{"id":18797,"date":"2017-03-10T09:35:31","date_gmt":"2017-03-10T14:35:31","guid":{"rendered":"https:\/\/college.unc.edu\/?p=18797"},"modified":"2024-07-02T16:35:39","modified_gmt":"2024-07-02T16:35:39","slug":"outsmarting-an-outbreak","status":"publish","type":"post","link":"https:\/\/collegearchive.unc.edu\/?p=18797","title":{"rendered":"Outsmarting an outbreak"},"content":{"rendered":"

When Ebola strikes, what is the proper response? What measures should be taken to protect communities in a time of crisis? Should a neighborhood be quarantined? How? To help answer these questions, public health officials in Liberia turn to legal experts at the UNC School of Government, with assistance from research by Benjamin Mason Meier,\u00a0the Zachary Taylor Smith Distinguished Professor of Public Policy and an Associate Professor of Global Health Policy in the Department of Public Policy in the UNC College of Arts & Sciences.<\/i><\/p>\n

\"During
During the 2013 Ebola outbreak in Liberia, government officials placed signs across the country to convince people the virus was a real threat. But fewer than 50 percent of Liberia’s population can read.<\/figcaption><\/figure>\n
\n

 <\/p>\n

\u201cI don\u2019t want you to go \u2014 it\u2019s too dangerous.\u201d<\/p>\n

Aimee Wall<\/a>\u00a0smiles at her nervous 11-year-old daughter. \u201cI promise you it\u2019s safe,\u201d she says. \u201cLiberia has been free of Ebola for months. You have nothing to worry about.\u201d<\/p>\n

An hour later, as she finishes packing her bags, Wall\u2019s phone beeps. It\u2019s a text from her brother with a link to a news report: \u201cHave you seen this yet?\u201d<\/p>\n

Today is April 2, 2016, and a new case of Ebola has just been reported in Monrovia, Liberia \u2014 where Wall is heading tomorrow.<\/p>\n

Connecting Carolina to Liberia\u00a0<\/strong><\/p>\n

In October 2015, Wall received a phone call from\u00a0Francis Kateh<\/a>, the chief medical officer for the Liberian Ministry of Health. Kateh knew Wall from a decade earlier when he served as the health director in Anson County, North Carolina.<\/p>\n

\u201cWe regularly assist counties across the state of North Carolina with confidentiality laws and protocols,\u201d Wall says. \u201cIn the same way that we helped him in Anson County, Dr. Kateh wanted us to help him in Liberia.\u201d<\/p>\n

At that point, in the fall of 2015, the worst of the Ebola outbreak was over, and Kateh and his colleagues were busy looking for ways to better prevent and control future outbreaks. In order to quarantine a house, or a neighborhood, there must be a law on the books that details how and when to do that \u2014 and public officials must know it.<\/p>\n

That was one of Kateh\u2019s biggest frustrations during this unprecedented, widespread outbreak \u2014 Liberia\u00a0did\u00a0<\/em>have laws on the books for Ebola response, but people didn\u2019t understand them or know how to use them. Kateh had health officials in place, but when he went to them and said, \u201cDo this, it\u2019s the law,\u201d they responded with, \u201cWait, what law?\u201d<\/p>\n

It\u2019s a bit like having highways and state patrol officers, but no one knows the speed limit. The infrastructure is there, but the knowledge is not.<\/p>\n

Kateh presented Wall with a technical, three-part request. First, he wanted to organize foundational training for officials in Liberia to explain how law is integral to an effective public health system. \u201cDr. Kateh felt that there was a gap there \u2014 people didn\u2019t understand how important the law was to public health response. He wanted to build that foundation from the ground up.\u201d<\/p>\n

Next he wanted Wall and her colleagues at the\u00a0School of Government<\/a>\u00a0to help a team of Liberian attorneys and officials rewrite old laws and draft new legislation to bring Liberia\u2019s health codes up to date. \u201cWe help legislators draft legislation to do those exact things in North Carolina, and Dr. Kateh knew that,\u201d Wall says.<\/p>\n

Kateh\u2019s third aspiration included some kind of continued training in the future. \u201cSo we take this new body of law and train people in it,\u201d Wall says. \u201cBut we also have to help build capacity within the country to do that kind of training for public officials.\u201d<\/p>\n

Three ambitious and arduous goals \u2014 in a complicated country recently ravaged by a terrible virus. \u201cThere weren\u2019t a lot of people who were willing to take that on,\u201d Wall says.<\/p>\n

But she told Kateh she would look into it.<\/p>\n

Regaining lost trust\u00a0<\/strong><\/p>\n

In the midst of a crisis, a solid legal code can hold a community \u2014 or a country \u2014 together. This could include a law that requires a person who has been exposed to Ebola to comply with control measures, or a law that closes down all the schools in the event of a widespread outbreak. \u201cThere has to be this legal structure already in place,\u201d Wall says. \u201cAnd government officials must have the tools to enforce those laws.\u201d<\/p>\n

