Leader Development & Education for Sustained Peace Program: Cross-Cultural, Geopolitical & Regional Education

InReview: Ebola Crisis – Focusing on Africa’s Healthcare System

Since the deadly virus was first detected in March 2014, Ebola has been spreading rapidly throughout West Africa and now possibly other countries. The spread of diseases and viruses in sub-Saharan African countries highlights several problems facing the health situation in the continent from cultural skepticism toward Western medicine to a poor healthcare system. The following will look at the causes and consequences of West Africa’s health crisis.

First a significant and unique problem facing healthcare systems in the region is the cultural belief in witchcraft and superstition. Clair Macdougall, a writer living in Liberia explains in Foreign Policy  “Death and Denial in the Hot Zone”:

Why do so many people in West Africa think the Ebola outbreak sweeping through the region is a hoax?

The lethal virus has already arrived here too. According to Liberia’s assistant minister of health, Tolbert Nyenswah, 19 people from Zango Town have died. A few tested positive for Ebola and were treated in “case management centers” run by Samaritan’s Purse, an international Christian NGO. Yet many in Zango Town are skeptical of what they have been told. Some do not even believe Ebola has struck their community. They imagine the deaths were caused by something else or that health workers are killing patients.

A few weeks back, citizens of the town attacked a community health team that came to spray the area with chlorine, a cheap and effective way of killing Ebola, and tried to set its car on fire. Now a lone pink plastic bucket containing chlorinated water sits in the middle of the town, intended for people to use to wash their hands. No one touches it.

Henry Jallah, a 23-year-old farmer, recently lost five family members to illness, including his mother, an uncle, an aunt, and two of her children. He expresses his loss matter-of-factly and says that God is telling him to get on with his life. “There be no hope,” he says. “So many people are dying.”

Jallah says he has accepted the advice of Liberia’s Health Ministry to stay away from dead and sick people in the town, yet he is hesitant to believe it is really Ebola that claimed his family. He offers other explanations: poisoned drinking water as vengeance for a conflict over land, or some kind of curse. His family never took his aunt to a case management center, he says, because “some people say when you go over there, they can inject you — when you having the sickness, they inject you and kill you.”

Liberia, along with its neighbors, Guinea and Sierra Leone, were once racked by war. Today, they are all facing a new and deadly crisis: Ebola, a virus that attacks organs and leads to fever, diarrhea, bleeding, and in most cases death, has swept across the countries and threatens to extend its reach. The virus, which cannot be cured but can be treated, can kill up to 90 percent of those who catch it. The overall death rate in the three West African countries is currently around 60 percent. Roughly 1,200 cases have been identified, the most ever in an outbreak, and some 670 people have already died.


Yet the biggest hurdle in stopping the spread of Ebola seems to be overcoming denial and fear in communities that are deeply suspicious of the government, the health-care system, and international institutions. This includes remote areas, which are relatively untouched by the government or have only experienced it in the form of force and coercion. But Monrovia, the capital, is not immune: In bustling Duala Market, 92 percent of people said they did not believe Ebola existed, according to a recent survey of 1,000 people conducted by Samaritan’s Purse. In fact, many in the capital initially viewed the virus as a hoax created by the government to generate and “eat money” from aid donors.

Often, too, people here view life events, including tragedies, through the prisms of religion and superstition. There is a Liberian saying that goes, “Nothing for nothing” — meaning, everything happens for a reason. Even Ebola.

Over the weekend, in a community called Popalahun, in Liberia’s Kolahun district, residents staged a roadblock and attacked health workers traveling in a jeep. They smashed the jeep’s windshield and gashed its tires with a machete. Four Liberian health workers who were part of a team, employed by Samaritan’s Purse and tasked with collecting the body of a person who had died of Ebola, scrambled to safety in the bush. One who was beaten with a hammer managed to escape. Kendell Kauffeldt, the country director for Samaritan’s Purse, says his organization will be forced to cease outreach — that is, collecting patients and bodies from towns and villages. “We just cannot afford to put ourselves at that risk at this point,” he says.


