‘Lost generation’ threat of Ebola

Liberian schoolroom

Children's education is being disrupted by the Ebola outbreak. Ken Harper under a Creative Commons Licence

‘My two siblings and I lived with our parents before they both came down with the virus… one by one they died.’ These words, spoken by 13-year-old Liberian Ndebeh Kporloi, have become a familiar story in countries hit by Ebola. Across the worst-affected regions of Liberia, Sierra Leone and Guinea, at least 9,191 people have now been infected and 4,546 have died, according to the World Health Organization (WHO). While Ebola has dramatically changed everyone’s lives in these regions, children are experiencing a degree of suffering for which childhood cannot prepare.

One of the biggest concerns for children is the escalating number of orphans. In September Unicef estimated at least 3,700 children had lost one or both parents to Ebola. That number is growing, as Unicef’s Liberia spokesperson Laurent Duvillier explains: ‘WHO data shows the most Ebola-affected age group is aged 25 to 36 – that means most of them are parents. We have anecdotal evidence that the number is growing, following the exponential growth of the number of cases.’ The WHO has warned that by December there could be as many as 10,000 new infections each week.

Hugs denied

Supporting orphans in a humanitarian crisis situation is nothing new for Unicef. But the fact the virus is transmitted through bodily fluids and physical contact means NGOs supporting children have to take unprecedented measures. Any child of a parent who has died of Ebola may have contracted the disease themselves. But its incubation period of up to 21 days means no-one can be sure until the child presents symptoms. Up to that moment, the child must be isolated to prevent further transmission. But children of any age need adult support, particularly after suffering the loss of parents.

‘You want to give the children a hug, especially when you know they’ve lost one or both their parents. And you just can’t do that. We cannot touch them’

‘We put Ebola orphans into an interim care centre,’ says Duvillier. ‘We have one centre in Liberia run by the local authorities and supported by Unicef. We visited it and it’s extremely frustrating for us. Usually when you’re entering a place with kids they come and greet you and you want to give the children a hug, especially when they’re in those difficult moments where you know they’ve lost one or both their parents. And you just can’t do that. We cannot touch them.’

Ndebeh’s story is typical. ‘We went through a harsh and painful 21-day period of quarantine,’ he says. ‘We almost starved to death, but we are now certified free from Ebola.’ Like many children, Ndebeh suffered stigma as a result having infected family members. He is now being cared for by an aunt who receives financial support from charity Street Child. Founder Tom Dannatt says his team of social workers in Liberia and Sierra Leone are spending much of their time explaining to relatives of new orphans that it is safe to care for them. ‘You get some cases where a whole family has been wiped out, one child is alive, and people say the child is a witch,’ adds Dannatt.

Dannatt says poverty is another barrier to people agreeing to care for orphans. ‘These are families struggling to feed and send their own children to school, so the idea of taking on an extra one is really tricky,’ he says. ‘We have to provide food, clothes and bedding. These are essential because whatever belongings the children had would have been burnt in their home’s disinfection process.’

Some orphans are not as lucky as Ndebeh. Both Unicef and Street Child can site cases where orphans have been left to starve to death because their neighbours were too afraid to help them.

Stark changes

Children who have not lost parents are also experiencing stark changes in their lives, as Ebola-infected countries have closed schools indefinitely. Street Child runs schools in 127 communities across Sierra Leone and was due to open its first schools in Liberia in the autumn. But now Dannatt has shifted the organization’s resources towards keeping children alive.

Once Ebola has passed, the economic havoc it has wreaked may mean school is unaffordable for families in the future – the breadwinners may be dead

He is concerned the loss of school will not only set pupils back educationally, but break the practice of going to school forever. ‘In this time out of school they will have got used to working, either because they have to work or because it’s something to do. Will they then go back?’ he asks. Dannatt says these concerns are particularly pertinent to children with a history of falling in and out of school and those in rural areas where one may have only recently opened.

UK Sierra Leone Diaspora Ebola Task Force member Khadijatu Mansaray agrees Ebola could sound the death toll for many children’s school days. Her organization is preparing lessons for children in Sierra Leone to be broadcast over national radio. This would add to radio shows already on the air through a collaboration between the Sierra Leonean Ministry of Education, Science and Technology and Unicef. She hopes the approach will hold young people’s interest in education.

