Over the decades, the international community has confronted a wide variety of humanitarian emergencies. We have slowly but surely built up a body of knowledge to improve the delivery of lifesaving assistance in some of the most challenging environments. Best practice has been documented, sector-by-sector, in the form of papers, guidelines and checklists. This body of information includes the recognition that every humanitarian emergency, regardless of its cause, creates new vulnerabilities and puts those already vulnerable – often women, children, older people and people with disabilities – at heightened risk: children orphaned or separated from their families - tick; disruption or breakdown of traditional, social or political systems that regulate behaviour - tick; lack of or discriminatory access to critical services - tick; elevated risk of gender-based violence, including sexual assault, sexual exploitation and abuse and transactional sex - tick, tick and tick. All of these indicators were present in the countries affected by Ebola in West Africa, but the boxes remained empty because the checklists were never even taken out. In the series of reviews, studies and evaluations that will certainly be conducted organisationally and systemically following this crisis, it is vital that we ask ourselves why.
Protection in the context of Ebola
All humanitarian crises - Ebola included - emerge or unfold in the context of complex societies. In doing so, they may exacerbate existing vulnerabilities and expose new ones. Ensuring that protection for the most vulnerable - particularly women and girls - is part of assessment and response in humanitarian contexts is a UK priority. What follows are the findings of a very rapid and informal assessment of protection concerns conducted as part of the UK response to Ebola in Sierra Leone in October 2014.
First, unaccompanied and separated children were not systematically identified. In some cases children were taken in by family or community members, but fear and stigma meant that these community coping mechanisms played less of role than they might have done in a different type of emergency. The government and concerned organisations were involved in family tracing and reunification, but capacity did not meet the level of need. Moreover, there was very little follow-up on the well-being of children once they had been placed with carers.
Second, restrictions on movement, including health checkpoints and quarantine, created opportunities for abuse of power and/or (sexual) exploitation and abuse. Vulnerability to such abuses was potentially exacerbated by inconsistent levels of assistance to families placed under quarantine. Specific protections were not consistently provided to female- or child-headed households.
Third, transportation, isolation and treatment services for people infected or suspected of being infected by Ebola were not adapted to accommodate the most vulnerable: there was a lack of dedicated caregivers for children, there were few facilities accepting pregnant women and no facilities were adapted to cater for people with disabilities or older people. Pressure on all of these services also meant that even basic measures to preserve the safety and dignity of patients were often not possible, such as separating men from women and children from adults. Observational interim care centres (OICCs) designed to care for unaccompanied children during the 21-day quarantine period took a long time to establish, and the lack of alternatives meant that on some occasions healthy children were admitted to Ebola treatment centres with their mothers. Rumours were rife of sexual activity, including sexual violence, in treatment centres, particularly in areas where survivors were convalescing.
Fourth, school closures and enforced proximity of family members increased the likelihood of abuse in the household, and the breakdown of existing programmes and services meant reduced avenues for reporting, referral and response to these issues, as well as other forms of gender-based violence.
The challenge of detecting and responding to protection issues was made more difficult because systems were not put in place early or were not integrated throughout the entire response. Even basic measures, such as disaggregation of data by sex and age, were not routinely taken, or the information was not shared in such a way that it could effectively inform the response.
As the cluster approach was not activated, humanitarian coordination was not rolled out in the usual configuration. Coordination was led by the Sierra Leonean government through the National Ebola Response Centre, which did include a child protection and psychosocial pillar. At the time of the assessment, however, it was largely siloed and protection issues were not adequately or systematically integrated into other pillars of the response. For example, excellent things were done by organisations working with people with disabilities to ensure that Ebola messaging reached vulnerable groups, but their engagement did not extend to other pillars, so transport, treatment and quarantine often failed to take special needs into consideration.
Operational coordination mechanisms took some time to roll out, but eventually District Emergency Response Centres (DERCs) connected the alert system with ambulance services, treatment referral, quarantine and burial teams for a more fluid response. Again, however, protection was not incorporated from the outset, and as a result the system had to be retrofitted to incorporate a separate desk to handle protection concerns. Once this was in place, it allowed for detection and referral of cases and, importantly, provided the first real capacity to quantify the scale of protection needs.
There have been few opportunities for Sierra Leoneans to lodge complaints or express concerns about the Ebola response. Many of the measures that were taken were top-down, and while social mobilisation efforts aimed to help the population understand the need for quarantine and isolation, feedback could not be systematically relayed to inform the response or address problems as they arose. It remains to be seen whether reports will emerge of widespread sexual exploitation and abuse as a result of restrictions on movement. What is certain is that, if this has been taking place, there has been no way to report it and no course of immediate redress for victims.
