Protect Health Workers, Limit Quarantines, Promote Transparency
(Nairobi, September 15, 2014) –West African governments should ensure rights protections as a crucial element in controlling the unprecedented Ebola epidemic ravaging the region, Human Rights Watch said today. Human Rights Watch expressed its sympathy to the families, friends, and colleagues of those who have died as a result of the Ebola outbreak, and recognized the courage of many health workers and others in caring for the sick.
Governments in Ebola-affected countries should better protect health workers from infection, limit use of quarantines, address the gender dimensions of the outbreak, ensure security forces responding to the crisis respect basic rights, and facilitate independent monitoring of emergency measures and donations, Human Rights Watch said. Donor governments, through international assistance and cooperation, should help these governments fulfill the right to health and efforts to address the epidemic’s broader impact.
“Given the tragic magnitude of this epidemic, the affected governments cannot and should not be expected to fulfil the right to health on their own,” said Corinne Dufka, senior West Africa researcher at Human Rights Watch. “The international community must help assume this responsibility, while insisting that governments do their part by ensuring transparency and respect for human rights as they respond to the crisis.”
As of September 5, 2014, there have been 4,784 confirmed or suspected cases of Ebola virus, and more than 2,400 deaths across most regions of Guinea, Liberia, and Sierra Leone, and in two cities in Nigeria. Cases were confirmed in 7 of 8 regions in Guinea; 10 of 15 counties in Liberia; and 13 of 14 districts in Sierra Leone, as well as in the Senegalese capital Dakar, and the Nigerian cities of Lagos and Port Harcourt. Among the dead are over 140 health workers.
Doctors without Borders, the World Health Organization (WHO), and the US Centers for Disease Control, among other organizations, have repeatedly warned that the outbreak is spiraling out of control. A WHO statement on September 8 said the number of new cases is increasing exponentially. Ebola treatment centers are overflowing and turning highly infectious patients away.
The epidemic has resulted in severe contraction of West Africa’s economies and a near collapse of health care systems in the worst-affected countries, Human Rights Watch said. It is reducing access to health care for children, pregnant women, and others with chronic and acute health concerns. Health workers have expressed concern about the lack of health care for, and increasingly mortality from, other diseases and conditions like malaria, typhoid, dysentery, and childbirth complications. Local nongovernmental organizations need increased support to educate the population about the disease and monitor government response, including the use of humanitarian assistance.
The Ebola epidemic is unfolding in three of the world’s poorest countries. Each has had decades of violence and instability, including brutal armed conflicts in Liberia and Sierra Leone and authoritarian rule in Guinea. When the three countries’ presidents assumed office (Liberia’s Ellen Johnson Sirleaf in 2006, Sierra Leone’s Ernest Bai Koroma in 2007, and Guinea’s Alpha Condé in 2010), they inherited nations with deeply broken infrastructure, weak rule of law institutions, communal tensions, abusive security forces, crushing poverty, and phenomenally high unemployment.
While these governments have made progress in ensuring respect for human rights, including the right to the highest obtainable standard of health, serious challenges remain. Health indicators. including maternal mortality, child mortality, and life expectancy, are among the world’s worst. Endemic corruption, weak road networks, the “brain drain” of medical personnel, and the widespread destruction of health facilities during armed conflict have undermined the right to health for decades.
“As they respond to the Ebola crisis, Guinea, Liberia and Sierra Leone should address ongoing governance challenges by ensuring the transparent use of funds, improving health infrastructure, making the security forces more accountable, and improving communication between government and the population,” Dufka said.
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Protecting Human Rights in West Africa During the Ebola Crisis
The following section addresses the obligation to protect health workers; human rights and quarantines; gender dimensions of Ebola; the right to information and conduct of state security forces; the need for oversight and monitoring of the Ebola Response, and role of the international community.
Obligation to Protect Health Workers
Domestic and international health workers have frequently raised concerns about the lack of personal protective equipment for health care workers treating actual and suspected Ebola patients, including rubber gloves, safety goggles, and protective suits. Health professionals, janitors, cleaning staff, drivers, and burial staff who may come in contact with infected people or contaminated material also require protection and prevention. The shortages have contributed to the deaths of at least 140 doctors, nurses, and other health workers in Guinea, Liberia and Sierra Leone. A local journalist told Human Rights Watch on September 7, 2014, that 15 health workers he had recently interviewed complained of inadequate supplies, including being forced to recycle gloves.
