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Ebola: Some thoughts from my time in Liberia By John Spray, ODI Fellow, Ministry of Commerce and Industry, Liberia.

 

A lot has been written about the Ebola crisis in West Africa in the last few weeks. Many excellent articles have highlighted the plight of those suffering with Ebola (Newsweek), and the people on the frontline trying to tackle the virus (Time) and the consequences on the affected countries as a whole (How we made it in Africa). However, the real tragedy is how an inherently preventable virus was able to spread like wildfire throughout West Africa and why public health facilities failed on such an enormous scale.

I first heard about Ebola in March 2013, four months after the first patient died of the virus in a small village in south-eastern Guinea, the first ever in West Africa.
With the death toll rising across the border in Guinea, discussions in Monrovia turned to the threat of it reaching the capital: “no previous outbreak has killed more than 300 people”, “it is easy to avoid just don’t go near sick people and you are safe”, and “the disease kills people so quickly it will die out before it reaches Monrovia”. The general message was “it is scary, but we can control it with basic public health.”

Despite these reassurances, everyday you check the news: how many infected? How many died? How many health clinics were beginning to shut due to healthcare workers leaving their posts? Despite the growing chaos, we in Monrovia continued to rationalize the situation. We knew things were getting worse but we didn’t act in time.

So when did it get “out of control”? Was it when MSF declared it to be so in June? Was it when the virus hit Conakry, Freetown and Monrovia, making control of the disease in crowded urban environment increasingly hard? Perhaps it was when the Liberian-American Ministry of Finance consultant died after flying to Lagos, inadvertently putting a planeload of passengers and Africa’s most populous country at risk.

Whenever it was, there is no question that we are now in the middle of an unprecedented crisis. Every day, I dread reading the news. The front page of every newspaper is full of articles discussing the bleak picture of Liberia’s largest slum quarantined like something out of a science fiction novel. I read about the almost complete collapse of the government’s health care facilities and the justifiable fear of the healthcare workers too scared to go to work. We hear terrifying stories of suspected cases being turned away from treatment centres because there is no space to treat them, and bodies left on the street for days without someone coming to pick them up. Most of all, I fear for the secondary threats should countries follow through on plans to impose economic embargoes on the country.

Already five airlines have stopped flying to Liberia through fear of the disease. Earlier reports that West African ports have refused entry to vessels which have docked in Liberia appear false, but raise an alarming prospect of the country cut off from essential imports. This is dangerous given that Liberia is completely dependent on imports with an import bill equal to 60 percent of GDP including two of the most important commodities, fuel and rice. Even without an economic blockade importers are worried.

Early reports suggest for the last four weeks the number of import certificates are down 30 percent from the previous year. Not to mention, the travel restrictions inside the country making movement of agricultural goods from farm to market next to impossible. These developments will raise the price of essential goods necessary for the Liberian economy to function and will harm the very poorest. They also raise the possibility of riots on the street and a return to the days of anarchy last seen during Liberia’s bloody civil war.

So how did this happen? The underlying causes of this outbreak are many and difficult and will be discussed for years to come. Fundamentally, they focus on the fragility of West African states and the failure of emergency planning to tackle the crisis when it was at a manageable level.
What can we do about it? Despite the fear, there are many brave West Africans and foreigners continuing to fight this disease. The Ministry of Health is working to open new treatment centres, MSF continues to fight the battle on the front line and are managing patient care alongside national governments. The World Bank has promised USD200million to fight the disease in West Africa. The African Development Bank has promised USD210million to build West African public health facilities. The World Food Program has begun the process of bringing in food to tackle the secondary crisis. NGOs on the ground, including Oxfam, have begun gearing up awareness campaigns to get the message out that Ebola is preventable. These things are vital to the immediate fight and the world needs to react, and react fast.

Once the immediate crisis is brought under control, we must consider measures to strengthen the state institutions especially the health service in order to effectively deal with health threats in the region.

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Lost in translation: reflections from the 20th International AIDS Conference (July 2014) By Gracia Violeta Ross: UNITAID Board Member for Communities Living and Affected by HIV/AIDS, TB and Malaria

With great enthusiasm I started my 33 hours flight from Bolivia to the big country-continent: Australia. But my first night in Melbourne was filled with tears as I turned on the television and heard of the attack to the Malaysian flight MH17.

