Ebola outbreak

The first case, “patient zero,” of the 2013-2015 EVD outbreak was identified in the Guinean border town of Guéckédou in late 2013 (Baize et al., 2014). EVD is transmitted through contact with the body fluids of an infected person and can lead to fever, headache, joint and muscle pain, weakness, diarrhoea, vomiting, rash, impaired organ functioning, internal haemorrhaging, and death. Within several months it had spread to Sierra Leone and Liberia, two post-conflict low-income countries with long-standing and growing inequalities of access to even basic health care. Without effective isolation, each EVD patient was estimated to transmit the virus to around one to eight additional people, leading to the exponential growth of infections approximately doubling every 20 days (Meltzer, 2014).

Figure 4.7 Confirmed, probable, and suspected EVD cases worldwide Notes: Sourced from (World Health Organization, 2016a)

What started as a West African public health emergency was then declared a global threat to international security by the UN Security Council and quickly became the worst EVD epidemic in recorded history. Unlike in previous outbreaks in central and eastern Africa, the virus soon spread over a wide area. In a region characterised by poor public health

infrastructure, high mobility across porous borders combined with densely populated urban centres and traditional beliefs driving high-risk health behaviours, the spread of EVD would eventually take the lives of 11,323 people (World Health Organization, 2016a).

The virus has since been brought under control, but the extent of the deaths, damage to the social fabric, economic loss, disruption to normal grieving practices, and stigmatisation that it caused still presents considerable challenges to the Sierra Leone population, and to providers of mental health support. The Ebola epidemic demonstrated how little capacity existed both in the local governments and international institutions to deal with crises of this kind and the need to strengthen health systems and provision. It also showed the importance of contextualised information about psychosocial needs when responding to a humanitarian emergency.

4.4.4.1 Traditional beliefs, fear and the spread of Ebola

There are a number of explanations for why this was the largest known outbreak since the discovery of the virus in 1976, and why it was so much more deadly than previous

outbreaks in central and east Africa. Several factors including the arrival of the disease in highly populated urban areas, poor health facilities, and a general lack of awareness of the disease among affected communities perpetuated the spread of the disease (Manguvo & Mafuvadze, 2015). Sometimes very practical issues played a part. For example, the difficulties of finding someone to care for their children or farm animals may have

discouraged people from seeking help, or from fear of not being able to obtain the necessary resources to see them through a quarantine period (Elston et al., 2016). In addition,

researchers (Elston et al., 2016; Manguvo & Mafuvadze, 2015) concur that the widespread traditional and religious practices among West African communities had tremendous negative effects on the spreading of the disease and difficulty encountered by the response.

An epidemic of fear in Sierra Leone led to suspicion and alarm surrounding the disease and contributed to its spread. In an opinion piece from Schultz, Baingana and Neria (2015, p. 567) authors explained that “the already resource-poor health care systems have been further challenged by myths and misinformation, often driven by erroneous news reports and inadequate public health messaging.” This was made all the more likely by early public health messages that there was no vaccine or cure for Ebola; people therefore felt that they were more likely to obtain effective treatment from non-biomedical sources. Findings from a survey of 1493 individuals from across 14 districts in Guinea showed that while a majority of respondents said that they did not know the origin of EVD, 21.1% blamed it on one or more of the government, scientists, politicians, international NGOs or miners (Polygeia, 2016).

The mistrust of public health officials dates back to Sierra Leone’s history as a British colony and more recent Western economic policies and projects that have left a legacy of suspicion of Western motives. Such distrust towards outsiders influenced community

reactions to the Ebola response. Where people attributed the virus to divine action or sorcery for communities not respecting traditional rules and prohibitions, this did not necessarily preclude seeking medical care, but often help would be sought first, or instead, from traditional or religious healers (Manguvo & Mafuvadze, 2015).

