For the first time in more than a year, no one in either Sierra Leone or Liberia is being treated for Ebola, raising hopes that after more than 11 000 deaths and 28 000 infections throughout West Africa, the epidemic could finally be winding down.
But 18 months after the World Health Organisation (WHO) formally announced the beginning of the Ebola outbreak in March 2014, the last thing the region needs is another false dawn. Three months ago, Liberia was declared free of the virus only for new cases to emerge.
Although there are just three known cases left in the region and just 629 potential contacts still under observation, the epidemic isn’t yet over.
Here is where things stand:
Guinea is where the outbreak started in December 2013 with the death of a two-year-old boy. Now, 20 months on, much of the country is Ebola-free, including the southeastern forest region where the index case originated. But there remain a few pockets of resistance, particularly in and around the capital Conakry, where the only three current cases in the entire region were recorded during the week ending 23 August. Approximately 600 people are still under observation in Guinea and WHO warns that “there remains a significant risk of further transmission,” particularly because one of the positive cases – a taxi driver who was not previously on any contact lists – could have spread the virus to his passengers. Guinea is also the site of the first health worker infection in more than one month.
Cases: 10 672
Deaths: 4 808
Last month, Liberia began a 42-day countdown to being Ebola-free, but not for the first time. The outbreak was previously declared over in the country on 9 May. But on 30 June, the Ministry of Health announced that a teenaged boy had tested positive in a small town on the outskirts of Monrovia. Over the next two weeks, five more cases were confirmed. The source of the second outbreak is still unknown, but Ebola response teams were able to quickly contain the flare-up. The last patient was discharged on 23 July and all potential contacts have since passed the 21-day incubation period. Liberia could once again be declared Ebola-free on 3 September.
Cases: 13 541
Deaths: 3 952
Sierra Leone has now gone two consecutive weeks without any new cases being reported. The last patients were sent home as survivors on 24 August. Just 29 contacts are still under a 21-day surveillance period, which is set to end on Saturday. If no new cases surface, Sierra Leone will be declared free of Ebola on 5 October.
For the last 13 years, Sierra Leone has seen a dramatic decrease in its maternal mortality rate, due in large part to the introduction of free health care for pregnant women. One of the most devastating and yet rarely acknowledged impacts of the Ebola epidemic is that it threatens to undo all this good work.
It’s not just the loss of more than 220 health workers, including many midwives, to the virus, with little training or wiggle-room in the fragile health system to replace those skills. It’s also the lingering fear of hospitals and doctors among the local population, which remains traumatised by an outbreak that has claimed almost 4 000 lives and still sees new infections each week, albeit small numbers.
A World Bank report in July – Healthcare Worker Mortality and the Legacy of the Ebola Epidemic – estimated that Sierra Leone’s maternity mortality rate could increase because of the current crisis by 74 percent, to levels not seen since the end of the civil war in 2002.
“During the Ebola outbreak, there were many challenges that we encountered that led to many pregnant women not coming to the hospital and this may have led to the [recent] increase in death rates [among pregnant women],” A.P. Koroma, medical superintendent at the PCMH (Cottage) Hospital in Freetown, told IRIN.
The hospital has lost 85 mothers since the outbreak was first reported in May 2014, which Koroma said is “definitely a sharp increase compared to previous years.”
“People were, and are [still], afraid,” he added.
Before Ebola came, an average of 10 700 women each year gave birth at Cottage Hospital. Since the outbreak, this number has dropped to 6 723.
The most recent maternal mortality rate is not yet available at the national level, but given the hospital attendance records and the risks of at-home childbirth in Sierra Leone, it is expected to rise.
“During the Ebola outbreak, people had the impression that when they come to the hospital, they may be infected,” Koroma explained. “For those coming to the hospital, we did our best… but some of them came to the hospital late because they were told that if you have bleeding, which is one of the symptoms of Ebola, no nurse or doctor will want to touch a patient until an Ebola test is done, which can take up to three days.”
Others, who did come, died while waiting for the Ebola test results.
The hospital now has access to a rapid diagnostic test, which can give results in less than three hours.
Despite this, and better safety measures generally, many hospital staff are still afraid to tend to pregnant women, given the fact that childbirth puts them in direct contact with bodily fluids.