Health workers at the government-run Ebola treatment center in Kenema, Sierra Leone, where at least 26 health workers died of Ebola, and Phebe Hospital and John. F. Kennedy Medical Center in Liberia went on strike to protest the shortages and unpaid wages. In some cases, health workers reportedly used plastic bags on their hands to protect themselves. Liberia’s Dolo Town Health Center closed when it ran out of gloves; 37 people in the area have died of Ebola, including 7 health workers.
While health workers have an ethical obligation to care for their patients, even if doing so involves some degree of risk, the government has an important obligation to provide health workers and others involved in the response with appropriate training in infection control and protective gear. National governments, with the support of international donors, need to ensure that health professionals and others involved in the response are promptly paid, and that social protection programs are in place for the families of government workers who die or become ill as a result of their work in addressing the crisis.
Human Rights and Quarantines
Since the beginning of the Ebola crisis, Guinea, Liberia, and Sierra Leone have imposed quarantines, restricting people’s rights to liberty and freedom of movement as well as their livelihood and access to health care and other rights. The quarantines have been imposed on individual houses, neighborhoods, villages, and in a few cases entire administrative districts.
International human rights law requires that restrictions on human rights in the name of public health or public emergency meet requirements of legality, evidence-based necessity, and proportionality. Restrictions such as quarantine or isolation of symptomatic individuals must, at a minimum, be provided for and carried out in accordance with the law. They must be strictly necessary to achieve a legitimate objective, the least intrusive and restrictive available to reach the objective, based on scientific evidence, neither arbitrary nor discriminatory in application, of limited duration, respectful of human dignity, and subject to review. When quarantines are imposed, governments have absolute obligations to ensure access to food, water, and health care.
Quarantines imposed during this epidemic have frequently not met these standards. They have not been based on scientific evidence, have been applied arbitrarily, and been overly broad in implementation. The quarantines have not been adequately monitored, making them ineffective from a public health perspective and disproportionately impacting people unable to evade the restrictions, including the elderly, the poor, and people with chronic illness or disability.
Social mobilization efforts that expand understanding of Ebola and appeals for voluntary limits on movement combined with social support – including home-based care and food aid – can be as effective as measures that restrict rights and can be achieved through community engagement and attention to the special needs of disadvantaged groups.
“Adopting overly-broad quarantines and other rights-abusive measures can undermine efforts to contain the Ebola epidemic,” said Joseph Amon, health and human rights director at Human Rights Watch. “The better approach is to ensure that people have access to health information and care, and to restrict liberty or movement only if and when absolutely needed and with the protections outlined under international human rights law."
Gender Dimensions of Ebola
Women appear to be at greater risk of Ebola than men, according to the United Nations, health workers, and governments. The UN children’s agency, UNICEF, has reported that women across the three most affected countries account for 55 to 60 percent of deaths in the epidemic. Guinea’s Health Ministry reported that as of September 7, women made up 54 percent of Ebola cases. Liberia’s Ministries of Health and of Gender and Development reported that 75 percent of those infected or who have died from Ebola are women.
The higher infection rates appear to result from the roles women traditionally or disproportionately occupy – including cross-border traders, health workers, and traditional birth attendants – which put them at greater risk of coming into contact with the virus. Furthermore, women more often take care of the sick and in the case of death, traditionally wash and prepare a body for burial. Pregnant women may be at increased risk because of increased contact with health workers, And, according to the WHO, men who have recovered from Ebola can still spread the virus to their partner through their semen for up to seven weeks after recovery, further endangering female sexual partners.
The ministries responding to the Ebola crisis need to ensure that prevention efforts address the particular vulnerability of women, that women are able to access information about how to prevent and respond to the epidemic, that any obstacles to accessing care – including financial and cultural – are removed, and that they are engaged at the community and national level in shaping response to the crisis. Efforts to educate communities and remove the stigma around the disease will go a long way toward making women feel comfortable reaching out to the proper authorities for help. Such education efforts could also encourage more equitable household decision-making and the sharing of care-giving activities.