Even the simplest interactions between people with Ebola, their families and health- care workers were complicated by the precautions needed to prevent infection. Because doctors and nurses can wear their heavy personal protective equipment only for short periods, they focus on providing treatment. Tasks such as counselling bereaved families are often left to mental health providers from aid groups. Although severe illness and death were not new to the people of Sierra Leone, the sight of health workers in personal protective equipment and body removal teams was frightening.

West African health systems were severely disrupted and overstretched by the outbreak and their capacities were significantly reduced as almost 900 health care workers

were infected with Ebola and more than 500 died (van Bortel et al., 2016). In 2015, Elston and colleagues conducted health needs assessments in two districts of Sierra Leone to identify and quantify the impact of the outbreak on the health system (Elston et al., 2016). The fear and mistrust led to a breakdown in relations between the health system and communities was demonstrated leading to marked and significant reductions in utilisation of health facilities. In addition, to the direct losses of staff, there was a diversion of resources to the Ebola response across all levels of the health system from management to health care workers and disruption of essential programmes such as childhood vaccinations, HIV/AIDS, TB and malaria. People who needed treatment for other health concerns, for instance routine pregnancy or infections, were unable to access care. A recurring theme derived from almost all interviews was that health care workers felt that they had been let down by a health system that they perceive could and should have done more (Elston et al., 2016).

Table 4.3 Moyamba government hospital admissions

Notes: Sourced from (Elston et al., 2016)

Exposure to an emergency situation of any kind, be it a natural disaster, conflict situation or an infectious disease outbreak, has a devastating effect on psychological and social wellbeing of people involved. Populations exposed to emergencies are vulnerable to a range of stress responses, including posttraumatic stress disorder as well as complicated grief, depression, somatoform disorders, and drug and alcohol abuse (Silove et al., 2008). During the EVD outbreak people were vulnerable to psychological distress:

• At the point of diagnosis and afterwards, for the infected person and family members who might have to deal with fear, grief and coping with stigma • With the grieving process following bereavement, particularly due to the

disruption to customary grieving rituals which might have helped adjustment; • Following recovery from the virus, when stigma and fear of infection may

make it difficult to reintegrate into the community;

• And, for Ebola response teams who work with the infected and their families (Polygeia, 2016).

Table 4.4 Psychosocial effects of an Ebola epidemic

The absence of mental health services and the lack of well-trained professionals in Sierra Leone amplified the risks of enduring psychological distress and progression to psychopathology (Shultz et al., 2015). Already inadequate mental health services were

unprepared to cope with the increasing need. The Ebola outbreak led to more people reporting mental health and psychosocial problems (International Medical Corps Sierra Leone, 2014). The only psychiatric hospital in the country, the Sierra Leone Psychiatric Hospital (SLPH), was closed to admissions during the outbreak. Therefore, no government facility was available for those requiring mental health care. As part of the Ministry of Health &

Sanitation’s (MOHS) Ebola emergency response which aimed to improve access to care, co- ordinated with the help of the WHO Sierra Leone Country Office, the Government created mental health units in each of the 14 districts, called District Mental Health Units (DMHU).

The nature and extent of psychosocial needs in emergency situations are such that they may exceed the immediate coping capacity of the affected community to the extent that every-day resources are insufficient in order to be able to respond effectively (Saynaeve, 2002). The key psychosocial domains threatened by disasters include: interpersonal bonds and networks (e.g., family, kinship groups, community); identities and roles (e.g., parent, worker, citizen, social leader); and institutions that confer existential meaning and coherence (e.g., traditions, religion, political and social participation); security and safety (Silove et al., 2008). Van Bortel (2016) called for EVD response strategies that included communication, education, community engagement, peer support, resource mobilisation and prevention activities (e.g. risk assessment, psychosocial support) as well as mental health care. Establishing mental health services that addresses these domains can help to shape future mental health policy for countries experiencing and recovering from disaster.