“When we started hearing of our colleagues dying, everybody was afraid and nobody wanted to even touch a patient,” Koroma explained.
But not all women are staying away.
“Some of my friends said that if I came to the hospital I would get Ebola… so I became afraid,” said 22-year-old Mary Conteh, from Freetown, who gave birth earlier this month. “But later I decided to come to Cottage Hospital…. I thank God I had a safe delivery.”
Shortage of health workers
Sierra Leone lost an estimated seven percent of its nurses and midwives to Ebola, according to the World Bank report – a devastating loss for a country that had just over 1 000 to begin with.
“This is just a terrible shock to an already weak healthcare system,” said David Evans, Senior Economist at the World Bank Group. “And if one were to put this [loss of health care workers] into actual numbers, that’s an additional 1,850 women dying per year [in Sierra Leone] just as a result that we’ve lost health care workers due to the Ebola epidemic.”
If Sierra Leone is to prevent its maternal mortality rate rising further, experts say more investment is drastically needed to plug the gap in maternal healthcare.
“In terms of response, it’s not rocket science,” Evans said. “These countries and the international communities supporting them need to hire more health workers and provide resources so they are well paid and want to be in Sierra Leone working there. And, as the Ebola epidemic wanes, as it continues, making sure they have protective equipment.”
In the short-term, to avoid a further increase in maternal mortality, Evans suggested a “stop-gap measure” of employing foreign healthcare workers and birth attendants, allowing local capacity to be built up over the longer term.
Women in Sierra Leone say they are praying for just that.
“All I want is to have a healthy baby,” said 25-year-old Frances Tucker, who is five months pregnant. “I don’t want to have problems like other pregnant women have had by staying at home, afraid of coming to the hospital… putting you and your baby’s life at risk.”
More than 2 000 Zimbabweans displaced by xenophobic attacks in South Africa have packed their bags for home. But Zimbabwe, a country teetering on the verge of economic collapse, is unlikely to offer them the means to restart their lives.
The attacks on foreigners – mainly Zimbabweans, Somalis, Malawians, Mozambicans and Nigerians – started in Durban more than two weeks ago following comments by Zulu King Goodwill Zwelithini, suggesting that African migrants in South Africa were criminals who should go back to their countries and stop stealing jobs and opportunities from locals.
Machete- and gun-wielding South Africans burned foreigners’ businesses and homes, looting goods, and forcing their inhabitants to flee. Six foreign nationals died in the attacks, which spread from Durban to other parts of the country, including Johannesburg. The worst of the violence has, for the most part, subsided, but African migrants are well aware that they could re-surface at any time.
Several countries, including Malawi, Mozambique and Nigeria, have tried to evacuate their citizens from affected areas, but Zimbabwe, which has by far the largest number of nationals living in South Africa, is faced with the biggest challenge. Over years of political and economic upheaval in Zimbabwe, some 1.5 million Zimbabweans are thought to have made the trek south in search of safety and better opportunities. Zimbabwe has set up an inter-ministerial rescue taskforce to repatriate several thousand of them.
Labour and Social Welfare Secretary Ngoni Masoka told IRIN that the Zimbabwean government expected to receive some 2 400 returnees who had opted to return home following the attacks, but added the actual numbers returning could be higher.
“We are getting constant updates from our embassy in South Africa. There could be Zimbabweans who might have decided not to approach us for help for various reasons, so it is difficult to know how many are coming back exactly,” he said.
The first batch of 433 returnees arrived last week in government-provided buses at Beitbridge border post from a Durban transit camp where they were being housed following the attacks. According to Masoka, the taskforce is determining their needs, qualifications and destinations so they can be referred to provincial and district welfare officers for help with reintegration. The Zimbabwe Red Cross Society and the International Organisation for Migration (IOM) are providing returnees with food and other essentials, while specialists are offering counselling and medical attention.
Masoka declined to say whether the government had set aside a budget for the returnees.
Under no illusions
Jairos Mangwanya (36) is under no illusions that life back at home will be easy. He was among the first batch of returnees last week, but decided to hitchhike to Harare, the capital, after becoming impatient with delays getting on a government bus. He left his pregnant wife and two other children to follow on the government-provided transport and went ahead to organise them some temporary accommodation.
Mangwanya had worked in Durban as a teacher for the past eight years. He fled with his family when Zimbabweans at a neighbouring house were attacked and their belongings looted.