Liberia\u2019s history of governance is complicated at best. The last decade, while relatively peaceful, was proceeded by 20 years of bloody wars, a 10-year period of dictatorship, and over a hundred years of one-party rule, gouging a deep distrust of government and democracy in the Liberian psyche.<\/p>\n

Since the\u00a0Accra Comprehensive Peace Accords<\/a>\u00a0in 2003, a more calm and stable energy has settled into the country, according to\u00a0Jeff Austin<\/a>, a research associate at the UNC School of Government who lived and worked in Liberia in those early years of peace-keeping. \u201cThere has been a lot of collaborative work on rebuilding the country and a lot of optimism,\u201d he says. \u201cBut the capacity challenges are just very deep, and the distrust remains.\u201d<\/p>\n

That distrust played a major role in the chaos and devastating loss of life caused by Ebola.<\/p>\n

West Point is a slum on the peninsula of Monrovia and home to roughly 75,000 of the city\u2019s most impoverished residents. With no access to running water and only four communal toilets, it is exactly the kind of place that breeds disease. When officials started reporting cases of Ebola in West Point, the government reacted impulsively. \u201cThey were asking questions about public health and emergency powers, and what tools they had available, but no one knew what to do,\u201d Wall says.<\/p>\n

With no good protocol in place, President Ellen Johnson Sirleaf ordered the army to quarantine the slum on August 20, 2014. When armed soldiers rolled into the neighborhoods and began erecting barricades, they were met by hundreds of angry and terrified people. Soldiers fired shots into the air in an attempt to disperse the swelling crowd. In the chaos and confusion that ensued, four people were injured and a 15-year-old boy was fatally shot.<\/p>\n

Ten days later, amid building international criticism, President Sirleaf lifted the quarantine. Many government leaders expressed regret over how the situation was handled, according to Wall. \u00a0\u201cTalk about mistrust \u2014 it must have been terrifying for those people.\u201d<\/p>\n

Trapping them in an area where a highly contagious virus has been reported created a huge rift between government officials and their citizens. Another major point of contention revolved around the traditional practice of carrying a dead body and keeping it in the home for a few days. \u201cThese are things their communities have always done. But public health practice and law says you should not do that in some situations,\u201d Wall says. \u201cThere was so much confusion about forbidding customary practices, and huge trust issues. People kept asking,\u00a0Is the government trying to trick us? Why is the government stealing our dead bodies<\/em>?\u201d<\/p>\n

<\/div>\n
\"Jeff
Jeff Austin and other members of the team from UNC and the CDC walk across a makeshift bridge in a neighborhood outside Monrovia.<\/figcaption><\/figure>\n

Reaching the people\u00a0<\/strong>Liberia is home to a tropical climate where the air hangs heavy with heat and humidity year-round. During the rainy season (May through October) water pours from the sky, saturating the earth for days on end. The intense rain often washes out bridges and roads, making travel and communication to remote villages nearly impossible.<\/p>\n

This presents yet another major challenge for public health officials to cope with when Ebola hits. \u201cWe heard that this area was experiencing an outbreak and the people living there didn\u2019t understand it,\u201d Wall says, pointing to a county outside of Monrovia on a map. \u201cThe public health officials and volunteers had to park their cars and walk for two days to explain the proper protocol to the tribal leaders there.\u201d In remote areas, people have almost no contact or connection with government officials \u2014 their trust lies solely in the tribal leaders.<\/p>\n

Jeff Austin and other members of the team from UNC and the CDC walk across a makeshift bridge in a neighborhood outside Monrovia. Photo by Emily Rosenfield, courtesy of the CDC.<\/p>\n

Across the country, officials erected huge billboards declaring \u201cEbola is real\u201d in an attempt to convince people that the virus is indeed a real threat, and not some sort of government conspiracy.<\/p>\n

But fewer than 50 percent of Liberia\u2019s population can read. \u201cThey talked about adding things to the law that didn\u2019t make sense practically for their population,\u201d Wall says. \u201cHow important is signage when people can\u2019t read it? You can\u2019t impose a literacy requirement.\u201d<\/p>\n

Seemingly every facet of public health protocol was met with misunderstanding at best and animosity at worst. In Liberia, burning a dead body is a massive taboo. More than a year has passed since Ebola swept across the country, but the men who helped end the epidemic \u2014 the \u201cbody burners<\/a>\u201d \u2014 are still shunned by their communities.<\/p>\n

Mapping new laws \u00a0<\/strong><\/p>\n

Taking all these unique challenges into consideration, Wall knew that transplanting public health laws from North Carolina wouldn\u2019t do any good. She needed to examine public health laws that work well in places similar to Liberia.\u00a0 Fortunately, the U.S. Centers for Disease Control (CDC) had already initiated a project that involved mapping out public health laws from many vulnerable countries including Liberia. The lead researcher on that team is from the UNC Department of Public Policy \u2014\u00a0Ben Meier<\/a>. \u201cMy research doesn\u2019t go into the politics of reforming laws,\u201d he says. \u201cIt deals with comparing the existing laws of some 20 sub-Saharan African countries.\u201d<\/p>\n

