As of the 31st of March 2015, 418 out of 815 infected health care workers1 had died from the Ebola virus in Guinea, Liberia and Sierra Leone, according to a recent WHO report. 217 recovered and the fate of the remaining 181 is unknown. These figures alone attest to the heavy price paid by medical staff responding to the crisis. In addition to the high risk of contamination, healthcare workers have regularly faced rejection by the communities they sought to help, which has sometimes led to direct violence, as well as stigma and social ostracism.
Risk of contamination
According to the same report, health staff, through direct contact with patients, account for 3.9% of the 20,955 confirmed and probable cases reported. They can be between 21 and 32 times more at risk of infection, depending on the health profession, than the rest of the population above 15 years of age. While doctors, nurses and nursing assistants account for 64% of the staff contaminated, all medical and health professionals are vulnerable and have been constantly worried about the possibility of infection.
The vast majority of staff infections have been contracted outside of specialised Ebola treatment structures where protection and IPC (infection prevention and control) procedures were either lacking or inappropriate. In comparison, staff working in Ebola treatment centres are at a much lower risk, accounting for around 6% of the 199 health staff infections in Guinea.
Twenty-eight MSF employees contracted Ebola in Liberia, Guinea and Sierra Leone – fourteen of them died. Internal investigations showed that the majority of these infections took place through contacts in the community. However the three expatriates who contracted Ebola (all were cured after receiving treatment in their home countries), were infected while working in treatment centres, likely in triage areas although it is difficult to determine where transmission took place.
It has become common for health workers combatting Ebola to face threats, intimidations and sometimes even violence at the hands of the populations they have come to help. In Guinea, the refusal of some communities to cooperate coupled with active hostility in some instances, forced MSF to quickly evacuate several areas of intervention and also temporarily suspend activities. In February 2015, the Guinean Red Cross estimated that its employees had suffered an average of 10 attacks – ranging from verbal to physical assaults – per month.
The most dramatic episode to date took place in southeastern Guinea in September 2014, when eight people from a governmental delegation raising awareness of Ebola were assassinated. Among them were three health officers, including the District Director of Health and the Deputy Director of N’Zérékoré district hospital. Although this is an extreme case, acts of intimidation and violence by community members against national or international actors had been observed by MSF during previous epidemics of viral haemorrhagic fevers, such as in Gabon in 2002 and Angola in 2005.
This hostile behavior is to a certain extent understandable, as Ebola generates reactions which are often irrational and driven by the universal fear of epidemics. Mistrust is further fuelled by the very conditions created by control measures: the systematic use of full protective gear, isolation of the sick, and safe burial of the dead.
Populations’ suspicion is also driven by the long list of rumours that accuse aid actors of being the source of the disease. Poor awareness campaigns have not helped in calming these serious doubts. Government, NGOs and the UN did not always manage their communications well, sometimes spreading messages that reinforced people’s fear. One common line illustrative of this flawed messaging was “no treatment, no vaccine”, which was interpreted by people as: no use going to the hospital!
However, the consequences of this rejection of control measures can be serious and lasting not only for attacked staff, but also for the people in areas where the virus is still a threat. By rejecting teams tasked with containing the outbreak, populations expose themselves to the risk of the uncontrolled propagation of the virus in their communities.
From physical to social violence
Fear of infection can result in health workers being stigmatised and ostracised by their communities, friends and even immediate families. At a time when they need the support of their loved ones more than ever, there are instances of local staff lying to their families about working in Ebola treatment centres, moving to live by themselves or with other health care workers, or being rejected from public transport.
International workers also face problems when returning home. In the US, some states introduced mandatory quarantines for health workers, even if they displayed no symptoms of the virus. Restrictions were so tough in some countries, such as Canada, that MSF offered its staff the ability to stay in more “friendly” countries in Europe for 21 days to avoid potential problems.
Conclusions – human and national loss
Eighteen months after the first case, the largest Ebola epidemic ever is in the process of being contained. On May 9th 2015, Liberia, the country which reported the highest number of cases at the peak of the epidemic, was declared free of Ebola. Hopefully, Sierra-Leone and Guinea will soon follow, since active transmission is low and limited to a few districts, while areas which had previously reached worrying levels of transmission do not report any new cases since several weeks.
However, health staff have paid and continue to pay a very high price for their professional commitment: they are at risk of being infected by Ebola and of dying from it, accused of being responsible for the disease, often rejected or abused by the populations they have come to help, and sometimes treated with fear or even ostracised when they return home.
Health workers show immense courage and professionalism in dealing with such challenges despite minimal levels of support. The fact that many hospital staff in Guinea do not have work contracts and depend for their pay on hospital incomes is indicative of the minimal levels of support health workers received, even before the crisis. While health workers faced incredibly high levels of occupational risk, ministries of health failed in their reciprocal obligation to inform, protect and support medical staff.
Looking ahead, Sierra Leone, Liberia and Guinea are likely to suffer the consequences of more not being done to protect health workers. Additional strain will be put on health systems, which were already largely underfunded, dysfunctional, and lacking skilled human resources on the eve of the epidemic.
Although some of the problems discussed here have decreased in severity – for e.g., contamination of health care workers has decreased since March 2015, partially due to better IPC standards – serious challenges remain. At the end of this May, violent protests in the north Guinea town of Boke saw two Red Cross cars attacked and a warehouse containing equipment for safe burial incinerated.
Even as the number of cases continues to fall and most communities reject violence, anger and frustrations around Ebola have failed to fully subside.
Marc Poncin (PhD Biophysics) is working for the “Research Unit on Humanitarian Stakes and Practices” of the Swiss section of ‘Médecins Sans Frontières’ (MSF). He was the coordinator for MSF in response to Ebola outbreaks in Bundibugyo (Uganda) in 2007-2008, and in Guinea from April to December 2014.