“We didn’t have the time to pack our belongings because the attackers were coming to our house. We only took some blankets and clothes and fled to the police station. We left our passports, educational certificates, money and other vital belongings behind,” Mangwanya told IRIN.
“That means we have virtually nowhere to start from. I can’t look for another job without my certificates and I know it will be a long time before the examinations authorities and birth registration officials here can replace my documents.”
Finding a place for him and his family to stay in Harare will be tough. Space at his two brothers’ homes is already limited.
“My brothers say my wife and the two children will go to one of the houses and I to the other. That must be for a short period, though, because they also have large families and dependants from the extended family,” said Mangwanya.
The other option is to take the family to their rural home in Mount Darwin, some 200km away from Harare. But going there will greatly reduce his chances of being able to provide for his family or of his two children being able to attend school.
Mangwanya left South Africa before receiving his April salary and is likely to forfeit his pension and other employment benefits.
Trynos Musumba (41), who was travelling from Beitbridge with Mangwanda, had been working as a plumber in Durban and sending part of his earnings to his 70-year-old mother and unemployed sisters in Zimbabwe. He left his South African wife and four-year-old child behind in Durban.
“With my return, it means no one will be able to fend for my family here. My wife is not employed and she will find life tough. I might have to look at ways of going back to a safe city in South Africa and looking for another job,” he told IRIN.
His mother, who is diabetic, and the rest of the family live in rural Mhondoro, some 50km west of Harare. The area is one of many in the country to have suffered crop failure this year following poor rains.
“This is a very bad situation being made worse for the migrants,” said John Robertson, an independent economic analyst. “They fled Zimbabwe to look for better opportunities and are returning home to the very economic crisis they tried to run away from. The situation could actually be worse than when these people went away.”
He added that unofficially, unemployment in Zimbabwe is close to 80 percent, despite official figures putting it at 11 percent.
Japhet Moyo, secretary general of the Zimbabwe Congress of Trade Unions (ZCTU), told IRIN: “Most of the companies have closed down and the few that remain are struggling. Worse still, government cannot absorb [those being laid off] because it doesn’t have the money to employ more people.”
Government too broke to help
Robertson said it was unlikely that the social welfare department would help the returnees in any meaningful way. “Our government has never had an unemployment benefit scheme or social security policy and is too broke to fund any intervention to help the returning Zimbabweans re-integrate. It will thus leave everything to the extended family, hoping that relatives will cushion the returnees.”
Musumba said that on the bus he took home with other returnees “many said they will never return to South Africa to look for jobs, but I know as soon as there is peace, they will go back because the situation in our country is so bad.”
Gabriel Shumba, a South Africa-based human rights lawyer who heads the Zimbabwe Exiles Forum (ZEF), said some 2 000 Zimbabweans remained in camps near Durban. Although churches, NGOs and the South African government are providing some aid, many are still in need of food, clothing, counselling and medical attention.
“The situation remains precarious. There is need for the humanitarian community to scale up support for the people in camps,” he told IRIN.
Shumba said his organisation was working to provide legal assistance to those who had been attacked or their property looted in an effort to ensure perpetrators could be arrested and brought to justice. South African authorities have a poor record of prosecuting perpetrators of past attacks.
He added that he did not believe repatriating victims to Zimbabwe was the answer, arguing that it “would embolden the attackers and encourage more attacks”.
As rates of Ebola infection fall in Guinea, Liberia and Sierra Leone, planning has begun on how to rebuild public health systems and learn lessons from the outbreak.
Nobody is declaring victory yet. But in Sierra Leone, the worst-affected country, there were 117 new confirmed cases reported in the week to 18 January, the latest statistics available, compared with 184 the previous week and 248 the week before that. Guinea halved its cases in the week to 18 January – down to 20 – and Liberia held steady at eight.
The epidemic is not over until there are zero cases over two incubation periods – the equivalent of 42 days. “It’s like being only a little bit pregnant – there’s no such thing as a little Ebola. We have to get to zero, there can be no reservoirs of Ebola,” Margaret Harris, spokesperson of the World Health Organisation (WHO), told IRIN.
But after 21 724 cases and 8 641 deaths in nine countries since the epidemic began in Guinea last year, there is some light. And health workers are already starting to look at what’s next. “Right now important meetings are going on in each country to work out what needs to be done to rebuild – in some significant respects to build health systems almost anew – and to build back better,” said Harris.