The comparative legal data Meier provided filled a crucial gap for Wall as she and Austin sat down with Liberian officials and CDC attorneys, Emily Rosenfeld and Akshara Menon, to evaluate the best ways to reform various pieces of Liberia\u2019s public health code. She spread out copies of laws and supporting documentation from countries across Africa. \u201cIt was this incredible road map,\u201d she says. \u201cWe said, \u2018Okay, they want to do this differently in Liberia. Well, here is how they do it in Tanzania, and here\u2019s how they do it in South Africa.\u2019 The research Ben brought in made it so much easier to supplement and modify their laws.\u201d<\/p>\n

The marriage of the two projects highlights the benefit of different approaches to the same area of research, according to Meier. \u201cMy work on its own is not enough,\u201d he says. \u201cAnd Aimee\u2019s project requires the work that we\u2019re doing as a setup for it. So they are very complementary approaches \u2014 one can\u2019t reform national legislation without going to the country, and one can\u2019t go to the country without understanding what all other countries are doing.\u201d<\/p>\n

Supporting Liberia\u2019s legal system\u00a0<\/strong><\/p>\n

When Wall received that telephone call from Kateh in October 2015, she told him that she and her colleagues were not the right people to help him. \u201cWe don\u2019t do global health law,\u201d she said. \u201cWe do North Carolina public health law. But let me see if I can find someone who can help you.\u201d<\/p>\n

As she began contacting people, she realized Kateh may have reached out to the right person after all.<\/p>\n

\u201cThere are lots of people that could teach him about the foundations of public health law and the public health system, but there weren\u2019t too many people who were willing to go in and actually help rewrite the laws,\u201d Wall says. A pro bono group of attorneys provided assistance several years ago through the International Senior Lawyers\u2019 Project and the new team was able to build on much of their good work. But legal resources are scarce and attorneys trained in public policy, public health, and legislative drafting are even scarcer.<\/p>\n

Wall\u2019s ability to help is, in part, due to the close similarities of the United States constitution and Liberia\u2019s constitution. Liberia was founded by free black Americans from the United States so their legislative system has strong American influences. The country uses American law as precedent in its courts, teaches American case law in their law schools, and passes statutes that look a lot like U.S. laws. Liberia\u2019s current constitution, drafted in 1985, looks very similar to ours. \u201cIn the absence of that, our utility is minimal,\u201d Wall says. \u201cBut they have a constitution \u2014 it\u2019s funny how close it is to ours. A lot of the same concepts are in there \u2014 many of them improved.\u201d<\/p>\n

Liberia is currently considering a bill that would change the structure of their government by devolving a lot of functions from the national level down to local governments. \u201cThat bill would direct an organization called the Liberian Institute for Public Administration to provide support to the country\u2019s counties and towns,\u201d Wall says. \u201cThey would be providing technical assistance that is very similar to what we do here at the School of Government.\u201d<\/p>\n

If that law passes, the UNC School of Government\u2019s role in Liberia could go beyond the realm of public health. \u201cHow do we help them train local officials about finance? About purchasing and contracting? And how do we help them back up that training with technical assistance?\u201d Wall asks. \u201cWe do that kind of stuff here on a daily basis. I think that\u2019s what makes the School of Government so good \u2014 we get these phone calls and questions, and that feeds our training, writing, and research.\u201d<\/p>\n

Wall sees an opportunity to help her new friends and colleagues in Liberia build their internal capacity to do the kind of work that the school does in North Carolina. She has been working especially closely with Tomik Vobah, the General Counsel for the Ministry of Health in Liberia. Vobah visited Chapel Hill this past fall to learn more about our public health and legal systems. He also spent time with\u00a0Gene Matthews<\/a>, the former General Counsel for the CDC and Senior Fellow at the\u00a0Gillings School of Global Public Health<\/a>, who introduced Vobah to national and international experts in order to help him build out his own public health law network. Wall hopes that these relationships \u2014 with UNC, the CDC, and many others \u2014 will help give Vobah the support he needs to become a leader in this field for his country and region.<\/p>\n

Both Wall and Austin are quick to point out that their role is to provide guidance and support \u2014not to come in and write their laws for them. \u201cThey wanted our help, but they made it clear the final product will be drafted by Liberians,\u201d Wall says. \u201cAnd that\u2019s important. They need to own it and have pride in their product as Liberian-born.\u201d<\/p>\n

\u201cToday, more than ever before, they know the wars are over and they are an independent country that is about to experience a transfer of power \u2014 from one peacefully elected government to the next,\u201d Austin says. \u201cThere is a lot of pride in that.\u201d<\/p>\n<\/div>\n

\n

Aimee Wall is the Thomas Willis Lambeth Distinguished Chair in Public Policy at the UNC School of Government.<\/em><\/p>\n

Benjamin Mason Meier is the Zachary Taylor Smith Distinguished Professor of Public Policy and an Associate Professor of Global Health Policy in the Department of Public Policy in the UNC College of Arts & Sciences.<\/em><\/p>\n

Jeff Austin is a research associate at the UNC School of Government, and has worked in Liberia through the\u00a0Carter Center<\/a>.<\/em><\/p>\n

Story by Mary Lide Parker, Endeavors magazine<\/em><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

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