This Ebola outbreak has been characterised by its vast geographic spread, including across country borders. Médecins Sans Frontières is working along the porous border between Guinea and Sierra Leone to improve the cross-border cooperation in the region.
Many people in Kambia, in north-west Sierra Leone, lead lives that intersect the border with neighbouring Guinea. Families are often split on either side of the boundary, and people regularly do their shopping at markets in Forecariah, on the Guinea side.
“For the local population, the border hardly exists,” says Els Adams, MSF’s outreach nurse in Kambia. “There are at least 34 different crossing points, and probably even more. People identify with the region rather than the country.”
Despite this high mobility across the border, Ebola contact-tracing and surveillance teams too often stopped at the country boundaries, with little regional cooperation.
“It was very clear initially that the countries were focused on fighting Ebola only up to the borders. There was little exchange of information and follow-up of contacts across the border. There was low awareness that people could have been infected on the other side, or have contacts there,” says Els.
MSF has been aiming to improve the cross-border collaboration in the region. In Kambia, MSF has just completed a project focusing on case investigation of Ebola patients, particularly those cases that are likely to have a cross-border component.
The team distributed hygiene kits to contacts of Ebola patients, visiting every day for monitoring and to gain a greater understanding of cross-border movements.
The Kambia team collaborated with MSF colleagues and other organisations in Forecariah, on the Guinean side of the border, to allow follow-up across the border. During the two months that MSF was working in Kambia, there were 29 confirmed Ebola cases, seven of which had a clear link with Guinea, plus more that had an indirect link.
“For instance, recently we had an Ebola case in Sierra Leone who had visited a village in Guinea where two people had died of unknown causes. So we discussed that with our MSF colleagues on the other side, who sent out a team to that village to look into it,” says Els.
In Guinea, in the sub-district of Farmoriah and Benty, the team works with local communities which cross the border every day. In this area, MSF conducts health promotion, supports health structures and deploys outreach teams. These teams respond to alerts, pick up the patients and bring them to the French Red Cross Ebola Centre in Forecariah.
“There is still a significant lack of knowledge of Ebola in this area, despite the work that has been done for one year in Guinea. In some areas, for example, communities are afraid of white cars (seen as a symbol of aid organizations). As the cars pass through a village raising dust, some mistakenly fear the dust could spread Ebola. This rumour is just one among others. There is still a lot of work to do to improve the understanding of the disease in these areas and avoid the spread of Ebola and reduce stigmatization,” say Florence Denneulin, field coordinator in Farmoriah.
MSF teams every day see many movements and face complicated situations: "People move a lot between the two countries for trade. One day, we were contacted for an alert of a suspect case, a woman on the Guinean side. Her husband had gone to Sierra Leone for commerce and unfortunately the woman refused to go to the transit centre without the permission of her husband. So the team had to wait two days until the husband came back to give his permission,” says Florence.
Outreach nurse Els Adams says a key part of the response has been raising awareness about the importance of cross-border issues with other organisations. MSF has worked to establish connections with other organisations, such as the World Health Organization, to help ensure that information is exchanged between different groups and across the country divide. MSF has also lobbied to have a cross-border component introduced into the training of district surveillance officers, and into routine forms used for contact tracing.
Recently the governments of Guinea and Sierra Leone took a significant step towards greater regional cooperation with the signing of a Memorandum of Understanding between the two countries. Thankfully cross-border issues are now a much more integral part of the case investigation.
MSF’s Kambia project has now been completed as other partner organisations are addressing the regional challenges in the area.
“It’s always difficult to leave, but the system has been put in place that will the address the cross-border context and will hopefully help bring this epidemic finally to an end,” says Els.