In recent years, numerous ‘wake-up ‘ calls have been issued to alert the global community to the urgent and pressing needs of fragile states. In 2013 World Bank President, Jim Yong Kim, stated that the lack of progress for many fragile states “should be a wake- up call to the global community not to dismiss these countries as lost causes,” and that “timely and critical support [is needed] to improve the lives of people living in these fragile countries”.

So, what do we need to wake-up to this time? The Ebola Virus Disease, rather than mysteriously appearing at random, has emerged in regions with compromised local economies and weak public health systems. Guinea, Liberia, and Sierra Leone are struggling to cope with the epidemic that has shattered communities.  But this is not new as previous outbreaks occurred in the fragile states of Northern Uganda, the Democratic Republic of Congo and South Sudan, also regions where poverty drives people to survive by travelling further into forested areas to find food and fuel and thus exposing themselves to Ebola virus. 

The difference with earlier Ebola outbreaks is that the virus was contained in the locality of the outbreak. The question now is why has the virus been able to spread so rapidly throughout border regions and then from these more remote areas to their respective capital cities?  Within fragile states are even more fragile sub-national regions, remote not only geographically from national capitals but also remote from the notice of those in power. These particular border areas were notoriously neglected in general, but in this case, inadequate numbers of health personnel, surveillance systems, diagnostic facilities, isolation wards and protective equipment meant that all three health systems were slow to recognise and respond to the crisis before becoming overwhelmed. These fragile areas within fragile states are also more connected to other areas and capitals through roads and trade than before. The combination of greater connectivity, marginalization, and weak institutions proved to be toxic.

The cases of Ebola in the U.K., Spain and Texas, however, show that even well prepared public health systems can make grievous errors in recognising the Ebola Virus Disease. The nonspecific nature of the symptoms could be mistaken by health workers as influenza, or, in Africa, for malaria, typhoid, or in the West African region, lassa fever.  The key to timely action relies on the ability of local health workers to recognise a potential outbreak and to report it to the Ministry of Health. The ability to swiftly recognise cases, trace contacts, and isolate infected and exposed patients relies on the capacity of the health system, which in Guinea, Sierra Leone and Liberia, was revealed as dysfunctional.  

Health facilities in Sierra Leone, for example, are chronically understaffed by poorly trained, overworked healthcare personnel. Only a fraction of Sierra Leone’s 136 doctors are trained in infectious disease control. They are working in conditions that are not supported by adequate logistics. The basics of sanitation, electricity and personal protective equipment to ensure the safety of health workers from infection are not always available when required.  Furthermore, training has been done during the outbreak instead of before, in preparation of a potential outbreak. Local diagnostic capacity was also low, although this is now being slowly rectified.

The encounter between affected and frightened communities and a functional health system is equally important in controlling such outbreaks. However, the time to build trust and better communications between the health system and the community is not during an epidemic when fear and panic are high. This needs to be in place before these events and is part of building a responsive and resilient health system. In Sierra Leone today, high levels of distrust have led communities to avoid health facilities, associating them with the virus, relying instead on traditional healers or self-medication.

The UN Secretary General, Ban Ki-moon, described this in mid 2014 as the “biggest global health threat since AIDS” and the international response “inadequate”. The World Bank committed $400 million, and the IMF gave $130 million in emergency financing. More than a cheque, the region needs people to fight this epidemic and to build a more resilient health system.

The call to action is urgent – and needs to be heard.



Suzanne Fustukian

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