On the Ground Experience with Ebola Recovery

This summer, I participated in a trip to Sierra Leone where I learned about the impact of Ebola and related efforts to recover from the epidemic. I have worked in international affairs for over two decades. During that time I have lived in and traveled to dozens of countries across Asia, sub-Saharan Africa, and the Caribbean. None of those experiences prepared me for my trip to Sierra Leone.  

In discussing strategies for controlling the 2014 West Africa Ebola epidemic and addressing its impacts, I have used the words “densely populated urban areas” more times than I can count. The reality of what those words meant hit me hard during this trip. I saw people traversing open sewers, which could easily spread Ebola, and sharing cramped spaces, which would make isolation virtually impossible. One evening we met three Ebola responders. I was humbled listening to these people tearfully attest to bidding their families good-bye on a daily basis, never certain how long it would be before their own lives were claimed by Ebola. In my eyes, these people were heroes. Their actions made me think: Would I risk my life without compensation to case my neighborhood in search of those sickened with Ebola and shuttle them to the nearest treatment center or isolation unit? And if I did, how many times could I do that before quitting?

By the time the outbreak ended in June 2016, over 28,000 people had contracted Ebola, more than 11,000 of whom died. Roughly half of the cases and about one-third of the deaths occurred in Sierra Leone. Surviving Ebola has not been an easy task. I am very familiar with the long-term health effects of Ebola, blindness, muscle weakness, and nerve damage. It wasn’t until I was on the ground in Sierra Leone that I realized I’d overlooked one of the most pressing long term effects of Ebola, orphanhood.

We visited a village where half of the population was killed by Ebola. While standing, eyes blurred with tears, listening to a woman describe her harrowing tale of isolation, loss of her family, and finally economic recovery, I felt a little finger slip in between mine. I looked down to find the sweetest distraction to this tale of misery: a chubby cheeked little girl smiling up at me, completely oblivious of the tragedy into which she was born. Before long, I felt another finger slip between mine and up popped another child. Within seconds, I was out of fingers to hold. There were three children holding onto each of my hands. I looked around and noticed for the first time how severely the children outnumbered the adults, maybe by ten to one. Ebola had robbed these children of their parents and for the surviving adults, members of their support network. The remaining adults, who were already struggling to make ends meet now had to figure out how to care for an additional three or four children. They were visibly traumatized and exhausted but the children were exuberant and joyful. If I was feeling overwhelmed during a brief visit, how must it feel to live in such a reality?

The children soon became my focal point. Once I started to watch the children, I noticed another oversight of mine. Orphans, in my mind, were like the little girl who soothed my spirits. I did not think about teenagers. At one site, we met a 15-year old girl who lost both parents to Ebola and now had to care for her 9-year old brother. I immediately thought of my 16-year old daughter, for whom 90% of all conversation revolves around boys and fashion, being made suddenly responsible for her siblings. I’m sure she’d rise to the challenge with the support of a life insurance pay out, as well as aunts and uncles who are financially secure. This girl had none of that, and most of those in her community were in the same boat.

The loss of her parents was only the beginning. Barely able to feed herself and her brother, this teenager suddenly needed a large sum of money to pay for her brother’s surgery. This new caretaker described how she benefited from a program where members of the community paid for the surgery through a village savings and loan program (VSLA) that was designed to help girls and women access capital for meeting their needs. Woman after woman stepped up to share her story about how the members provided each other with much needed comfort and support in a time of tribulation. One woman who lost her husband to Ebola described how the program provided her not only financial support but also emotional support. After she contracted Ebola, people avoided her, feared touching her. After she finished retelling how the members of the VSLA provided her emotional and financial support, she resumed her position next to me.

