Thoughts on "The Path to Zero Ebola Cases"

If you read anything in the Sunday papers or on social media today, make Sylvia Olayinka's Blyden's commentary a must. On her Facebook wall, Blyden responds to Jim Yong Kim's recent Op-Ed in the New York Times. Read on.

 These two photos are scenes of a now-typical day at the Kingtom Ebola Burial grounds in Western Sierra Leone. Scores of corpses are thrown into graves hastily dug by overworked grave diggers. Freetown has never seen a thing like this in contemporary times. We are being psychologically scarred; the World needs to end this scourge - fast. However, we all have roles to play especially those of us who can engage in critical thinking.

In today's update therefore, I am drawing attention to what, in my view, is one of the BEST articles ever written on our Ebola crisis. It is authored by the President of the World Bank, Dr. Jim Yong Kim and was published this month in New York Times newspaper. Read it carefully. His listed steps, especially as to what locals and their leaders can do, have many solutions for ending Ebola. I salute that article!
Here below are key extracts from that article with my inputs as well. This is one of my longer updates but please, be patient to read through it... 

"The communities need to be engaged, empowered and true partners in the drive to zero. It will also begin these countries’ recovery process by providing work for potentially thousands of local people, and teach skills that are much needed to build effective community health care systems." 
- DR. JIM YONG KIM.

****My Comments: I AGREE and it is in this light that the recent executive decisions to empower MPs and Paramount Chiefs, must be applauded.

"We must especially focus on one particular piece of data: The percentage of new cases not on previous contact lists. In other words, did trackers previously identify the people who are newly infected as contacts of other cases, or do the new cases represent unidentified transmission lines?" 
- DR. JIM YONG KIM

****My Comments: I AGREE, BUT I will add that Contact Tracing should include tracing those persons/areas contacted pre-symptoms and post-symptoms.


MY FURTHER THOUGHTS:

For now, the tracing is mostly limited to post-symptoms contacts. We are thus bypassing the chance to identify possible actual sources of where and from whom the patient caught the disease rather than just tracing who the patient contacted AFTER catching the disease. What about BEFORE showing symptoms? Whom was the patient with & Where? Epidemiologists should pay better attention to these aspects. This is how we can eliminate the "unidentified transmission lines" mentioned by Dr. Kim above.

To buttress this my point, let me use a recent example of Bonthe district which has had two new Ebola cases within the last fortnight; marking the district's 4th and 5th cases. The 5th case, Madam Suba Tucker, who died three days ago on 18th December caught the virus from the 4th case, her daughter Martha Tucker who had died 2 weeks before at UBC Hospital in Mattru Jong. However, so far, all we know about where/whom Martha caught the virus from, is that Martha had visited Moyamba district and came back sick to Bonthe with what turned out to be Ebola. Where in Moyamba (and with whom) was she, we do not know.

Meanwhile, 108 people in 22 households including health workers, relatives and friends of Martha, have been quarantined at Luawa Jong, Mokabba and Mattru Jong communities in Bonthe where Martha had lived and with whom she had contact after she fell ill. However, these are all contacts of Martha's AFTER she had acquired the disease. Tracing backwards to WHOM and from WHERE in Moyamba she caught the disease, will ensure we discover and eliminate possible "unidentified transmission lines" so eloquently described by Dr. Kim.

There is another element that has been mostly missing throughout narrative of this crisis and sadly, Dr. Kim also leaves it out in his otherwise brilliant piece. This is the need to pay better attention to the role played by WASH (Water, Sanitation & Hygiene) issues in transmission of this virus especially within heavily populated parts of Sierra Leone. There has not been much highlighting of the use of communal toilets and wash yards as 'fomites' in transmission.

We have heard a lot about transmission through corpses and touching sick people but we have not heard enough about transmission through bathrooms and toilets. 

My strong conviction is that a lot of Ebola transmission actually takes place without physical touching. I do not really think Ebola is airborne (well, at least not significantly) but I believe we are overlooking the role played by the communal use of latrines and wash yards in its transmission.

Let me expound. Freetown's population growth exploded during and after the war years when throngs of our provincial brothers and sisters, escaping machete-wielding rebels, swarmed in here. However, whilst the population swelled upwards, the attendant water and sanitation services did not increase. Rather curiously, a negligent governance system allowed deforestation around water catchment areas resulting in a reduction in water supplies to Guma Valley Dam and other dams at places like Regent. 

The authorities pretended not to see that Western Urban residences were overcrowded with humans but with little water supplies and without much hygiene or sanitation. 

An unregulated building culture resulted in homes haphazardly dotting the Freetown hillside but with no potable water supply. Not just the hills but also down by the Freetown seaside slums that stretch from Murray Town to Congo Town to Kingtom to Kroo Bay to Susan's Bay to Mabella all up to Cline Town and beyond, it is common to see up to 50 persons waiting to use a single communal wash yard every morning.

In those Freetown urban slums and also up the over-congested, poorly planned Freetown hillsides, we find single pit-latrines serving dozens in congested compounds. These are just not enough to serve the residents so what do they do when they feel like defecating? Simple. They defecate into buckets and the 'kaka' produced is then poured from the buckets into already-blocked Freetown gutters. The more 'sophisticated' amongst these inhabitants will 'kaka' into plastic bags before throwing the feces-filled plastic bags into the Freetown gutters. This my deliberately graphic explanation is for emphasis. It is just the reality buddies - real happenings on a daily basis.

An almost similar scenario eerily plays out in Port Loko's mining areas. For this piece, I want to single out Marampa's Lunsar where a recent population explosion, without attendant improvement in Water, Sanitation & Hygiene services, has left that chiefdom and its neighbours, torn apart at the hands of the cruel Ebola virus. The influx of outsiders swarming into this rejuvenated mining area, looking for jobs or related opportunities, mimics mass influx into Freetown during war years. 

Sadly, like in Freetown, there was non-provision of WASH services in Marampa to match the exponential population growth therein caused by the influx of outsiders; neither was there a concomitant increase in housing. 

As a result, Marampa accommodation became over-congested with poor sanitation. It is therefore no surprise the Ebola is thriving in Marampa and its environs.

In sharp contrast to all this, places like the eastern Kailahun district where the virus first reared its head (and which is now almost Ebola-free) are sparsely populated and with less of such WASH - water, sanitation & hygiene - issues. Overcrowding, congestion, poor hygiene, inadequate water supplies & low sanitation are not much of a factor in Kailahun as they are in places like our over-populated Freetown or Lunsar.

So, to add to Dr. Kim's excellent points about the need to "build effective community health care systems", I will also urge for huge attention to be simultaneously paid to building effective community Water, Sanitation & Hygiene Systems and de-congesting the over-populated urban towns like Lunsar and Freetown. Policies that encourage urban-rural re-migration, should be actively encouraged by the government, the World Bank and international donor partners. Robust town planning that will include the enforcement of laws against poor sanitation, should also be actively brought back. The Freetown I grew up within, used to have a very robust culture of cleanliness alongside stringent urban planning. I understand Lunsar also used to be the same in terms of cleanliness and firm town planning. Ebola has taught us we need to go back to those days.

Dr. Kim's article ["The Path to Zero Ebola Cases"] with his tacit acknowledgement the world failed on Ebola (underestimated, he euphemistically writes) can be read at following link:

Sylvia Blyden, a physician, newspaper publisher, and a former executive to the president of Sierra Leone, is a politician.

Sylvia Olayinka Blyden on Facebook

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