A European Union donor conference is due at the beginning of March in Brussels. “What we want to see as a country is a resilient health system that can withstand shocks,” Liberia’s Assistant Health Minister Tolbert Nyenswah told IRIN. “Our plan [to be presented in Brussels] will be finalised by the end of February. It will be well costed with tangible goals.”
Ebola tested the public health systems in the three West African countries to near destruction – most places in the world would have also struggled. But where the three failed was at the basic “nitty-gritty” level of “standard surveillance, testing and monitoring, the containment of cases, the bread and butter of public health”, said Adia Benton, a social anthropologist at Brown University in Rhode Island.
Citizen and state
A successful malaria campaign in Sierra Leone last week, which reached 2.5 million people, and a planned polio and measles vaccination programme in Liberia, are positive signs for the health services. But the list of necessary reforms is long: stronger surveillance; healthcare that will work after the international partners leave; access to affordable services. The list must also embrace longer-term structural changes, including the relationship between citizen and state.
According to Antonio Vigilante, Deputy Special Representative for the Consolidation of Democractic Governance in the UN Mission in Liberia, and Resident Coordinator, “there is a golden opportunity to have a different start, to have a more balanced development that leaves outcomes in the hands of the people. It’s a very delicate stage, full of opportunities, which should not be missed.”
Liberia is one of the world’s poorest countries and Ebola has been a tragic addition to the burden. It has destroyed livelihoods; already dizzying rates of unemployment have worsened; and food prices have soared. Both rural and urban communities are suffering.
Vigilante is worried the economic impact of Ebola, and the interruption of immunisation and reproductive health services during the crisis, could put more people at risk than the virus itself did. “A number of [social protection] measures in the recovery phase would need to be universal,” he said. One example would be if Liberia scaled up its pilot Social Transfer Programme, launched in 2009, to provide just US$40 per year to two million children. There would be sizeable “knock on effects on local markets and entrepreneurship” at minimal cost, according to the Washington-based Centre for Global Development.
Schools are due to re-open on 2 February in Liberia, and a strong case could be made for a universal school feeding programme to attract and retain children in class. “Even before Ebola many children were out of school,” UNICEF spokesman in Liberia, Rukshan Ratnam, noted.
But will the donors come to the party? Donors pledged $1.5 billion to a UN coordinated appeal for Ebola last year, but $500 million is still unpaid. “If we cannot close that funding gap we will snatch defeat from the jaws of victory. It’s as simple as that,” Bruce Aylward, WHO assistant director-general in charge of the Ebola response, told reporters on January 23.
Wasted dollars can be expected in a crisis when the priority is effectiveness – stopping the outbreak – rather than efficiency in how the money is spent. That equation will change if Ebola does not come roaring back with the rains in April, and donors begin to look at competing needs.
There is potential to re-purpose Ebola infrastructure – some of it now idle with a glut in treatment facilities – if donors are willing to be flexible, said Vigilante. Laboratories used for testing could be incorporated into national laboratory services; some of the more permanent treatment units could be re-launched as community-based health facilities; contact tracers could be used as community mobilisers.
“We certainly lost staff as a result of Ebola. But the converse of that is there was a very rapid upskilling as people were trained to work in the treatment units or as contact tracers. It’s a group we should build on,” said Harris. “It’s really important we don’t lose them in the transition to a normal service.”
Among the lessons learned across the region has been the importance of consulting, engaging and empowering local communities: their lack of trust in central government was a major handicap in tackling the epidemic. “Community, community, community. Engagement, engagement, engagement,” said Harris. “We need to listen more. We need to do a lot of work with sociologists and anthropologists.”
Liberia in particular has a highly centralised system of government, but local communities have emerged as critical players in the response with a new can-do attitude. “People given a chance can do a fantastic job,” said Vigilante.
Human rights groups are warning that Kenya’s controversial Security Amendment Act still poses a threat to refugees’ rights despite a high court decision on Friday that suspends parts of the bill for 30 days pending a full court hearing.
The suspension included a section of the wide-ranging bill, popularly known as the ‘anti-terror’ law, that amended Kenya’s Refugees Act. The amendment stipulates that, “the number of refugees and asylum seekers permitted to stay in Kenya shall not exceed 150 000.”