Mansaray suggests teenage girls are particularly vulnerable. ‘It’s difficult for teenagers in general and when women in Sierra Leone get to childbearing age you want them to get their education out of the way,’ she says. She also points out that once Ebola has passed, the economic havoc it has wreaked may mean school is unaffordable for families in the future. ‘The breadwinners may be dead,’ she warns.

Economic activity is at a standstill in affected countries. Since summer, employers have ordered staff to stay home to avoid physical contact, or laid off workers as business ground to a halt. Governments have imposed quarantines on communities experiencing high numbers of Ebola cases. By restricting people’s movements, they cut off traders from their markets and plunged many families into poverty. As a result, food prices have risen by 30 per cent in some parts of Liberia. And with land borders closed around affected countries, people are experiencing food shortages and living off hand-outs provided by the UN World Food Programme.

Psychological impact

The health risks associated with poor nutrition have not gone unnoticed by other organizations. Charity Mary’s Meals is currently providing food for 69,000 children in Liberia. The organization’s head of programmes, Joseph Goelo, says checkpoints have impacted on parent’s ability to feed their children. ‘A lot of parents have decided not to move from one place to another and this has made their lives very difficult,’ he says.

Normally, Mary’s Meals provides impoverished children with a meal a day at school, as a way of enticing them into education. With schools closed, the charity is now distributing emergency take-home rations to parents. ‘You can see the anxiety in people when they come to receive food,’ says Goelo. ‘When the parents receive a ration they are very excited – it’s something overwhelming for them.’

He adds that the situation is having a negative psychological impact on the children. ‘Children are not really feeling happy at home. They are asking when school will open or when they can eat food again,’ he says.

Food insecurity is also being affected by a reduction in farming. In October, the UN suggested up to 40 per cent of farms in Sierra Leone had been abandoned. Red Cross programme manager for West Africa Christine Tokar explains: ‘When the Ebola outbreak was reaching its height in July, that was planting season for some staple foods like rice. In some communities, where there was high incidence of Ebola, they haven’t been able to plant their seeds. And perhaps the yield is down of what they planted because they planted it late.’ When Ebola is finally expelled from West Africa, it could take years for children to recover from its impact. Dannatt warns that like the decade-long wars that destroyed children’s lives in Sierra Leone and Liberia from the 1990s, the virus could provoke a second lost generation of young people. ‘I’m quite apocalyptic about what I think is going to happen,’ he says. ‘I don’t think we’ve really grasped the scale of the humanitarian tragedy that’s coming on top of Ebola.’

Fighting Ebola on the frontline

Dr Oliver Johnson

Dr Oliver Johnson at work in Sierra Leone. © Mike Duff

British doctor Oliver Johnson is fighting Ebola on the frontline in Sierra Leone’s capital Freetown. He leads a team of volunteer doctors and nurses from the Kings Sierra Leone Partnership at the country’s Connaught Hospital. They have been treating cases in an isolation unit since the outbreak emerged in March.

The virus is now present in Sierra Leone, Liberia, Guinea, Nigeria and Senegal. It has so far killed more than 1,550 people and infected more than 3,000. Last week the World Health Organization (WHO) warned that cases could exceed 20,000 before the outbreak is halted. There is no known cure for Ebola.

In this interview, Oliver Johnson talks about the situation in Sierra Leone, and warns that without urgent international assistance Ebola threatens to undo all the reparations the country has achieved since the end of its decade-long civil war in 2002.

During the civil war, much damage was done to the health system. Some of that was because hospital buildings were destroyed. But a lot of it was because senior staff were either killed or left.

The war was also damaging because many NGOs took over health services. This undermined confidence in the government health system, which was already weak. NGOs don’t stay, and when they go they often leave a massive gap because people have become dependent on them. Government facilities get weakened by having an NGO next door that’s providing really high-quality care.

If you look at what is going on now with Ebola, health-service buildings are untouched, by and large. The infrastructure is not the issue. But more than 50 health workers in Sierra Leone, and more than 130 across all Ebola-affected regions, have been infected. Two in Sierra Leone were senior doctors. Dr Sheik Umar Khan was the country’s leading virologist. Dr Modupeh Cole held one of only three consultant positions at the main referral hospital. The loss of Khan and Cole is a big gap that will be difficult to fill.