Instinctively, I hugged her. As soon as I hugged her the following thoughts ran through my mind: "Wait a minute, your hand is touching a woman who is an Ebola survivor. Her sweat and tears can carry the virus. You can be contracting Ebola right now." I was ashamed by these thoughts flooding my mind. My second group of thoughts went to the people in the community. I thought of the stories in the press of people chasing away foreign health workers, believing that they'd introduced the virus into their community; or other stories of how people with Ebola would hide in the forest to avoid stigma; or how relatives of those infected with Ebola would hide the illness from others and secretly bury their loved ones. I finally had some insight into the fear they must have felt of an unknown virus that was rapidly and visciously killing them and their loved ones. I also thought about the conundrum they must have faced: to care for your loved one could be your own demise. 

As those groups of thought waned another one emerged: I am an American with access to health care, which was used to save the lives of Westerners who contracted Ebola. I reminded myself that my chances of survival were pretty high. These conflicting thoughts cycled through my mind as I forced myself to continue hugging this woman. I decided that I would not let the fear of contracting Ebola prevent me from demonstrating to this woman that she was not a periah. 

This trip was like an emotional rollercoaster. I would vacillate within minutes between feeling despondent and hopeful. The tales of death and further impoverishment would be counterbalanced with steely determination and incremental advancements.  

Just before arriving, Sierra Leone’s health ministry announced that local scientists had detected a new Ebola species in healthy bats. I was giddy with excitement having met one of the Sierra Leonean epidemiologists who identified the new strain and peppered him with loads of questions. This was big news! As a partner country of the Global Health Security Agenda, the United States has been helping countries prevent, prepare, and respond to disease outbreaks with pandemic potential. Disease surveillance is a critical component of prevention. Discovery of a new strain before it causes mass animal casualties can protect humans if the information is used to create new vaccines or treatments against that strain. 

In our interconnected world, disease that were once confined to the tropics are becoming increasingly endemic in the United States and other Western societies. Policy makers in industrialized countries are increasingly recognizing that bolstering disease surveillance and control capacity abroad provides mutual security for people in the tropics as well as those in their own societies. An important part of my work is explaining how diseases are transmitted, deliberating strategies for controlling and addressing their spread, and of course considering resource levels for such actions. Discussions in Washington about foreign aid programs can sometimes amount to a bland consideration of numbers, making it is easy to forget that behind those numbers are survivors (teenagers without parents, widows without any financial resources, and of course chubby cheeked toddlers) and people working for our mutual self preservation (Sierra Leoneon first responders and scientists). 

Raising Girls (and Boys) in the Age of Porn

I am a mother of four children: two boys and two girls. Helping my children to understand their place in a society that is saturated with sexually charged imagery and messaging is a constant struggle. The other day, my six-year old son and I were watching a basketball game. The cheerleaders came out in their skimpy outfits and started "dancing." My son turned to me and asked, "Mom, why are they putting their legs up like that and bending over like that?" Last week, I picked up my 14-year old daughter from a skate party and she said, "Mom, I was really surprised at the music they were playing. The songs were really inappropriate and they weren't even playing the radio version." Last year, the principal at my then-nine year old's school called me with a very nervous tone to tell me that an incident happened at school but that it had been resolved. Long story short, my daughter was eating her lunch and one of her classmates told her that he wanted to taste her hot, juicy pu**y.

It appears that pornography (defined by Merriam-Webster as "movies, pictures, magazines, etc., that show or describe naked people or sex in a very open and direct way in order to cause sexual excitement") is becoming normalized and used more broadly throughout our society. Widespread use of pornography (or otherwise sexually titillating activities) appears to be skewing public perception about its acceptability. According to a 2013 Gallup poll, roughly half of young adults between the ages of 18 and 34 deemed pornography morally acceptable.




If roughly half of young adults believe that pornography is morally acceptable, what do children younger than them think? Children often replicate what they see and in growing numbers, our children are emulating the sexually explicit images that surround them. My daughter has infrequently returned from high school and shared tales about videos being circulated of her female classmates performing oral sex and engaging in other sexual acts. I feel like there is a well-oiled machine at work that tirelessly uses propaganda to convince girls and women to proffer their bodies for the sale of goods and services and for the sexual pleasure of boys and men. It seems as if the machine is winning. One day over dinner, my daughter told me that one of her classmates sent a boy nude pictures of herself, after which he shared them with his friends, and they later spread them throughout the school. My daughter told me that she was shocked that the girl did it because she was one of the "quiet" girls. Even the "quiet," "smart," girls are falling sway to the machine.

