Ebola emerged in the conflict-affected Gulu district of Uganda in October 2000, with two clusters first coming to the attention of authorities, among a group of funeral attendees, and among health staff at St Mary’s Lacor hospital, run by an Italian Roman Catholic mission in the district [23]. The index case was never identified, but it is thought that movement of people across the Ugandan, Sudanese and the Democratic Republic of Congo borders is likely to have been implicated [24], and it was speculated but never confirmed that the disease had been carried by Sudanese rebels operating in Gulu,
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or by the Ugandan military on return from Congo [25]. The potential for troop movements to be associated with disease outbreaks has also been demonstrated by the post-earthquake cholera outbreak in Haiti [26].
The disease infected 425 people, 224 of whom died, a case fatality rate of 53 %. 17 among the 224 dead were health workers. Centres for Disease control (CDC) [27], Lane and Nicoll [24], Okware et al. [28], and Lamunu et al. [23] provide descriptive accounts of the control response that by 16th January 2001 had brought the outbreak officially under control, with the last confirmed case occurring on the 14th January. The Ministry of Health was first alerted to the outbreak on 8th October 2000 and a National Task Force (NTF) was established on 12th October 2000 to coordinate the response; inter-ministerial and district task forces followed. Response strategies consisted of contact tracing, public education and community mobilization, isolation of cases, infection control through universal precaution and safe burial of the dead using trained burial teams. CDC established an on-site field laboratory for case confirmation. The NTF ensured that international support contributed to the agreed strategy and work plan: more than 25 international organizations contributed.
The cited accounts credit the success of the control efforts to a number of factors: prompt action and effective coordination at both national and district levels; conducive community protocols for dealing with infectious disease among the Acholi people [29]; effective public communication; use of trained burial teams to ensure safe burial in cases of suspicious deaths; effective surveillance mechanisms reaching into communities by the employment of community level scouts, trained for the purpose. The role of the media is highlighted by Okware et al. [28] as supportive of the control efforts, educating the public about control behaviours, reassuring and limiting panic, and explaining government actions such as quarantines. Media briefings from the National Task Force were organised twice per day. Despite newspaper stories reporting panic, stigmatizing reactions and a mix of likely effective and ineffective responses to the risk posed by the outbreak, Kinsman’s [25] account of the media’s coverage does not suggest that the media was itself a significant spur to these reactions. Moreover, it appears that the media was used strategically by the Ministry of Health as a means of advising the population on appropriate precautions and health providers on control measures.
The effective response may have been supported by the country’s successful management of its AIDS epidemic, widely attributed to its strategy of openness and leading to an understanding of the implications of being seen to hide information in public health emergencies. Uganda’s ‘open’ AIDS policy initiated in the 1980s encouraged officials at all levels to raise AIDS regularly at public meetings [25]. Uganda had also very recently controlled its largest recorded cholera outbreak that emerged at the end of 1997 [30] with likely significant opportunities for learning relative to the Ebola outbreak.
The control effort was not without problems. It was forced to operate in the context of continued conflict with army escorts employed to accompany surveillance teams to insecure areas [23] and the death of one scout during an attack on a medical team [25], although Okware et al. [28] report cooperation by rebel groups with the control effort in some instances. Supplies for barrier nursing were scarcely sufficient in the early phase of the outbreak and prior training had been insufficient [31] and 14 of 22 health workers were infected during the establishment of the first isolation ward [24] leading to the reinforcement of infection-control measures [27]. Health workers were not at first compensated for the additional risks or their families compensated for their deaths, until approximately two months into the outbreak [25].
Hewlett and Amola [29] describe the experience of the outbreak from the community’s perspective. The illness was first understood as any other, with recourse to a mix of biomedical and traditional treatments, the latter in particular responsible for significant use of family resources to secure traditional healers’ intervention. When this failed, the illness was reclassified in traditional terms, producing community responses including isolation of the sick, contact only by survivors of the illness or the elderly and constrained movement between villages, a set of responses that was highly consistent with those biomedically recommended. Burial practices were also changed in ways that may have reduced transmission, but only after the initial phase when normal burial practices were probably associated with a high level of transmission, particularly to women who are most exposed by traditional practices. Issues of trust between local communities and Euro-Americans may have affected the control effort as people sought to evade transport to hospital for fear of theft of their body parts if they died, initial post-mortems and sample collection having generated such rumours. The speed and lack of public visibility of burials conducted under control protocols contributed to this fear. Stigma also significantly affected survivors in ways likely to lead people to seek to conceal the early stages of illness [29, 24].
While some desertion from their posts by health workers is documented [31, 25] the more dominant behavior was to remain despite the risks and at times inadequate protection and this may reflect the reality that the health workforce already persisted in delivering services in the midst of conflict in which they were regularly at risk.
Life histories with health workers in the Acholi sub-region found that the Ebola outbreak of 2000-1 added to their ongoing challenges, such as experiencing injury and living under threat, with increased workloads and minimal professional support [32]. Those who stayed (largely mid-level cadres) were supported by encouragement from managers and elders, and appear to have been intrinsically motivated, taking pride in their work as health workers. Health workers coped with increased workload by taking on higher levels of responsibility than those they were qualified to do and by working in shifts. Allowances for outreach from NGOs to cope with epidemics such as Ebola also helped to keep them going in the absence of regular salaries, and other support from NGOs including unprecedented levels of training and engagement with international experts were also motivating [32, 33].
Despite the inevitable difficulties, Uganda appears to have managed well in the context of a conflict affected health system by providing good national leadership, likely benefiting from the national institutions in the central part of the country which had avoided recent conflict, enabling better coordination and oversight than might typically be expected. Uganda’s emergence from conflict at the national level was relatively immature, the outbreak occurring only 15 years after Yoweri Museveni had come to power and brought stability after a long period characterized by intermittent civil war and localized conflict. Nevertheless, its institutional development in that period has been considered rapid. Museveni’s first term until 2001 was strongly supported by foreign aid and the country experienced rapid economic growth [34, 35] While the North of the country generally failed to benefit from these trends [36] the availability of the national resources and institutions appear to have been a factor in the Ebola response.
As the conflict in the North was ongoing, the region was not at that stage significantly penetrated by a major international aid presence with concomitant concerns of co-ordination and sovereignty, thereby easing the coordination task. A major resource appears to have been provided by the St Mary’s Lacor hospital, a well-equipped, long standing and internationally supported and partially staffed facility. The standard of care and facilities at this hospital probably underpinned the comment of a WHO official that local facilities in Uganda were ‘outstanding compared to the classic Ebola situation’ [25].
Distrust of the national government, implicated in the regional conflict, appears to have constrained the control effort with respect to suspicions about the rationale for rapid and isolated burial and beliefs such as those that implicated Ugandan government forces in the origin of the outbreak. Overall, though, the national effort appears to have secured community acceptance in the main, and the success in controlling the outbreak may have contributed to confidence in the national government.