Compounding these problems, even when people believe Ebola exists, many are wary of hospitals because they believe the institutions provide poor care — a concern that existed well before the current crisis. To be sure, Liberia’s health-care system has improved since civil war ripped the nation apart; there has been a reduction, for example, in the under-5 child mortality rate. Yet Monrovia’s largest hospital, John Fitzgerald Kennedy Memorial Medical Center, or JFK, is nicknamed “Just For Killing” among locals because people go there with treatable diseases such as malaria and still die. There have been reports that, recently, health workers at JFK refused to treat patients suspected of having Ebola, even abandoning the facility’s emergency room. (The hospital’s Ebola ward has since been closed. JFK was “dangerous,” according to Kauffeldt, as proper procedures for dealing with the disease were not followed.)

(Foreign Policy, emphasis added)

New York Times expressed a similar sentiment of how “Fear of Ebola Breeds a Terror of Physicians” with an explanation of a historical context:

Eight youths, some armed with slingshots and machetes, stood warily alongside a rutted dirt road at an opening in the high reeds, the path to the village of Kolo Bengou. The deadly Ebola virus is believed to have infected several people in the village, and the youths were blocking the path to prevent health workers from entering.

“We don’t want any visitors,” said their leader, Faya Iroundouno, 17, president of Kolo Bengou’s youth league. “We don’t want any contact with anyone.” The others nodded in agreement and fiddled with their slingshots.

Singling out the international aid group Doctors Without Borders, Mr. Iroundouno continued, “Wherever those people have passed, the communities have been hit by illness.”

Health workers here say they are now battling two enemies: the unprecedented Ebola epidemic, which has killed more than 660 people in four countries since it was first detected in March, and fear, which has produced growing hostility toward outside help. On 25 July alone, health authorities in Guinea confirmed 14 new cases of the disease.

Workers and officials, blamed by panicked populations for spreading the virus, have been threatened with knives, stones and machetes, their vehicles sometimes surrounded by hostile mobs. Log barriers across narrow dirt roads block medical teams from reaching villages where the virus is suspected. Sick and dead villagers, cut off from help, are infecting others.


Health officials say the epidemic is out of control, moving back and forth across the porous borders of Guinea and neighboring Sierra Leone and Liberia — often on the backs of the cheap motorcycles that ply the roads of this region of green hills and dense forest — infiltrating the lively open-air markets, overwhelming weak health facilities and decimating villages.


There is no known cure for the virus, which causes raging fever, vomiting, diarrhea and uncontrolled bleeding in about half the cases and up to 90 percent of the time, rapid death. Merely touching an infected person, or the body of a victim, is dangerous; coming into contact with blood, vomit or feces can be deadly.


The wariness against outside intervention has deep roots. This part of Guinea, known as the Forest Region, where more than 200 people have already died of the disease, is known for its strong belief in traditional religion. The dictator who ruled Guinea with an iron fist for decades, Ahmed Sékou Touré, was only partly successful in a 1960s campaign to stamp out these beliefs, despite mass burnings of fetishes.

(New York Times, emphasis added)

The phenomenon of fear and superstitions resulting in the spread of disease is not new to this most recent Ebola crisis. In fact, the same cultural factors have led to the spread of AIDS in the continent. Benjamin Radford writing for Discovery.com reports on “How Belief in Magic Spreads AIDS in Africa”:

In many countries throughout the world belief in witches is common, and black magic is considered part of everyday life. A 2010 poll of 18 countries in sub-Saharan Africa found that over half of the population believe in magic. Witch doctors are consulted not only for healing diseases, but also for placing, or removing, curses or bringing luck.

One human rights activist in the small African country of Malawi, Seodi White, has been fighting for years to stem many traditional beliefs that help spread HIV, especially among poor and underprivileged women.

According to a CNN story, widows in some parts of southern Africa are expected to engage in unprotected sex in order to “cleanse” them. The belief is that the husband’s spirit will return otherwise, cursing the family.

