How Thousands of Ugandan Health Workers Defeated a Deadly Ebola Crisis

Now the country’s ordinary health workers are being praised for what the US described as a “major accomplishment”.

KAMPALA – It was a typical day for Dr Hadson Kunsa, an intern at Uganda’s Mubende Regional Referral Hospital, 90 miles from the capital, Kampala. A patient came in with severe abdominal pain and tests found he had a perforated stomach. He was rushed to surgery, but it was too late. Several of his organs had shut down and no amount of resuscitation could help.

At the time, Kunsa and colleagues did not know they had just been exposed to Ebola – a rare, infectious virus that has been known to have a fatality rate of up to 90 percent.   

Looking back, the signs had been there. This was mid-September 2022, and a handful of other patients that week had died suddenly with similar symptoms. “One died on arrival at our hospital,” Dr Emmanuel Batiibwe, Mubende’s hospital director, told VICE World News.

But still, nobody could work out what was going on. Investigations into these mysterious deaths led the hospital staff to Madudu’s surrounding villages. “We found that nine deaths had already occurred, and the locals were also suspicious that something was wrong,” Batiibwe added.

Map of Uganda showing the Mubende and Kassanda districts. Photo: VICE

Many families in these villages had allegedly been seeking treatment from traditional healers, so it was hard to gauge the full extent of whatever this outbreak was. “Seeing people falling very sick at once and then dying one after another was strange,” Silvest Lwambuka, a community leader in Kassanda, one of the worst-hit districts, told VICE World News. “Instead of going to the hospital, many went to traditional healers to chase these evil spirits away.” Some of these treatments included drinking a concoction of local herbs and chanting specific, spiritual words.

Going to hospital, Lwambuka added, was their last option.   

Eventually, when a 24-year-old man with a bleeding nose arrived at Mubende hospital, a sample was instantly taken for testing and returned on the 19th of September. It was Ebola, the Sudan Variant, a strain that’s especially feared because it has neither a vaccine nor specific treatment.

Days later, Kunsa and several colleagues started experiencing ferocious bouts of fever, a drastic loss of appetite, overpowering body aches and intense diarrhoea. “I remember thinking of running away, anywhere, to avoid my reality,” Kunsa said as he came to terms with both what this could mean for his personal health and also his professional responsibilities in the coming days.   

Five staff members died within days – four health workers and a hospital driver. Two other health workers in nearby smaller community clinics also died. Morbid fear and confusion gripped the hospital staff, along with grief.

“We hurt,” Batiibwe told VICE World News, his voice just a whisper.

As word of the positive Ebola tests spread, governments and the media around the world started to paint a grim picture of Uganda’s ability to contain the outbreak, especially when cases spread beyond Mubende. The Telegraph would later report a leaked assessment that claimed 500 people would die by April, 2023. Memories of 2013-16, when a major outbreak across Liberia, Guinea and Sierra Leone killed more than 11,000 people were still fresh, with any new cases in the interim period sparking anxious updates on news wires.  Yonas Tegen, the WHO Country Representative described these reports as dramatic. The country’s tourism sector started to take a hit as visitors cancelled their trips to Uganda.

On the 11th of October, the US urged its citizens to reconsider travel to Uganda, and introduced special screening for passengers who had visited or transited through the country. “We anticipated that it would take 1-2 years to manage the outbreak, especially as Ebola cases presented in a complex urban setting such as Kampala,” Anne Robins, the United Nations Children’s Fund (UNICEF) Chief of Child Survival and Development, told VICE World News.

Yoweri Museveni, Uganda's 78-year-old president – a military strongman ruler who has been in power since 1986 – instructed senior army medical personnel to lead the fight against the disease.

“The government mobilised its resources,” Lt. Col. Dr. Kyobe Henry Bbosa, who was appointed to run the government’s response, told VICE World News. “It was a combination of skills coming together to get work done.”

He said his core team of 20, which he called “the engine of the operation,” partnered with around 3,500 health experts from across the country. But the first two weeks of the operation did not go well.

The normally busy Mubende-Kampala highway seemed deserted. The bustling Mubende market was just as mirthless; a few women could be seen hawking produce, but unsure whether the customers were comfortable with them moving close. In the worst-hit villages in Madudu, the roads are just as empty as the highway, save for the occasional farmer.

It took around 10 days for the government to establish a working relationship with local communities, where many people were still relying on local healers they knew and trusted. As a result, identifying and extracting suspected cases from their communities was a challenge. A task force was created to track and engage with suspected cases, while a series of risk analyses were carried out to identify the most at-risk areas and determine the worst-case scenarios.

Yet cases just kept rising and the Mubende Regional Referral Hospital – one of the biggest in central Uganda, with approximately 200 beds – was becoming overwhelmed with new cases. “In the first week alone, we had almost 49 admissions,” Batiibwe said. “In a few days, three people had already died. It was tough.”

Treatments that had worked against other Ebola variants were much less effective. On the 15th of October, nearly a month after the first confirmed case, and after an estimated 19 people had died from Ebola, President Museveni announced a lockdown for the roughly one million people who lived in the worst affected districts of Mubende and Kassanda.

