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This series is a collection of insights from BRAC practitioners who have led responses to mass-scale crises across the world. We present key factors for other practitioners; healthcare professionals, governments and development authorities to consider in preparation, management, relief and recovery.
As the world finds itself in uncharted territory struggling to combat the rapidly escalating COVID-19 pandemic, BRAC’s work in Africa during the Ebola crisis can offer valuable lessons for responding to public health crises in low-income countries.
The start of the worst outbreak of Ebola.
Mohammed Abdus Salam was heading BRAC in Liberia.
He was sent to the war-torn country in 2008 with USD 5,000 and one goal – to start a BRAC operation. Recruitment was difficult. People were afraid to come out of their tents. Electricity connections were hard to come by.
Salam’s work had just started to pick up pace when Ebola struck.
When asked what we can learn from the Ebola outbreak in Liberia, Salam starts on a grim note.
It is deathly critical that quality health services are not compromised.
“Crises can lead to far more deaths than the virus or natural disaster itself. The health centres are overwhelmed, and in a state of emergency, many facilities are shut down or abandoned.
“Maternity clinics were closed. Pregnant women could not get treatment,” Salam recalls harrowing images of pregnant women dying from the lack of services.
According to reports there were approximately 12,000 Ebola deaths in Upper West Africa during the first wave of the Ebola outbreak, but abandoned and closed facilities resulted in many additional fatalities.
This is consistent with BRAC’s general experiences in crises, for example after cyclones, where more deaths are often reported because of snakebites, injuries and drowning as children are left unattended while parents focus on rebuilding houses and sourcing food.
BRAC has kept all 41 of its maternity centres open to provide maternity healthcare and normal delivery services to pregnant women during COVID-19. Frontline health workers and facility-based healthcare providers have provided over 200,000 pregnant women with individual counselling and services since the pandemic began.
BRAC’s health programme was already working with the Liberian government when the first Ebola case was identified in the country. Salam stresses on the importance of cultivating a strong partnership with the government.
“All our Ebola response activities complemented and supported the work of the Liberian government. Our regional health coordinator was in regular communication with their health ministry, and BRAC was present in ministry forums to see where gaps existed and how they could be filled.
“Working with the government gave us space to work effectively for the community. We were not experts on Ebola; it was the Liberian government that was in the frontlines. Our approach was clear – support the government wherever they needed us.”
The initial support needed was getting accurate information on symptoms and preventive measures across to as many people as possible. Door-to-door communication and group meetings were held by health workers initially, but the government imposed lockdown two weeks later. After that, messaging was spread through SMS to clients and beneficiaries, and through leaflets, posters, community radio and television – similar to BRAC’s approach in Bangladesh for COVID-19.
The focus then shifted to supporting facilities – also similar to the current approach for COVID-19. Ebola Treatment Units, large field treatment centres, were being set up by the government and Médecins Sans Frontières, and BRAC supported by providing beds and food to the units. “We provided food support and sanitisation kits to our clients and staff. Then we supported the government by establishing approximately 25,000 handwashing stations across Liberia.”
Some things were not as straightforward though – like tackling stigma.
The world is seeing an increase in social ostracisation due to COVID-19. In Bangladesh, people are abandoning their relatives fearing that they might have been infected by the virus. There are an increasing number of cases where patients who have tested positive and been ordered to stay in quarantine have fled their residences in fear of retribution or alienation.
The misconceptions around Ebola were debilitating for those who were infected. People refused to speak to or go near patients, even though they knew the virus spread through bodily fluids. This gave rise to other problems.
“Food scarcity became an issue for people quarantined. No one wanted to go to their homes, and people in quarantine did not want to come outside. Some people would wait until nightfall to go out of their homes, walk long distances to a marketplace to buy food. They would do anything to avoid places where their faces could be recognised – to the point of going hungry.
People were terrified of people in quarantine. They were leaving their families behind, leaving with people in strange suits, they saw that half of the people who got infected eventually died. No one would come close to them, no one would attend their last rites. People lost hope and strength, they became like the walking dead.”
It was not just while people were showing symptoms, or in quarantine, either. Ostracisation continued after a person recovered.
“I remember meeting a mother and her child who was being thrown out of their homes upon returning from the treatment unit. There were more than 4,500 survivors in Liberia. Reintegrating survivors into society was crucial.”
Salam’s team quickly prepared to begin psychosocial activities. Again, government partnership was paramount – the Liberian government already had a psychosocial pillar which was a unit focusing on mental health.
A train-the-trainer course was compiled in line with the World Health Organization’s psychosocial first-aid guidelines. BRAC’s health managers, the counties’ mental health counsellors and the pillar’s focal person attended. This core group then brought together a large committee comprising 300 Ebola survivors, 600 health volunteers and 300 social work assistants. Everyone in the committee was trained on communication and psychosocial first-aid.
Popular theatre was this committee’s most powerful work. Community leaders and Ebola survivors came together to recreate the stories of thousands of people in the counties – how a person was infected by the virus, their time spent in a treatment centre, their recovery and how, even after their recovery, their community was reluctant to welcome them back.
The dramas were called Welcome Ceremonies, and included a session on hugging and shaking hands with survivors – to break the commonly-held perception that survivors could still be carrying the virus.
In parallel, advocacy meetings were held with community and religious leaders, and, with the help of the government, BRAC disseminated widespread messages welcoming Ebola survivors back into communities through brochures, text messaging and jingles on television and radio.
The initiatives, particularly the dramas, were effective; Salam recalls that this initiative was not only appreciated by the Liberian government and Ebola survivors, but people in the community as well, and community observation showed visible perception change towards survivors.
Salam was in Liberia until 2016, right when the epidemic was coming to an end.
Now back in Bangladesh and facing another pandemic, he says; “the way out of the current situation is going to take all of us working together and trusting each other. The government cannot do all the work on its own – partnerships are the only way to come out of this intact.”
Amidst the complex and protracted effects of a pandemic, Salam’s key takeaways are clear; ensure that quality health services are not compromised, work in synergy with governments to amplify effectiveness and focus on the impacts of stigma.
Luba Khalili is Deputy Manager at BRAC Communications. Sarah-Jane Saltmarsh is Head, Programme and Enterprise Communications.