“It’s a mindset issue,” White told CNN. “Even the widows, they’ve told me, ‘I don’t want to die, I don’t want a curse to come to my husband.’ They cry to be cleansed.”

Because this spiritual cleansing involves unprotected sex — just as sex with the deceased husband was assumed to have been — the widows are placed at increased risk of contracting HIV, which is endemic on the continent. There are even professional “cleansers” who charge high prices for their services, which the widows are often eager to pay to avoid a curse on their families.

“It’s a mindset issue,” White told CNN. “Even the widows, they’ve told me, ‘I don’t want to die, I don’t want a curse to come to my husband.’ They cry to be cleansed.”

Because this spiritual cleansing involves unprotected sex — just as sex with the deceased husband was assumed to have been — the widows are placed at increased risk of contracting HIV, which is endemic on the continent. There are even professional “cleansers” who charge high prices for their services, which the widows are often eager to pay to avoid a curse on their families.

In her book “The AIDS Conspiracy: Science Fights Back”, Nicoli Nattrass, director of South Africa’s AIDS and Society Research Unit, notes that there “is a rich South African literature suggesting that many black people believe that HIV may have spiritual causes, notably witchcraft attacks or loss of protection from ancestors through violating cultural taboos. As Adam Ashforth observes, ‘a disease or complex of symptoms better suited to interpretation within the witchcraft paradigm than AIDS would be hard to imagine.’ This is because the symptoms of AIDS — diarrhea, tuberculosis, and wasting are also the classic symptoms of poisoning through witchcraft. Thus, even where people accept that AIDS is caused by a sexually transmitted virus, suspicions of witchcraft may be retained as potential explanations for the ultimate reason behind the infection.”


Finding treatments — and possibly even cures — for AIDS is one thing, but changing deeply-rooted cultural beliefs that perpetuate the disease is almost as difficult. Seodi White has had some success fighting such beliefs, for example recruiting former professional cleansers who have since contracted HIV to visit villages across the country condemning the tradition they once practiced as dangerous and irresponsible.

(Discovery.com, emphasis added)

In excellent reporting from Malawi, the Independent offered the following article on World Aids Day 2012: “The Curse of Being One of the Witches of Malawi

Until recently, Kasarika had one of the highest rates of HIV in the south-east African country, more than double the national average of 12 per cent. One in four people knew they were HIV positive in Kasarika, but more did not know, and the real figure was undoubtedly much higher.

Every day the local vicar held at least four funerals, sometimes more. The village was dying. With no knowledge of how the virus was transmitted, the villagers looked for someone to blame. So they blamed the elderly, including Enifa.

The community – like so many others across Malawi – believed that HIV/Aids deaths were caused by a curse from God. They believed that curse was cast by witches. And a witch was anyone who lived to be “very, very old” or in local parlance, anyone over the age of 60.


“Instead of rejoicing that God had kept us this far, when people died, other people pointed their fingers at me and said I was bewitching them,” Enifa told The Independent. “It went on for years. In the end the whole village was accusing me. They used to say, ‘You are a witch. You are killing people.’ It was very painful. I just couldn’t believe it.”

Worse was to come. Enifa’s own family turned on her. They ransacked her house shouting, “Why aren’t you dead yet? We want you to die”, she says.

“If your own children and grandchildren rise against you, what will happen to everyone else?” she says. The answer was that they joined in. Enifa was repeatedly attacked and on one occasion an angry mob carrying sticks set upon her, apparently intending to beat her to death, before she was rescued.


Two-thirds of all people of living with HIV/Aids are in Africa. The terrible effect on those of working age, who often leave orphans to be brought up by others, is well-known. But this is a hidden side to the HIV/Aids pandemic in Africa.


‘Things have started to change,” says Enifa. “In some cases people came to apologise to me. They said, ‘We’re very sorry. We know that you have nothing to do with the deaths that have happened’.”