Although almost 50% of young adults reported that pornography is "morally acceptable," girls and women are often shamed when their nude images surface. Our children are being raised in a society that encourages girls and women to present themselves as sex tarts, but then are condemned when they do. Reconciling these competing messages is difficult and navigating my children through them is complicated. When I think about the challenges I face in confronting the rise of porn culture, I think about millions of people around the world who are attempting to navigate cultures that promote practices that are harmful to girls and women.

In my post on HIV/AIDS, I mentioned that I lived in a Zimbabwean village for about a month. In the rural areas, hierarchy is important. The hierarchical order of authority is: man, boy, woman, girl. Women and girls are to sit on the floor and men sit on benches and in chairs.  Girls usually stopped attending school after fifth grade, while boys usually continued through high school. Women and girls tend to the home front (cook, clean, and farm), and the men are to oversee the households. It wasn't unusual for a man to lead his family with an iron fist. In fact, one of my classmates asked for a change in residence because she could not stand the screams from the wife as she contented with nightly beatings from her drunk husband.

I think one of the reasons that I bonded so closely to my host family is that they resisted some of the conventional wisdom on gender roles. My father let his girls and wife sit on benches when company wasn't around. He helped his wife in the field and kept only one wife. He was also determined to see his second daughter complete school. My father and I talked often, and during one of our conversations, I broached the issue of his girls and wife sitting on benches. I asked him why he made them scramble to the floor when visitors arrived, but allowed them to sit in chairs and benches when no one was around. I also asked him about other socially acceptable practices in which he chose not to engage.

My father talked about his love for his wife and how he was personally satisfied with her. He also talked about how important it was for him that his daughter should be educated and that he thought that girls and women had equal intellectual capacity as boys and men (some people truly believed that girls and women were of lower intellect). I asked him that if he believed these things, then why didn't he openly openly oppose practices that he believed subjugated his wife and daughters. He told me that he could not go against the traditions. "But don't men make the rules?" I countered. He acknowledged that they did, but that he felt powerless to change them. I was confused. I never expected to hear a man express feeling powerless in a society that seemingly gave him all the power.

Many global health and development programs aim to address gender inequities by educating girls and women, providing them with access to capital, and raising awareness about the risks of certain sexual practices (e.g. extramarital relationships) and about the benefits of key health interventions (e.g. birth spacing). Even with the knowledge about the importance of monogamy, condom usage, birth spacing, and delayed sexual debut, many girls and women lack the authority to carry out these life-saving actions. Indeed, the President's Emergency Plan for AIDS Relief (PEPFAR), recognized that gender inequity was standing in the way of achieving an AIDS-free generation and launched the DREAMS program to empower women.  Without a doubt, efforts like these are important. I would like to see more programs, however, that focus on empowering men to become change agents.

There are many men like my host father who are eager to see societal norms change but don't know how to go about the business of driving this change. I have struggled with this in my own household. When my son was in high school, I'd often tell him, "Girls are under a lot of pressure to be sexually aggressive. Even if a girl is pursuing you, you don't have to take advantage of her. A lot of girls' self esteem is tied up in whether she is sexually desirable. Please don't take advantage of girls like that. If you don't like the girl, leave her alone." I was also often in the awkward position of telling girls not to come to my home uninvited (they'd just show up and wait for him).

It may seem counter intuitive that boys and men need support in changing a system that seems to put them in full control, but they do. At the same time that my father celebrated the small victories he made in contradicting gender norms in his private life, he was wary of promoting change in the broader society. Men need a support network of other like-minded people who can validate their ideas and join them in advocating for change. It is time to broaden the framework for addressing gender inequities by embracing men as partners in our fight against sexism and empowering them to believe that they can.