Months after the first case in Sierra Leone, policy directives began to emphasise community engagement, coordination and mobilisation of social networks as a vehicle for

effective service delivery (Abramowitz & Kleinman, 2008; Kutalek, Wang, Fallah, Wesseh, & Gilbert, 2015). Published in September 2014, the WHO Ebola Response Roadmap dedicated one of four key pillars to social mobilisation (World Health Organization, 2014). This pillar was designed to engage and motivate a wide range of partners and allies at national and local levels to raise awareness of public health messages with the main objective to stop transmission of EVD. Recognition of the critical need to engage with local communities was apparent yet particularly challenging due to the widespread fear and mistrust.

But, in the context of Ebola using social strategies was especially challenging, as the spread of the disease is through human contact, and thus the MOHS outlawed all public gatherings (including funerals). Restrictions on how families and communities tend to ill loved ones disrupt human interactions that are considered necessary for healing and end-of- life care. Many survivors found themselves isolated, as a result of the stigma of having had the virus and the disruption of social networks caused by the deaths and disruption to communities. This was also compounded by the economic effects of the epidemic on livelihoods, with lost employment, possessions or position in the community leading to a decline in economic security and social roles (World Health Organization, 2014).

Even if people recovered from the virus, often their problems were not over. In Sierra Leone, social networks are an essential safety net, with the majority of care being conducted by close friends and relatives when someone falls ill. The death toll had already reduced social networks, but some Ebola survivors also found that they were not readily accepted back into their communities. Reintegration can be further complicated where survivors find their homes and belongings burned as an infection prevention measure, potentially leaving them destitute (World Health Organization, 2014).

Due to a sustained lack of investment in health systems, communities in developing countries are vulnerable to infectious disease outbreaks and their psychosocial repercussions (van Bortel 2015). In the case of Ebola, there was a failure to respond, both by the

international and local communities. The severity of this epidemic and its long-lasting

psychosocial consequences should prompt investment in health systems, including for mental and physical health. While there is now investment dedicated to rebuilding health systems in Sierra Leone, it is essential that the global response to humanitarian emergencies considers psychosocial needs and is committed to robust community-based initiatives so that health systems will be better prepared in future.

These developments are part of a broader shift in the global health community’s attitudes toward mental health. The WHO and international NGOs such as Médecins Sans Frontières (MSF) increasingly address psychological care in its reports and are becoming more amenable to supporting mental health programmes in low-resource settings. But there is still a critical gap in addressing psychosocial needs during emergencies. Mollica et al (2004) argues donors and aid organisations should press for research and assessment in mental health to be a funding priority during complex emergencies. Whereas some have argued that

research wastes limited resources and increases the likelihood that the scientific community will exploit vulnerable populations, better understanding of the effective, evidence-based mental health interventions is needed.

4.5 Conclusion

This chapter described the setting for the thesis and the impact of recent humanitarian emergencies including both prolonged conflict and infectious disease outbreaks in Sierra Leone. It is a low-income country with an uncertain economic future. There is a public health care system available at the community level, however out of pocket spending for health care is common, and there is a lack of commitment to general mental health services at the

government level. As a result, human resource capacity for mental health services is limited to just one (retired) psychiatrist, 19 mental health nurses (as of 2018) and a handful of

community workers with just a few days of psychosocial training. The treatment gap provides a clear rationale for intervening in mental health services.

As the chapter highlighted, there is a dearth of research from Sierra Leone, although evidence does exist to explain the extent of mental health services in the country and the particular population groups that have been studied. Betancourt et al. (2016; 2008) have studied the mental health needs of former child soldiers, and people affected by EVD. Others have reported on capacity building for mental health workers in the country (Shackman & Price 2013; Stewart et al. 2016). These are important studies to build upon as they reflect the need for enhanced services and enhancing skills of the mental health workforce. The

country’s highly underdeveloped mental health and social services must be strengthened to respond to the reality of adversity due to both war and the recent outbreak. This chapter has provided the rationale for intervention in Sierra Leone.

In the next chapter, the methodology is described in detail for three key phases of study. These include a feasibility and acceptability study conducted in July 2013 (prior to the Ebola outbreak); the intervention model development and subsequent iterations based on the contextual changes outlined in this chapter; and the pilot study which evaluated the