to finance.

Speaking on role of UN in bridging the gender gap, Amina Mohammed identified acquiring education and the right skill sets as some of the key factors necessary to pull down gender barriers in work places and women economic empowerment. She noted that UN had shaped a new developmental agenda over the last few years. She added that,  “It was clear that the consultations we had and the agenda we came out with in the STGs including businesses, and we challenged them on how we can move gender equality from STDs to MDGs and what do they need to take down in terms of barriers. And I think that much of what we have today are playing out in the implementation stages. So, finding government policies will incentivise that, pushing targets and indicators that we set not just for countries but for businesses and partners that are involved. That it makes good business sense; and there is economic dividend to open up the space for women at all levels.” She went further to say that “Incentivising the education because I think even if you get education, what type of education; what type of skill sets are you bringing to the work place. We can’t find women in certain positions because those skill sets are not there and that is why we have to start knocking at the door of education and development. We are work in progress. I think what we need now is how to put this into national plan; we have to deal with business, we have to open our space.  The really big challenge we have now is how to put this into national plan that will incentivise business.”

In her contribution, IMF Managing Director, Christine Lagarde, said IMF was committed to the inclusion of women and gender issues in its surveyance work. “We have decided not just to analyse, talk about it but to walk the talk. So, what we do now, we have 22 pilot countries which have agreed to include women issues, women inclusion in the job market, women contribution in the economy as part of the annual surveyance. And that has helped us identify for each and every one of them what policies, whether tax measures, fiscal measures, structural reform measures that can decide what will actually improve the situation of women. Another area we are pushing women is in our lending capacity in line with countries programs, and we have traction when we do that.”

She noted that IMF was working with Egypt where most women do not join the job market due to security issues and transportation. She added that IMF intervention in such situation was to ask the authority to earmark particular budget item to transport, security and childcare budget so women can participate in work places.

Speaking from the business perspective on how his company boosts women participation in leadership positions, Coca Cola CEO, Muhtar Kent, who described himself as a “proud feminist” said the situation he met on ground when he first became the CEO about eight years ago on women leadership positions was “terrible.”  In his words “When I first become the CEO almost nine years ago, I looked at who were the sharpest of our products. At this time we were connecting with our consumers years ago by 1.3 billion times a day, 66 per cent times women were the sharpest. And I looked at inside the company; the numbers for women leadership were terrible. In middle level management there were low 20s, in senior management they were in the tens. And so there was a big disconnect.”

To address this imbalance, he said his company embarked on a multi-year policy program aimed at promoting and incentivising women to leadership positions. “The whole idea was how they are going to break down the barriers, how do we hire, train, retain and promote women leaders in the company. Since the last eight years the numbers have gone up to mid-30 to mid-level managers and more importantly, the pipeline for women leadership has gone up to 50 per cent now.” The effect is an increase from two to four women in boards while working towards achieving parity in a board of about 13 members.

Coca Cola has also created the largest women empowerment programme ever undertaken by a commercial enterprise called five by 20 in its 206 global markets in 2010. The goal was to generate and create five million women entrepreneurs outside of the four walls of Coca Cola system. “We select women leaders, then train them in basic accounting, logistics, distribution, retain and connect them to a total of $200 million IFC credit. They get launched as farmers, distributors, retailers. We now have 1.7 million and we are on our way to reach the five million goal.

However, the situation varies from country to country. In Norway, where women in 2008 surpassed men in acquiring higher education with 40 percent representation in parliament, government anchors the drive for more women in work place on three major touch points, according to the country’s Finance Minister, Siv Jensen. These are free education up to university level which has enabled more women graduates, family friendly working life that has to do with parental leave for both parents, paid leave for sick children, flexible working hours; and the third element was affordable day care. With 90 per cent of Norwegian children in kindergarten at the moment, Jensen said it makes it easier for women to take part in the work place.

Executive Director, Oxfam International, Winnie Byanyima, in her presentation gave more insights into how women could be empowered besides education. According her, education was not much a factor in the informal jobs like trade, agriculture, unskilled workers, etc. “The big issue is to increase women participation in business and what can work for their rise in companies has much to do with corporate policies. When the policies put in place works for women to juggle the roles of the family and career, when they are given incentives to rise, targets and quotas in boards and senior leadership positions. But the big issue is that women are stuck in the middle by unpaid care work primarily.” She also concurred that countries with good child care policy, public transportation facilities, equal pay and healthcare facilities tend to have more women that stay in employment.

The Law And Women Equality

Inequality under the constitution surprisingly was identified to be a big issue even among civilised world. Lagarde revealed that IMF team found out that 90 per cent of advanced economies, developing, middle income economies countries of the world actually have sometimes in their legal system constitutional provisions that discriminate against women. She said when the constitution was changed to embed the principle of equality, the economy’s circumstances change, the participation of women in labour force and the perennial gender gap actually reduces. She added that a universal imperative was for each country to look at the legal system and from the top to the bottom decide that that has to change.

The challenge in changing the laws, according to Mohammed was that advocacy comes in the way. Since the men dominate the parliament, the decision to change the law by implication lies with the men.’ So, it comes to equal access, equality; how do we help the ones that understand that the law has to change in allowing that to happen. Until we get more women in parliament, in executive positions making the case for it, it will be still a work in progress.”

Practical Solutions to Closing  Inequality Gaps

Kent submitted that flexibility and creative architecture were also key elements in promoting women in leadership positions. With the digital high level of mobility among the leadership cadre, mobility could be taken care of. This has enabled Coca Cola to appoint for the first time two African American CFOs of Fortune 50 companies as well as appoint more women at high level functions because of intensity of mobility and travel countries to countries because of the children. With technology, Kent said in a few years, barrier of mobility and office spaces would be rid of as work could be done from anywhere at one’s convenience.

Byanyima listed changing the rules of economic model must change, promoting equality and reducing economic inequality, payment of minimum wage that counts towards a living wage, restoration of collective bargaining, unpaid care work, healthcare and care services, transport and using advertising to tackle social norms are some of the policy measures that should be put in place to close the inequality gap.

For Mohammed, though the policies are in place, there should be measures to incentivise the actions we get through the budget spending.” If we budget on education, how do we measure the outcome of the education we want to see; so in real practical terms, how do you help policies become actionable with the results; how do we incentivise those resources to make things work for women.”

She also suggested that part of the flexibility in work place could be investing in young women to own businesses so that they will have the flexibility to have family, career and to put money in their pockets; to make better families, communities for it. More importantly, breaking the barriers of access to financial solutions, technology, like the menfolk is key.

On her part Jensen said that when companies convert the huge number of women working part time to full time, companies will be raising their resources in addition to reducing the gender gap in the regional economy.