Many Sierra Leonean senior staff live between Freetown and London and a lot of them are on holiday at the moment. We’re yet to see whether or not they return, because many are now afraid to come to work. They are scared the hospital isn’t safe. We’re desperately trying to keep confidence up in the government health system, but after this epidemic, we’re going to have a job to do to restore confidence.

We need to do two things. There has to be a technical effort to make sure staff have the right training and the right supply of drugs, aprons, soap and water. We also need to make a psychological effort. The leadership required across the health system to convince people that it’s safe will play a big part.

How long that takes depends on the international community and the Sierra Leonean government. Once you close a hospital it collapses confidence. So far Connaught, the main government referral hospital in Sierra Leone, has stayed open. But it’s a constant effort and we simply don’t have enough support from the international community right now.

‘We’re turning the clock back to exactly what we were trying to get away from: a pop-up NGO, aid-run system, rather than strong, government-led heath system run and led by Sierra Leoneans’

Kings has a whole team out here and so far we’ve been able to keep up staff confidence and keep the hospital open. The children’s hospital down the road is closed. This is an important point. Kings has stayed. Most NGOs in the country have pulled out. They have evacuated their staff, which means those long-term efforts to strengthen the health system have all been interrupted. Everything is on hold.

It will be very hard for some NGOs that left the country to come back and restore those relationships. A lot of local staff will say: ‘You left us when things got bad.’ A lot of people might be suspicious. They’ll say: ‘You told us we were colleagues and partners, but when things got tough you ran away’. Kings is one of the only organizations that have stayed. And that’s one of the reasons why Connaught has stayed open.

The other issue now is that NGOs are taking over the health services again. Médecins Sans Frontières and the Red Cross were winding down here since the war. But now all those organizations are back running services. There’s a danger that if we invest only in NGOs right now we’ll restore a situation where the NGOs run the health system for a couple of years and then leave. We’re turning the clock back to exactly what we were trying to get away from: a pop-up NGO, aid-run system, rather than strong, government-led heath system run and led by Sierra Leoneans.

Right now we’ve got strong leadership from the government. But the support from the international community continues to be virtually non-existent. We’ve seen so little support on the ground. As far as I’m aware, Kings is the only organization still working clinically in a government hospital. All the others have left, apart from the WHO in Kenema’s hospital in the interior.

We need massively more support from the international community to strengthen government hospitals, so that normal services can continue and staff can be safe and not die. We need to keep staff confident to make sure patients keep getting good quality of care and keep attending. We don’t want to create a parallel NGO structure.

We need NGOs to be willing to work in government hospitals and a lot of them are afraid. They’re saying to Sierra Leonean doctors and nurses: ‘You should go into the isolation units.’ They won’t go in themselves. International NGOs are advertising fundraising, but when it comes to it they’re not actually willing to go shoulder-to-shoulder with colleagues on the ground.

Health workers wouldn’t be dying here if we had good infection control. When the outbreak ends, that’s what we’re going to have to focus on. We’ll need a major programme around infection control and strengthening the health workforce. We’ll also need to restore patients’ trust in the government health system.

Gabriella Jóźwiak is an award-winning freelance journalist. She mainly writes about issues affecting children and young people in Britain and developing countries, particularly West Africa. She has recently reported widely on the Ebola epidemic.

Prison reform promised in Togo

Togo prisoners

A detainee presents a gift to the minister of justice: a portrait of the minister painted by the detainees of Lomé prison © Togo YMCA

‘Remember our brothers and sisters in prison, because in life even the bad guys need love.’ As singer Coco de Kofi ends his song, the crowd outside Togo’s main prison cheers. It gathered in the capital Lomé on 11 February to launch the West African country’s annual Week of the Detainee. Among attendees sat the prisoners named in Kofi’s song, whose cheers were weighted with bitter understanding.

The Week of the Detainee, now in its fourth year, is a unique attempt to address the acute numbers of people held in pre-trial detention and the horrific conditions within Togo’s penal system. Overcrowding, sickness and death are common across the country’s 12 institutions. Lomé Prison, built to hold 650 prisoners, houses some 2,070 inmates. They stand shoulder to shoulder in filthy cells where they take turns to sleep. One meal a day is all their nourishment. Medical staff and supplies are extremely limited. Between January and May 2012 alone, 18 prisoners died.

But most shocking is that around 70 per cent of the prison population have never brought their case before a judge, and some have waited for years. Often detainees have been accused of petty crimes – stealing a chicken or failure to payback a micro-finance loan. In many cases, they are innocent.