The evolution of the Ebola response
In attempting to understand the role of humanitarian protection in the response to the Ebola outbreak, it is important to look at how the response evolved. The 2014 outbreak occurred in ideal conditions to foster its spread. Previously unknown in West Africa, governments and communities were not expecting it, nor did they have the knowledge or systems to cope with it or curb its spread. In all of the affected countries, struggling health systems were further weakened by the toll that the disease took on their staff. It was clear that the critical issue was to stop the transmission of the disease, but there were several barriers. International specialist health agencies such as the World Health Organisation (WHO) and the Centers for Disease Control (CDC) possessed a good technical understanding of how to tackle the disease, but lacked experience in mobilising an effective humanitarian response. By contrast, humanitarian agencies, with the exception of Médecins Sans Frontières (MSF), lacked the medical and public health experience to confront the disease directly. Moreover, the humanitarian system overall was severely overtaxed, coping with several concurrent acute (Level 3) emergencies. Into the breach stepped a wide range of new mechanisms and actors: national and foreign militaries; foreign medical teams and private health actors; and the first-ever UN emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER). As these new actors scaled up, some traditional humanitarian organisations stepped in, first tentatively, and then with increasing confidence.
To their great credit, many humanitarian organisations took on roles in the Ebola response that they would never have anticipated, including high-risk tasks such as providing treatment, safe burials and contact tracing. With so many organisations working in such an unfamiliar area it is perhaps unsurprising that opportunities to mainstream protection were missed. Meanwhile, a substantial amount of the response was being implemented by organisations with limited experience in humanitarian contexts, and for whom protection would not necessarily be a key issue. Indeed, it seems likely that one of the main factors that led to the weakness of protection in the Ebola response was that it was launched and led with a public health approach, by actors whose professional grounding does not include protection as understood by humanitarians.
Whilst public health and humanitarian assistance often meet in situations of emergency, their aims are subtly different. Humanitarian action focuses on saving lives, alleviating suffering and restoring dignity; it addresses the consequences of the emergency, but generally does not attempt to address the cause. Public health responses, on the other hand, are targeted at preventing or arresting the cause itself, generally addressing directly only those consequences with a bearing on health.
The primary aim of most actors in the response was to reduce transmission of Ebola to zero. The objectives identified by UNMEER provide a good summary of how this played out in terms of priorities: to stop the outbreak; treat the infected; ensure essential services; preserve stability; and prevent further outbreaks.+UN Mission for Emergency Ebola Response: https://ebolaresponse.un.org/un-mission-ebola-emergency-response-unmeer. It is a solid approach that has certainly helped push towards the aim of zero cases, but there is a crucial gap: it fails to put the dignity and humanity of the affected community at the centre of the response; fails to look at the social and cultural context of the crisis; and fails to look at the humanitarian consequences of the outbreak.
This is not to suggest that public health and humanitarian approaches are mutually exclusive. Indeed, the more the two are blended, the more likely we are to attain the goal of zero cases. Unless we apply the learning that the humanitarian community has painstakingly built up about how to make people safer, however, success will remain elusive.
Challenges and opportunities
The challenge of Ebola has resulted in a unique response, both from affected countries and the international community. This has resulted in some very creative and innovative thinking. It has also highlighted where more is needed. One key issue that arose in the Ebola response is the importance of early funding for protection activities. UK funding to UNICEF in July 2014 allowed for the development of a child protection strategy and the basis for important activities like family tracing and reunification. As the situation evolved, there was a greater understanding of the particular vulnerabilities created by the crisis, necessitating new approaches and types of programming. One example is observational interim care centres (OICCs), developed to provide shelter and care to children exposed to Ebola until the 21-day quarantine period had elapsed and homes could be found for them with their families or communities. In another example, to facilitate the identification and referral of people at risk protection desks were integrated into District Ebola Response Centres.
The response is still evolving and there are still opportunities to integrate lessons learnt and remedy deficiencies. Indeed, it is only in recent months that we have seen discussion of sexual violence during the epidemic+Sex Crimes Up amid Ebola Outbreak in Sierra Leone, IRIN, 4 February 2015; Report: Ebola Is Leaving Women and Girls Vulnerable to Sexual Violence, publichealthwatch, 12 January 2015. or attempts to quantify the scale of child protection concerns.+UNICEF, More than 16,000 Children Lost Parents or Caregivers to Ebola Many Are Taken into the Communities, 6 February 2015. In the coming months and years there will be a tremendous need for healing and recovery in Ebola-affected communities. Communities will need to mourn those they have lost, but also come to terms with the toll that stigma and rejection has taken on relationships. Mechanisms should be put in place to facilitate reconciliation and reintegration, provide safe spaces to disclose abuses or violations and ensure effective support to survivors of both Ebola and violations.
In December 2013, the Inter-Agency Standing Committee Principals made a ground-breaking statement recognising that protection must be central to our preparedness efforts, as part of immediate and life-saving activities, and throughout the duration of humanitarian response and beyond.+The Centrality of Protection in Humanitarian Action, Statement by the Principals, Inter-Agency Standing Committee, 17 December 2013. Just as we cannot wait for a conflict to end or every aftershock of an earthquake to cease before we start protection activities, we must think about wider vulnerabilities and potential rights violations immediately. Just as we have struggled to integrate or mainstream protection into situations of conflict or natural disaster, we must now ensure it is at the core of large-scale public health responses.
Clea Kahn is a Humanitarian Adviser currently working with the DFID Conflict, Humanitarian and Security Department Operations Team.