Currently there are over 600 000 refugees, asylum seekers and stateless people living in Kenya, according to the UN Refugee Agency (UNHCR).
Although the cap of 150 000 can be reset by the National Assembly, rights groups fear that the new amendment will result in large numbers of refugees being forcibly returned. This would amount to refoulement, a serious contravention of international refugee law.
On Friday, the Judge ruled that other sections of the new act that deal with refugees will remain in place including a requirement that anyone who has applied for refugee status remain in designated refugee camps “until the processing of their status is concluded.” There are over 50 000 non-camp based refugees living in Kenya’s capital, Nairobi, according to UNHCR.
A Court of Appeals will, within 30 days, rule on the constitutionality of 22 sections of the bill, which are being challenged by the Kenya National Human Rights Commission (KNHRC) and the opposition Coalition for Reforms and Democracy (Cord).
The Security Amendment Act was passed on 18 December after a heated debate in Parliament that culminated in a fistfight among members of the lower house. It was signed into law by the President the following day.
It took less than two weeks to draft and pass the law following a spate of terror attacks conducted by Somali terrorist group, al-Shabab in Kenya. On December 2, 36 people were gunned down by al-Shabab in a quarry close to Mandera town, an area close to the Kenya-Somalia border. Ten days earlier, less than 50 kilometers away, 28 bus passengers had been shot by the group.
Kenya has suffered more than 50 gun, grenade or improvised explosive device (IED) attacks since 2011, when it began its military operation against al-Shabab in Somalia.
Somali refugees disproportionately affected Amnesty International argues that while the new law, if enforced, would inevitably lead to refoulement, it could also be discriminatory in its implementation.
“We’re very concerned about who will be targeted to be sent back,” Michelle Kagari, deputy regional director for East Africa at Amnesty International, told IRIN. “We have been documenting that refugees, and Somali refugees in particular, have been disproportionally targeted by the link between refugees, terrorism and Kenya’s security operation in Somalia.”
UNHCR estimates that by the end of 2015, refugees and asylum seekers from Somalia will represent nearly 70 percent of the people of concern to UNHCR in Kenya.
Fears about the targeting of Somalis are echoed within the Somali refugee community.
“The anti-terror law is mainly meant for Muslims, and the Somalis in particular,” Sheikh Mohamed Abdi, a Muslim cleric living in Dadaab, the largest complex of refugee camps in Kenya where the majority of refugees are Somali. “There is nowhere to run. We fled from Somalia because of terror-related problems and here, where we thought it was a safe haven, is becoming another hell.”
“There are some refugees who are not registered and staying in the camp and so the police can arrest them, assume they are terrorists and hold them for one year,” said Abdi Ahmed, the Section N chairman in Dadaab, and a community leader. “The entire refugee community lives in panic.” Under the new law, terror suspects can be held for up to one year without trial.
Even registered refugees fear the restrictions on movement that the new law will formalise. “Getting a movement pass these days is very difficult and for students, not having it means missing classes and sometimes exams,” said a Dadaab youth leader, who wished to remain anonymous. He believed that the law will make movement even harder.
The Security Amendment Act comes in the wake of a worsening climate for refugees in Kenya. In April 2014, thousands of ethnic Somalis were rounded up in Nairobi, and held at a sports stadium as part of an operation dubbed Usalama Watch. Similar crackdowns have occurred across the country. Many refugees who had been living in cities were sent to Dadaab.
Government defends law
Kenya’s Attorney General, Githu Muigai, has defended the new law. In his response to the petition filed by the opposition party and various human rights groups, through the Solicitor-General, he said that the discretion accorded to Parliament to temporarily increase the numbers of refugees allowed to remain in the country would ensure that refoulement does not occur
He further argued that the laws were necessary to combat terrorism. “We currently have forces in Somalia and it is important to note that the country has been attacked several times. The law, as it is, enables the security personnel to counter threats posed to Kenyans. The issue of life is more important than anything else,” said Muturi.
However, rights groups strongly rebutted this argument. “The government needs to deal with security appropriately and do it in a way that respects human rights. The two are not contradictory,” said Amnesty International’s Kagari. “All three amendments are not only violating the spirit of the constitution but also Kenya’s commitment under the refugee convention.”