Ebola, Disease Outbreaks, and Inadequate Health Systems

I vividly remember the Kagadi Hospital run by the Ministry of Health. In 2002, I was visiting the communities that would benefit from an ambulance fundraiser project. That evening the need for emergency transportation in the Kagadi-Nakuulabye area of the Kibaale District could not have been made more clear to me. Driving back to our housing one evening, our pickup truck was flagged down to help at the scene of a bicycle accident where two riders had collided head on in the dark. One man was bleeding from his ears and obviously needed advanced medical attention. We drove him, lying in the pickup truck bed, to the Kagadi Hospital only to be turned away because the staff said they didn’t have any supplies to treat the man. I remember looking into the hospital windows and seeing nothing but empty walls.

It came as a shock to read news of the Ebola outbreak in that very same area where I had visited 10 years ago: Kagadi, Kibaale District. My first thought was that the health care system couldn’t possibly respond quickly enough, but hopefully things had improved over the last decade. Reports noted that the Red Cross, Doctors Without Borders, CDC, and the World Health Organization (WHO) were assisting with the response. This was a positive sign since the area is rural, difficult to travel to, and as far as I knew lacking a strong health care system.

“This outbreak is occurring in the same area where the Red Cross is already responding to the growing crisis caused by the influx of Congolese refugees fleeing violence in their country” said Charlie Musoka, Regional Operations Coordinator for the International Federation of the Red Cross.

On top of dealing with the Ebola outbreak, the Ugandan Red Cross was also managing the influx of refugees into the country. My initial thought was that Ebola is easily transmitted by close contact between people and usually kills 90% of those infected. With the regular movement of people across the Uganda/ DRC border it could be just days before an Ebola outbreak occurs in the DRC.

Shortly after the Ebola outbreak, news broke that the Ugandan Ministry of Health needed Sh3 billion to be able to contain and manage the disease and necessary health care facilities. I was also contacted by the local health center in Kagadi and told that were having difficulty responding to the outbreak as well. My fears seemed to have been true and the health system was feeling the pressure of responding to an Ebola outbreak in an area where there was very little health care capacity.

Roughly, two weeks after the request for supporting funds by the Ugandan Ministry of Health, the Ebola outbreak is reported as contained in Uganda and a Ugandan team would be sent to the DRC to help contain the new outbreak there. Reports said that it was a different strain of Ebola, but the first reports were in a Uganda/DRC border town that is a regular crossing point between the two countries. I had worried about the lacking health care system in Uganda, but the health care system in the DRC is in an even more strained. There are limited health care workers and facilities, which are usually filled by casualties from the ongoing violent conflict in the region.

Early this month, the WHO declared Uganda Ebola free after there were no new cases reported after August 3rd (24 confirmed cases, 17 deaths). The facilities in Kibaale District remain on alert, but the larger Ebola crisis is in the DRC. The WHO confirmed the Ebola outbreak is a different strain (see map above) and not connected to the Ugandan outbreak, however there have already been 72 confirmed cases and 32 deaths. Health workers were reported infected in the Ugandan outbreak, but in the DRC so far 23 of the 32 deaths have been health care workers. Representatives of Medicines sans Frontiers note that the death of health care workers at hospitals scares people away from seeking treatment and they are more likely to continue the spread of Ebola. It seems that the DRC has been less equipped to deal with the Ebola outbreak or its just the nature of the area where the outbreak occurred that made it easier to spread.

Both of these examples of Ebola outbreaks in a remote region of Uganda and in a transit town in the DRC demonstrate the critical need for adequate health care systems and health care workers. Before conflict started in the DRC, the health care system was already underfunded and in need of investment. The United Nations reported that militias raided almost all of the health care facilities in rural areas where 70% of the populations lives. The conflict also disrupted transportation and everyone must travel by foot to get treatment. NGOs have tried to invest in the health care system, but Doctors Without Borders report regular attacks on their compounds. In Uganda, there has been similar conflict, but greater investment in the health system. However, a recent report highlighted the inadequate staffing and space in many key hospitals. In some areas there is 1 doctor for every 178,000 people. Due to financial constraints the Ugandan government has banned recruitment of health care workers.

No one can afford to not invest in health care capacity building. In these two countries it seems that health crises need to be managed by outside NGOs with additional funding. How can the international community better work to build the capacity of individual country’s health care systems?

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