All three are now back on good terms with their former accusers and their families. There is still plenty to do, but the prevalence rate of HIV/Aids in the village has also dropped to 15 per cent.

(The Independent, emphasis added)

The cultural barriers to providing healthcare, especially in times of crisis, are compounded by the problems facing the various healthcare systems in West Africa. While the wealthy have access to satisfactory hospitals and doctors offices, others like those living in Sinkor, Liberia are forced to rely on shockingly rundown and poorly kept hospitals. ABCNews reported on “Liberia’s Medical Conditions Dire Even before Ebola Outbreak”:

Ebola has run rampant throughout West African countries such as Liberia because the medical situation there is so dire to begin with, according to an American doctor who leads humanitarian missions into the region.

“The health care system and infrastructure are very poor,” said Dr. Anne Marie Beddoe, a gynecologist with Mt. Sinai Hospital in New York City. “Handling an outbreak of this magnitude only highlights the deficiencies in personnel and equipment.”

Liberia, a country of four million people, has only 37 practicing doctors, according to Beddoe and health officials.

Beddoe said that when she and her husband, Dr. Peter Dottino, who is also a gynecologist, took their first trip to Liberia in 2008 they were shocked to see the state of the medical facilities there. The JFK Medical Center in the capital city of Sinkor, once considered a center of excellence in West Africa, was left outdated and crumbling after withstanding a 30-year civil war.

“Most of the hospital’s windows were broken, the paint was peeling and walls were crumbling,” Beddoe noted. “In the entire hospital there was one working bathroom and a few functional sinks on the patient floors.”


The Liberian government is trying to address the crisis, Beddoe said. During the civil war that ended in 2003, the country’s only medical school was forced to close for long stretches and it took an average of eight years for students to graduate. But now, Beddoe said, a class of about 20 students is on track to graduate in 2016 and spend three years learning a medical specialty.

With the help of the Mt. Sinai team, a local doctor was able to open a tiny one-room chemotherapy clinic a few blocks from the hospital in 2012. Beddoe and Dottino teamed up with musician and film maker Stephen Harris, to film “Lay Your Trouble Down,” a documentary that shows their efforts to treat patients in Liberia and get the clinic up and running.

(ABCNews, emphasis added)

The website Global Health Africa is an excellent resource on the subject writ large and it features “a broad range of research, news articles and opinion pieces on health issues in Africa written from a unique perspective.” Guest blogger Udo Obiechefu, a public health researcher and professional, recently released a much-needed diagnosis through Global Health African on “West African Healthcare: Problems and Solutions”:

The issues related to health care delivery and access in West Africa is plentiful. Lack of adequate funding, a small workforce, poor organization, and a dearth of viable private sector solutions are just a few of the many dilemmas preventing countless West Africans from attaining sustainable access to quality care. Discussions addressing these issues are numerous and ongoing. I will attempt to contribute the discussion by starting a conversation revolving around three major dilemmas facing West African healthcare. In part two we will discuss possible solutions.

Part 1: The Problems

The Private Sector: Is Private Health Insurance Realistic?

A problem that is evident within the realm of West African healthcare is the lack of an adequate, cost appropriate private sector market. Much of this is due to the fear of high costs and conjecture surrounding the profit motives of potential investors. Although these suspicions may be warranted due to the insurance industries checkered history in other parts of the world, it is important to acknowledge the lack of strong private sector options as another problem plaguing healthcare access in West Africa.  Because of the high out of pocket expenses encumbered by those seeking medical services, healthcare providers have difficulty predicting the flow of revenue. This lack of predictability has lead to the inability of providers to improve the quality of services. As a result of this and many other factors the private sector has remained underutilized.

The reality is that West Africans have proven capable of and willing to prepay for services. This is evident in the success of prepaid cellular cards. Of course, the healthcare market has many complexities and comparisons with the mobile telecommunications market can be a stretch, but what is evident is the basic premise of prepayment is not a foreign idea. The problem resides in the fact that consistent access to quality medical care can be difficult to come by.