Lifting spirits

Kofi was one such detainee. He languished in Lomé prison for three and a half years before charity Togo YMCA found him. Aged 18, an agent invited him to perform in Germany. But the passport he provided was fake and Kofi was detained. The YMCA helped release Kofi, who now campaigns for change. ‘I support the Week of the Detainee to touch the hearts of authorities, volunteers and the public’s conscience to make their lives better,’ he says.

Often detainees have been accused of petty crimes – stealing a chicken or failure to payback a micro-finance loan. In many cases, they are innocent

The week was created by YMCA in 2010 to lift detainees’ spirits and draw public attention to the cause. Civil society organizations fund and organize games, competitions, dancing and singing, among other activities. The media is invited to enter prisons and broadcast events to the nation. Detainees deliver speeches to an audience of decision-makers and plead for improvements. Legal and medical experts give free advice to detainees. And the event is backed by the Togolese Ministry of Justice (MOJ). Former YMCA social worker and current head of social services at Lomé prison Hermann Gomina believes that, with ministerial backing, the event can prompt change. ‘The justice minister is aware of the problems in the prisons,’ says Gomina. ‘With him on board, things could go better.’

This year, justice minister Kofi Esaw spoke at the launch event. After listening to detainees’ speeches, he promised action. ‘I understand your pleas and I share your concerns,’ he said. ‘I know there are things that could be done immediately, and we will do those immediately.’ His words provoked a mixed reception. Basil, a detainee held without trial for eight years, was encouraged. ‘I hope the minister’s promises will come true,’ he says. ‘I feel he is engaged [with our needs] and with him change is possible.’

In 2011, the MOJ announced during the event that 70 prisoners nearing the end of their sentences would be released. They were, but other promises have not been upheld. Fatai, another detainee, says: ‘Since the outset of the Week of the Detainee, those in authority have made speeches and promises they never realize. After this week, life at Lomé prison will continue to be problematic, with deplorable detention conditions. The week won’t change anything of miserable prison life.’

Modernizing justice

The week’s co-founder, Togo YMCA national project co-ordinator Lambert Daisher, shares Fatai’s concerns. ‘I’m not convinced the government is committed to changing things in the prisons,’ he says. Daisher notes the government allocates only 0.6 per cent of its budget is to the MOJ. ‘What can anyone do with that?’ he asks.

A painting by one of the detainees.

Copyright Togo YMCA

Daisher insists the event is valuable even if it doesn’t provoke long-term change. ‘In the prisons there are no activities to distract detainees,’ he says. ‘The week gives an opportunity for them to realize their value, talents and creative spirit.’ He says the football tournament is particularly important. This year the detainees won against four non-detainee teams. ‘Their joy at winning the cup was immense,’ says Daisher. Without the week, he says the public would not care. ‘What has changed over the years is now a small part of the population understands better the conditions in detention, which helps,’ he says.

International agencies have tried to address the situation in Togo. Between 2005 and 2010 the European Union (EU) funded a national programme of justice modernization, to align the country with international standards. It replaced the military personnel who staffed prisons with civilian workers. But other aims, such as training more lawyers and improving MOJ buildings, failed to have profound impact.

British charity Y Care International (YCI) has worked with Togo YMCA since 2008 to support detainees. It funded the creation of four legal clubs – effectively paralegal services – within four prisons. The clubs address the fact that lack of education is one of the primary causes of high detainee numbers. Detainees often don’t know they should request a lawyer, or cannot write to one because they are illiterate. By training detainees about their rights and the judicial system, between 2009 and 2012 YCI helped free 1,070 detainees across the country. The organization restarted the programme last year and will fund the work with EU backing until 2016.

YCI Africa programme manager Harriet Knox says the government recognises the power of the clubs and wants them replicated across Togo. But she says the policy exists only on paper: ‘It has not been adopted or resourced.’ Knox says the Week of the Detainee is worthwhile, but limited. ‘People make promises, but what’s important is what happens afterwards,’ she says.

