The life-threatening situation for Red Cross Team because of a large community of people affected by Ebola who refused treatments. Emergency medical services have to face many dangerous and difficult situations.

The #AMBULANCE! community started in 2016 analyzing some cases. This is a #Crimefriday story to learn better how to save your body, your team and your ambulance from a “bad day in the office”! Sometimes good actions are not enough to save people, neither providing healthcare treatments. Our protagonist this time is a Registered Nurse (RN) with a Masters in Public Health with more than five years of work experiences in Clinical Emergency practice, pre-service training and clinical mentoring of Nurses and Midwives, Health Safety Security and Environment Nursing at ports and industrial areas, Community Health Nursing and a trainer for health workers on Ebola case detection/management, Infection Prevention & Control.

Here’s the story.

Ebola-affected community refused treatment

I led and coordinated the Ebola response with the Liberian Red Cross where I was responsible for high-level planning, implementation, monitoring and reporting of all Ebola activities in the 15 Counties of Liberia with all the different pillars of the response (contact tracing, community sensitization, psycho-social support, beneficiary communication & burials. I’m presently serving as the Health Manager at the Liberian Red Cross.

At the time of the incident, I was the National Ebola Coordinator for the Liberian Red Cross. We were working in all the 15 Counties in Liberia with community sensitization, contact tracing & psycho-social support. We also handled the burying of the dead bodies in one County where the capital city (Monrovia) is located and where the majority of the Ebola deaths took place. Furthermore, most importantly, we were also working on a special project called Community Based Protection (CBP) in hard to reach communities in the entire country.

Halfway into the Ebola response, we were trying to answer numerous questions about why entire households were getting infected with the virus even with the mass sensitization, and we found out that most communities were remote and inaccessible with little or no communication network coverage which makes calling an ambulance for a sick person nearly impossible or ambulances arriving in some of those communities taking more than 72hours or more most of the time.

Therefore, the Liberian Red Cross in partnership with UNICEF embarked on training people in such remote communities and supplying them with simple/light Personal Protective Equipment (PPE), basic medication (Paracetamol & ORS) and high protein bars in case they had anyone within their households showing any sign or symptom of Ebola and response time was more than two (2) hours. The culture in Liberia is such that it is very difficult to tell a mother or family members that they should not touch another family member that is sick and is not being picked up by an ambulance or not being attended to, so that was the reason why we ended up having entire households getting infected because they would try to do something even if it cost them their lives. It is just a normal way of life. So basically the CBP would train few community volunteers (trusted stakeholders like previous General Community Health Volunteers (gCHVs) trained by the Ministry of Health, Trained Traditional Birth Attendants) and prepositioned some of the protection kits for use by a single household member when the need arisen with supervision from the trained personnel (the concept of risking the life of one family member as compared to entire households being at risk. So it was literally isolation and care by one trusted family member until the sick person is picked up and taken to a treatment unit.

Liberia is on the West Coast of Africa with a total population of 4 Million. We have two seasons in every year, a rainy season that runs from April through September and a dry season that runs from Mid October to March. When it rains in Liberia it pours and the EVD started hitting hard during May June 2014 when the rainy season was getting to its peak in July August.

The strategy that the Liberian Red Cross used for the Community Based Protection was to hire trained and qualified Mid-level Health care professionals, trained than in the proper use of the protection kits, and expect them to further cascade the training to the community volunteers and also monitor the use of the protection kits on a daily basis in each county at Hotspot communities and if response time was more than 2 hours. There was support from other international Health Care professionals (IFRC Health Delegates) who also participated in this training and helped with monitoring in the field.

In terms of security, there were no major security measures put in place beside the normal rules of the vehicles not staying out of network connectivity range after 6 pm, the delegates moving into communities with their local counterparts etc. The Liberian Red Cross did not experience much resistance for most communities prior to this incident because of past activities of the National Society so there were no high-level security measures put in place when the teams are moving into communities.

Ebola-affected community refused treatment – The case

There were several of these incidents in Liberia during our fight against Ebola especially with the Red Cross burial teams but this one happened when I least expected it. I was leading a team of 7 to 9 persons for the Community Based Protection Training in a very hard to reach community when we were told by our volunteers that there were sick people showing signs of EVD that their family members were refusing to take to the treatment unit or even call the ambulance.

So I called the ambulance and went to convince the family members to allow their sick person to be taken to the ETU. They said NO and could not even allow us close to their houses. After a few hours, the ambulance arrived and these community members were very furious and wanted to know who called the ambulance and said we were not leaving and they will burn the ambulance. This was one of the scariest moments in my fight against Ebola. They were supposed to be under quarantine but they broke all the regulations of quarantine and wanted to touch us which would have exposed us to the virus also.

There were so many complications involved but this was really life-threatening for me and my team, yet we wanted to save the lives of those sick by taking them to the treatment unit.
We later learnt that two of our Volunteers that were within the community went to the town chief (happened to be a female and also a Red Cross Volunteer) to explain the incident and we had the others remain with us at the scene and was intervening (speaking in their local dialect) on our behalf whilst we were still pleading with them to allow their sick ones to be taken to the treatment unit. The town chief arrived in her Red Cross bib and intervened and the families accepted for their loved ones to be taken away with one request.

The request was that we should update them on the prognosis of their loved ones when they are at the treatment units. We accepted and quickly strategized and delegated responsibility amongst ourselves. I (Ebola Coordinator) was responsible to find out from the ambulance crew the name of the treatment unit that the patient was taken to and follow up daily and hence feed the health Officers in that County, then the Health Officers inform the volunteers and finally, the volunteers would inform the family members through the town chief. It was a perfect arrangement and it really helped to improve the relationship we had with the community members and also built further trust in the Red Cross work.

Analysis

There were lots of issues connected with this case. Community: The community members had little knowledge about the Ebola Virus Disease (its pattern of transmission, prevention and the dangers) and they even had a myth that it was Health Care workers that were spreading the virus and therefore they cannot go to the health facilities with their loved sick ones. They were also angry because they said that few patients were taken from the nearby community to the ETU and they did not hear anything from the ETU or the sick people (so they had the belief that once sick people were picked up, they will be sprayed with a poisonous solution that will help to kill them at the ETUs). There was a lack of trust in the systems. There was no feedback mechanism at the beginning and halfway into the response from the Treatment units to the community members about the progress of patients’ condition. The burial teams that were operated by the Red Cross were also faster than the ambulance responsible to pick up sick persons (operated by the government) and community members didn’t know the differences in roles played so that created lots of threats for us and our team

Responders: There was a lot of disconnect among the humanitarian workers and major partners including the government through the Ministry of Health. We were not responding on time due to a lot of factors that were beyond our control(deplorable road networks, raining season with flooded bridges, poor network connectivity etc.)and by the time the ambulance got to some of the communities to pick up the sick person, institute quarantine measures, almost all the members of the households might have had direct contact with the sick person, and in less than two weeks, most members of the household started to exhibit signs or symptoms and then most times, the entire household gets infected with the virus due to the delay or sometimes no show of the ambulance.