The opening ceremony of the 20th International AIDS Conference paid respect to the scientists and advocates who died in this tragedy. Throughout the conference, almost all plenary speakers spoke about the “now more than ever” feeling and the importance of Stepping Up the Pace of the AIDS response. In this blog I share some of my reflections from my week in Melbourne.

The highlights

• I was reinvigorated by the effective activism on Hepatitis and HIV as activists protested against the hypocrisy of the big pharmaceutical industry pricing life-saving medicine beyond the means of people and governments

• It was interesting to learn about the issue of “Grey HIV” as we are seeing people living with HIV getting older in developing countries. Getting old with medications and with HIV looks scary for me because I am also living with HIV and I am already 37!

• It was inspiring to hear daring talks about sexuality in conservative contexts such as those in some Muslims countries and Christian conservative settings. I was pleased to hear that faith leaders are increasingly tackling this issue and talking to their peers

• Although the theme of the conference was “No one left behind”, I heard a lot of the discourse of “shared responsibility” in the AIDS response. Ultimately, this is the idea that countries will have to “find your own funding”. For Middle Income Countries (MICs), the pressure is already mounting and there is a real risk that these countries will be left behind

• I did not hear a lot about women and girls as a key population and the links to gender based violence and HIV. Moreover the debate on vulnerability to HIV infection and impact must recognize that each community and country has its own vulnerabilities that need to be considered in AIDS response

• Children living and affected by HIV were notably absent and this is a fundamental mistake, given the fact that this group is really voiceless and vulnerable. There are huge gaps in the coverage of treatment for HIV and TB for children. I am really enthusiastic about UNITAID because it invests in shaping the market for diagnosis and treatment of children

• As someone coming from Latin America, I felt the strong absence of my region, not only in that very few delegates from Latin American and the Caribbean were present, but also in the fact that the UNAIDS’ “global analysis” included incomplete data from these two regions. At the conference, I realized that there is much misunderstanding about Latin America and the Caribbean. Some donor countries seem to believe these two regions have universal coverage of treatment and prevention services. The reality is that Latin American countries vary a lot and there is huge inequality and disparity.

At the end, I left Melbourne without seeing the sun nor one Kangaroo!

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Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind By Georgia Burford (CAFOD)

Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind By Georgia Burford (CAFOD) The International AIDS Conference in Melbourne 20-25 July 2014 is the 20th gathering of the largest regular conference of any health or development issue, bringing together politicians, scientists, epidemiologists, practitioners, policy makers, the private sector and communities of people living with and affected by HIV. There is uniqueness in this fight against HIV in that it is a social movement, pulling people together and putting people at the forefront of the response to sustain our efforts on addressing HIV. It’s a powerful reminder that HIV has not gone away and is still affecting the lives of many today. The theme of this year’s conference was ‘Stepping up the Pace,’ summarised by Bill Clinton when he said ’It says much good work has been done, but it’s not an excuse to slow down. Right now we must redouble our efforts on areas like stigma and discrimination, which after 30 years is still increasing in some regions. We have the tools; we need to step up the pace.’ There has been remarkable progress since the 1980s, when HIV was a condition that had no name, no tools to diagnose, prevent or treat it. Today, there are 15 million people on treatment, yet there are still alarming challenges that must be tackled in order to even contemplate an AIDS free generation. Statistics from 2013 show there were 1.5 million HIV deaths, 2.1 million new infections and 35 million people living with HIV. Of the 35 million people living with HIV, 55% (19 million) don’t know they have the virus. They haven’t been tested and if they don’t find this out, they will die. The conference highlighted many reasons as to why people do not access or drop out of treatment. Reasons can be due to lack of services; however, a large part is due to stigma. Studies and personal testimonies have shown that:

  • Men are less likely to come forward for testing [1] when their wives are being tested during pregnancy because:” pregnancy is about women not men”. Men may be testing but not telling their partners, claiming that “they’re too busy”
  • Women, who may often discover a positive test whilst pregnant, will opt out of treatment and out of disclosing to their partners for fear of loss of trust, abandonment and violence from their partner for bringing HIV into the home[2],[3].
  • For youth, where 2 out of 3 new infections is amongst girls aged 15-19 years old, HIV remains the biggest killer of adolescent girls. This can be attributed to the lack of education around sex and HIV[4],[5], the stigma and barriers to youth friendly sexual health and HIV services[6] and links between poverty and transactional sex[7].
  • For Key populations, including sex workers, men who have sex with men and injecting drug users, many are inhibited from seeking testing and treatment because of legislative, structural and societal barriers – fear of judgement or reprimand[8],[9].