The legal clubs system was reinforced in 2012 by a team of researchers from the Viennese Ludwig Boltzmann Institute of Human Rights. Their Atlas of Torture project responded to recommendations made by a UN special reporter in 2007. They established five legal clubs and freed 533 detainees over six months. Researcher Tiphanie Crittin suggests the project’s work in other countries has shown strengthening monitoring bodies can help. In Paraguay, it trained 20 lawyers to perform monitoring roles in prisons, who increased public exposure of heavy sentencing and corruption. ‘It’s often the case people don’t care about prisoners because they have no idea what’s going on,’ says Crittin.

Legal costs

Prison overcrowding and high pre-trial detention levels are common across Africa. International Centre for Prison Studies (ICPS) research suggests occupancy levels are more than twice capacity in nine countries. ICPS former director Rob Allen says the rate of detainees has decreased in Kenya following the government’s introduction of community service orders in 1998. He suggests this is one solution, but is rare in West Africa. ‘Even in Nigeria, they have little in the way of alternatives to prison,’ says Allen.

‘After this week, life at Lomé prison will continue to be problematic, with deplorable detention conditions. The week won’t change anything of miserable prison life’

Shortage of lawyers is another major cause of pre-trial detention. African Prisons Project founder and director general Alexander McLean says the costs of legal training prevents many entering the profession. Foreign aid can also hinder governments’ ability to afford judges’ wages. ‘In 2010 in Sierra Leone judges were paid in US dollars and their salaries were so high it was often difficult for the government to sustain them once donor funding was removed,’ he says.

McLean says countries are becoming more transparent about prison conditions. One prison in South Sudan has published a photobook documenting inmates’ shocking living conditions. ‘That’s the prison service saying they’re not happy with the way things are,’ he says.

In Togo, the Week of the Detainee ended with mass. Kofi’s prayer came with a warning. ‘Don’t forget our brothers and sisters in prison.’ He sang. ‘Today it’s them, but tomorrow you never know.’

Counting kids in Sierra Leone

Gabriella Jozwiak

Results are due shortly from Sierra Leone’s first nationwide headcount of street children. The figures will shed light on how many under-18 year olds live permanently on this West African country’s streets, with child welfare activists predicting the number has risen sharply since the 11-year civil war ended in 2002.

The count began in September last year, conducted by locally engaged volunteers who scoured the streets, ghettos and red-light districts of 16 cities over four months. It was funded by a British charity, Street Child of Sierra Leone (SCoSL), and backed by the country’s Ministry of Social Welfare, Gender and Children’s Affairs.

Early results suggest a total in the tens of thousands from a national population of only 5.2 million. This is just one indicator of the continuing challenge of poverty in this country, which is third from the bottom of the Human Development Index after Afghanistan and Niger.

An estimated 15,000 children were separated from their parents by the war, many of whom were left completely alone

Organizers say the headcount is the first step towards helping these children and stabilizing the nation’s future. ‘It’s vital we have a solid figure on the problem so we and others, including government, can plan a strategy based on hard facts,’ said Tom Dannatt, founder of SCoSL. ‘Our work with street children is not just for the children and families themselves – but deep-level peace-building and conflict prevention.’

Children turn to the streets following family breakdown. An estimated 15,000 children were separated from their parents by the war, many of whom were left completely alone or taken in by family members who could not afford their care.

Children at risk

‘Broken homes created an environment where children decided they would become the breadwinners,’ explains Salim Alim, who heads up SCoSL’s social work team and was a headcount trainer. ‘But when they come to the street they fall into child labour, prostitution or crime.’

Alim says that almost all street girls aged over 13 are involved in sex work. ‘They charge as little as 5,000Le ($1) per hour, taking as many men as possible. But often they are raped and beaten.’

Street children as young as six work in markets, washing dishes or carrying heavy loads, for which they are paid a small amount or fed a bowl of rice. They sleep under bridges or in abandoned cars. Many catch malaria or die from pneumonia.

Others beg or are employed by older street boys, the ‘bras’, who organize gangs of pickpockets and thieves. During the war, thousands of boys recruited as child soldiers were made to sniff cocaine ahead of battle to numb their fear. Today, gang-leaders force street boys to take drugs before stealing.

When the results are confirmed, the Ministry will call upon all Sierra Leonean street child organizations to join the government in tackling the problem. ‘We need a strongly committed, multi-sector approach to reduce the number of street children,’ explains the Minister for Social Welfare, Rosaline Oya Sankoh.

Headcount organizers also intend their methodology to set a precedent for other countries formulating street child policies.

The results will be published by SCoSL in February.

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