Right to Information
The response to Ebola has been hampered by lack of knowledge about the disease, fear, denial, and a deep-rooted mistrust of government. As a community activist from Sierra Leone said, “Community disbelief in the existence of Ebola at the initial stage encouraged the rapid spread of disease.” Governments should take steps to bridge the trust gap, step up public information efforts, and ensure much-needed community involvement in developing strategies to address the Ebola epidemic. International partners should step up support for groups engaging in public health education.
Access to health information is essential to realizing the human right to the highest attainable standard of health and, ultimately, the right to life. The International Covenant on Economic, Social and Cultural Rights (ICESCR) specifically obligates governments to take all necessary steps for the “prevention, treatment and control of epidemic … diseases,” and defines as a “core obligation” the provision of “education and access to information concerning the main health problems in the community, including methods of preventing and controlling them.”
Nongovernmental groups, local newspapers, and community radio are playing a key role in public health education. In Liberia, the Civil Society Organization’s Ebola Response Task Force has produced spot messages about how the virus is transmitted and how to prevent the disease in local languages and using the voices of traditional and religious leaders that have been aired on 44 community-based radio stations. The Task Force plans to establish a “situation room” to monitor the Liberian government’s response to the Ebola crisis, including the level of accountability in the use of resources by the National Task Force, and the access to health facilities.
In Sierra Leone’s Kailahun district, one of the epicenters of the outbreak near the borders with Liberia and Guinea, a local community radio station – Radio MOA – and other community-based organizations created an Ebola Response Task Force and organized a campaign to combat the rumors that were undermining the medical response. Each day, Radio MOA transmits interviews with health experts, officials, and Ebola survivors on their “Watin Di Bi Nah Yu Community” (“What is Happening in Your Community?”) radio program, which reaches tens of thousands of resides from the three countries.
International organizations such as Search for Common Ground are supporting the efforts of trusted communication channels to conduct public education on Ebola including local radios, traditional and religious leaders, motorcycle taxi associations, and drama programs.
Conduct of State Security Forces
State security forces are playing a central role in the Ebola response in the three countries, in some cases enhanced by states of emergency directives. In all three countries, the security forces have been mandated to enforce quarantines.
There have been several reports of extortion and excessive use of force by security forces responding to the Ebola crisis, notably during the enforcement of quarantines. During clashes between the security forces and angry residents protesting the quarantine in the West Point neighborhood of Monrovia, Liberia’s capital, a 15-year-boy was shot and later died, and four other residents were wounded. An inquiry was opened into the incident. Witnesses told Human Rights Watch that police and soldiers maintaining quarantines in Liberia and Sierra Leone have been accused of soliciting bribes from people wanting to leave quarantined areas.
The deterioration in health and food security conditions has been accompanied by a greater likelihood for unrest, which highlights the importance of professional crowd control. One international healthcare worker told Human Rights Watch, “We’ve already had security incidents, and the possibilities for unrest are many – as patients are turned away from health facilities; as food, water and chlorine are distributed; as workers remove bodies and set up mortuaries – all of these scenarios point to the growing risk of disorder and need for professional crowd control.”
Fear of Ebola has led to attacks on health workers. In April, an angry crowd attacked an Ebola treatment center in Macenta, 425 kilometers southeast of Guinea’s capital, Conakry, run by Doctors Without Borders (MSF), which it accused of bringing Ebola to the city. On August 29, people in N’Zérékoré, Guinea’s second largest city, protesting the spraying of a market with disinfectant they believed was infected with the Ebola virus rioted, causing injuries to over 50 people, including members of the security forces.
Human Rights Watch has for decades documented patterns of unprofessional and abusive conduct by the security forces of Guinea, Liberia, and Sierra Leone during armed conflict and civil and political unrest. However, the security forces have benefited from reform initiatives and considerable training and, as a result of this and better leadership, their conduct has notably improved since the end of their respective conflicts and unrest. The Ebola crisis provides the security forces with a key opportunity to build trust and put into practice the years of training provided by international partners.