In many cases it may be easier to ignore the positive status than deal with the consequences of seeking support. The need for this is highlighted in a recent report produced by STOPAIDS Entitled “Increasing DFID’s contribution to Addressing HIV among key populations which makes a series of recommendations about ways to advance the rights of communities who are disproportionately affected by AIDS. The report was launched at the conference alongside a recent film focusing on people who use drugs in Moldova. We must tackle stigma and discrimination at every level including state policies. The AIDS 2014 conference organisers released the AIDS 2014 Melbourne Declaration, calling for an end to discrimination against people with HIV and the eradication of criminalising laws and practices. [10] Another key issue highlighted at the conference is the importance of monitoring viral load to ensure PLHIV are able to access necessary medication in order for treatment to be optimally effective. However, currently very few high-burden countries routinely offer viral load testing to people receiving HIV treatment. Since 2012, UNITAID has supported projects working to make viral load testing technologies available in resource-limited settings in Sub-Saharan Africa, but these do not yet address viral load monitoring needs on the large scale required. More efforts are needed to make new viral load testing technologies must be affordable and appropriate for poor resource settings in order to be used effectively. In Melbourne, UNAIDS launched the Diagnostics Access Initiative which calls for improving laboratory capacity to ensure that all people living with HIV can be linked to effective, high-quality HIV treatment services. Lack of access to Treatment is still a huge concern especially that there is a 10 fold price increase from 1st line to 2nd line treatment. In reality, the international community is facing huge challenges to control HIV. Therefore, governments, policy makers, funders, and civil society need to:

  • Have a renewed focus to work on the Key Populations and those most at risk and focus on stigma, discrimination and the legislative barriers
  • Address the dysfunctional health systems that hinder treatment
  • Continue campaigning for effective, affordable and appropriate new medicines and medical technologies (e.g. viral load equipment)
  • Challenge the notion that HIV is over and ensure that decision makers realise that  we are at a critical tipping point, where if we don’t step up the pace now we will miss the opportunity to contain the epidemic
  • Ensure the unfinished business of MDG 6 is taken forward post 2015 into the health goal

In the expressive words from Sir Bob Geldof, ‘We have come so far but there is a preposterous reluctance to fund the last mile. The advocates get tired, the same message goes out to the same people and it becomes less effective.’ I can’t help but think that many of the UK based members of the STOPAIDS network feel the same. It’s not only a challenge on the global stage, but often within many of the organisations we work in. We must not become those tired advocates beating the same drum, but come back from the conference championing the successes of our work over the last 30 years and enter a phase of renewed energy to ensure we step up the pace and most importantly leave no one behind.


 

References

[1] Intrahealth International at AIDS 2014 Conference

[2] Rev Phumzile Mabizela, INERELA+, Pre Interfaith Conference
[3] Jennifer Gatsi Mallet, Namibia women’s health network, ICW, Plenary Session AIDS 2014 Conference
[5] UNESCO poster at AIDS 2014 Conference
[6] YWCA, PNG, Pre Interfaith Conference
[7] Cluver, L, Boyes, M, Orkin, M, Pantelic, M, Molwena, T, Sherr, L. Child-focused state cash transfers & adolescent HIV infection risks: A prospective multi-site study in South Africa. The Lancet Global Health
[8] Rev Phumzile Mabizela, INERELA+, Pre Interfaith Conference
[9] Khuat T. Oanh, MD, Vietnam, Diane Havlir, MD, United States, Daisy Nakato Namakula, Uganda, James Ward, BA, Australia, Wednesday Plenary Session AIDS 2014 Conference
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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.