Staffing: Understaffed, Overworked and Unemployed

The World Health Organization recommends, as a minimum standard, one physician for every 5,000 inhabitants of a geographic area. Many West African nations fall far short of this criteria. Burkina Faso, Benin, Senegal, Sierra Leon, Niger and Mali all average less than ten physicians per 100,000 inhabitants. This staffing crisis is also present in nursing and hospital administration. Despite the fact that Africa, as a continent, accounts for over 40% of the worlds communicable diseases, it comprises less than five percent of the global health workforce. Unfortunately West African nations are not producing healthcare workers at the rate of demand. Also troubling is the fact that many of the healthcare workers who are available are located in larger cities which leaves those in rural areas an additional burden.

Notwithstanding the issue of shortage, there is also the issue of funding. There are many nurses and midwives who are underemployed or unemployed in West Africa. This is due to nations lacking the financial ability to meet even modest salary demands. This has caused many capable medical professionals to leave the region in hope of finding more opportunity elsewhere. West Africa is being devastated by a “brain drain”. Due to economic, social, and personal reasons well educated, qualified and motivated healthcare professionals in West Africa are seeking opportunities in the west. Europe and North America are reaping the rewards of West African educated healthcare professionals. These issues have lead to an over reliance of many *ECOWAS governments on skeleton staffing or temporary foreign health workers. This dependency has produced a system where instead of making systemic changes to the current healthcare structure that would aid in the production and maintenance of a larger workforce, there is a culture of anticipation and need for the next available foreign assistance to provide relief to a poorly functioning arrangement.

Healthcare Financing: “…..Or lack thereof”

Donor funding accounts for 25% of healthcare financing in one third of African nations. This statistic also holds true for numerous ECOWAS nations. Many foreign funding sources that contribute large amounts of aid to West African countries operate cyclically and can at times cut funding without the host country being prepared to absorb the financial impact. Even more concerning is the high percentage of funding that comes from out of pocket expenses. Sixty percent of health expenses are paid for out of pocket in Africa. These expenses can come in the form of user fees at public facilities, direct payments to private providers and even cash payments to traditional healers.

Numerous West African nations struggle with developing revenue streams to finance their healthcare systems. User fees are currently a source of revenue for West African governments. Although many primary care services are exempt from fees (immunizations, family planning, treatment of communicable disease), it still has proven a burden to care for many poor families. User fees have shown to be largely unpopular and many ECOWAS nations are currently exploring their abolishment. With the abolishment of fees comes the need to find a suitable source of additional revenue which can be quite difficult for low income nations.


Part 2: Solutions

The availability of private health insurance in West Africa is quite limited. Many health insurance plans are only available and marketed to the wealthy and/or expatriate communities. As mentioned in part one, it is apparent that West Africans are willing and able to pay for reasonably priced prepaid services. There is great potential to improve healthcare access and delivery through the availability of well-priced, quality health insurance.

What would make the idea of purchasing health coverage more palatable for citizens of West African nations are more reliable health services. Even if given reasonable choices for coverage, there still has to be confidence in the system to provide the care required. The system can be improved if more is done with the resources available. Some of these resources include the user fees that consumers must pay out of pocket and international aid. The idea of providing private health insurance to low income Africans is already being put to practice. The Health Insurance Fund (HIF) is a foundation devoted to achieving this goal. Through the foundation, donor funds and international monetary aid are linked to health maintenance organizations and insurance companies. These organizations are responsible for the execution of the insurance plans. The mission of the Health Insurance Fund is to protect the wealth of low income African families by utilizing private insurance as a means to access quality care. The resources of the HIF are used to upgrade the medical and administrative services of the contracted insurers and providers. The first HIF program was initiated in Nigeria utilizing Hygeia, which is the largest healthcare service group in the country. At this point in time the HIF has over 120,000 enrollees.

(Global Health Africa, emphasis added)

For the West Africa News Headlines: See the PDF


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