To ensure a professional response by the security services, the governments of Guinea, Liberia, and Sierra Leone should direct the police, military, and gendarme leadership to strictly adhere to the UN Code of Conduct for Law Enforcement Officials and the Basic Principles on the Use of Force and Firearms by Law Enforcement Officials as they enforce quarantines, protect Ebola treatment centers, and respond to social unrest related to food and water distribution. The Basic Principles states that law enforcement officials must use nonviolent means as far as possible before resorting to force. Whenever the lawful use of force is unavoidable, law enforcement officials must use restraint, minimize damage and injury at all times, and respect and preserve human life. The authorities should ensure that credible allegations of human rights violations and corrupt practices by members of the security forces, regardless of rank, will be investigated and that those responsible will be disciplined or prosecuted.
Oversight and Monitoring of the Ebola Response
In response to the Ebola crisis, the governments of Guinea, Liberia, and Sierra Leone have instituted emergency measures that restrict basic rights and freedoms including to freedom of association, assembly, and movement. These governments should ensure that restrictions on public health or public emergency grounds meet requirements of legality, evidence-based necessity, and proportionality. Any restrictions should be clearly defined, well publicized, and subject to monitoring through the use of public hearings before the countries’ parliaments, by the national human rights commissions in Liberia and Sierra Leone, and by independent groups operating without unnecessary restrictions.
In his July 30 broadcast to the nation and then on August 7, Sierra Leonean President Koroma announced a state of emergency and a number of measures to respond to the crisis under section 29(5) of the 1991 constitution. The measures, which were to be for 60 to 90 days, include quarantines for all epicenters of the disease, enforced by the police; protection of health workers and centers by the police and the military; the restriction of public meetings and gatherings not related to Ebola sensitization; and surveillance and house-to-house searches to trace and quarantine Ebola victims and suspects. The statement further called on local leaders, or paramount chiefs, to establish by-laws that would complement other efforts to deal with the Ebola outbreak.
On August 13, Guinean President Condé declared, on state media, a national public health emergency, under the public health code law 97 of June 19, 1997. The measures announced include the establishment of a quarantine enforced by health workers and security forces, of everyone suspected of having the disease until test results come through. He said that, “Anyone who blocks or incites someone to block in any way the detection, isolation treatment, or examination of a sick person, of a suspect case or contact will be considered a menace to public health and will be brought before the law.”
On July 30, Liberian President Johnson Sirleaf announced several emergency measures, including closing schools and markets and quarantines in several areas. On August 6, she declared a state of emergency for 90 days, citing the need for “extraordinary measures for the very survival of our state.” The statement said the government could suspend certain rights and privileges, though it failed to define which rights were to be curtailed. Liberian security forces were tasked with enforcing all of the emergency measures announced by the National Task Force on Ebola. Liberian groups called on the government to regularly define in detail what rights are subject to the state of emergency.
Endemic corruption, including in health services, has long plagued the governments of all three countries and contributed to years of unrest and lack of development. While the presidents of all three countries have made statements about the problem, their governments have taken inadequate steps to address it.
To enhance public confidence in the Ebola response, the three governments should ensure transparency in the receipt and use of donations and other assistance. Sierra Leone has made a meaningful effort to do this by creating an Emergency Operations Center (EOC), which centralizes donations, regularly publishes lists of donations received, and independently monitors the EOC’s “Ebola Account.” The presidency’s website has issued 22 news releases related to donations, including vehicles and specific amounts of money, and the EOC website maintains a list of donations.
Similarly, the Liberian Executive Mansion issued four news releases detailing donations received, and the Liberian government Task Force on Ebola web page features a list of government agencies’ budgets and disbursements, and outlines measures it will take to ensure transparency. However, a measure to publish detailed, weekly information on contributions to and allocations from the Ebola Trust Fund has not been carried out. The Task Force promised to publish a report from the General Auditing Commission after the crisis abates.
Role of the International Community
The affected governments are the primary guarantors of human rights in their respective countries. Even with their limited resources, the governments must take steps to respect and protect the core minimum right to health. However, to demand that the government alone address the obstacles to the fulfillment of these rights would be to ignore the political and economic realities faced by these countries, some of the world’s poorest.
To promote the right to health, both the Committee on Economic, Social and Cultural Rights (CESCR) and the UN special rapporteur on the right to health have observed that, “States should ensure that their actions as members of international organizations take due account of the right to health.” The CESCR also has determined that “international assistance and cooperation, especially economic and technical” should enable developing countries to fulfill their core and other obligations. The UN special rapporteur has indicated that governments should pay particular attention to helping other countries achieve minimum essential levels of health.
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