Unfortunately, a pre-symptomatic Ebola case had travelled out of Mubende to Kampala and exposed up to 17 people to the virus, including six school children. Overall the number of new infections had dropped, but the presence of Ebola in Uganda’s densely populated capital signalled a new phase of the crisis.

Across Kampala, talk was of a potential lockdown, but while some people started wearing masks and crowded malls asked visitors to sanitise their hands before entering, most of the capital continued as normal.

Schools were eventually closed and some health experts lobbied for a wider lockdown, but authorities quickly ruled out the idea. “The entire public was tired of epidemics; many people refused to believe there was another one barely a year later," Dr. Richard Kabanda, the acting Commissioner of Health Services, told VICE World News.

The health ministry chose instead to launch a campaign to educate the public on the virus. Authorities believe the education programme proved the most successful aspect of the response. Thousands of flyers with messages from health officials were quickly circulated, encouraging people to seek help. “Your chances of survival and recovery are much higher if you seek early treatment and care from qualified health workers,” one read.

Posters with illustrations showing symptoms of Ebola with captions translated into multiple local languages helped the messages reach all ethnic groups. These were circulated in busy spots, such as markets, published in local newspapers and in TV ads. Toll-free numbers were shared, and the telecom companies played Ebola-awareness messages as people waited for their call to be picked up.

Authorities used a network of hundreds of Village Health Trainers (VHTs), who are the Health Ministry’s first point of community contact, known to help disseminate immunisation calls and family planning advice. Armed with portable megaphones, these individuals, trusted and loved in their local communities, moved from door to door, raising awareness.

"As we moved, we would also collect any information about who was not feeling well, and if the symptoms were similar to Ebola, we forwarded the details,” Anna Nalubega, a VHT in Kassanda, said.

“We gave people our numbers to call at any time, and we notified the district Ebola teams when they did,” Fedris Nambooze, also a VHT, added. Many VHTs had also been deployed during the COVID-19 outbreak, and we’re now doing the painstaking work of educating a populace on a unique virus all over again.

By mid-October, the biggest threat to the fight against Ebola was the myth in rural communities that the virus was spread by witchcraft. Bbosa’s Ebola taskforce successfully worked to educate traditional healers on the symptoms and dangers of the disease. They all agreed they would not treat anyone with Ebola symptoms but instead refer them to a hospital.

“We watched each other to make sure no one was putting themselves or the community at risk,” Mpuga Teribirye, the Uganda national inspector and chairperson of traditional healers in Mubende district, told VICE World News.

Despite the focus on education and prevention, the government widely failed to acknowledge the challenges communities faced by putting them into strict lockdowns, such as limited access to food and basic household items. “Should I stay in the house and watch my children die of hunger?” Gladys Kakulu, a casual labourer and mother of four in the Mubende district, said.

Communities blamed the government and called out  their elected officials, who voiced these concerns. “I appreciate the need to keep our people safe, but what should they eat in the meantime?” the Mubende Woman Member of Parliament, Hope Nakazibwe Grania. told VICE World News. “Most of these people live from hand-to-mouth; but now they can’t go out to work to put food on the table.”

However, the growing number of known Ebola-related deaths continued to take precedence. By the 30th of October, at least 53 people had died and about 136 had been infected by the virus. Benedicto Mweba, 11, from Kassanda district recalls answering more questions about his battle with Ebola than he could fathom. "I was so weak,” he told VICE World News over the phone. “I couldn't stand; even sitting was a problem. Sometimes I would be awake but hear doctors calling my name from far, and yet they were near me.”

Mweba tested positive for Ebola after his brother died from the virus; doctors found that he also had malaria. Before he died, his brother had been sick for a week, but they had assumed it was malaria, too. It wasn’t until Mweba tested positive that they realised he could have died from Ebola.

UNICEF's Robins confirms that several child Ebola and malaria cases – a common disease in Uganda – manifested simultaneously, with a near 60 percent fatality rate. UNICEF quickly started providing preventive medicine for malaria in the Ebola-affected districts and helped get faster referrals and more suitable treatment for child patients.

“There was a family that lost a mother, a baby, and then the remaining 7-year-old was left for treatment in the Ebola Treatment Unit to die alone,” Robins added. “He died after 19 days and his suffering, both physically and emotionally, was heartbreaking for all.”

UNICEF set up a child-friendly treatment centre in the lockdown districts that included a play area, and by extension, they also distributed picture-filled posters with messages about Ebola targeting children in and out of school.   

According to Dr Scott Murcko, a doctor with Doctors Without Borders, the treatment centres were a challenging place to work. “Some days you had three critical patients in the Intensive Care Unit fighting for their lives, and those were tough days,” he said.

Murcko said they did everything possible to keep people in good spirits, including once dancing for a patient in intensive care. “His morale was low, we needed him to feel hopeful again, so we danced for him,” he said. “Later, when he was discharged, we danced again to celebrate and give him more hope.”

This period also marked an important turn in the fight against the crisis, as hospitals started to note fewer transmissions and more recoveries.

“As soon as the minister and her team arrived and partner organisations like WHO, CDC, MSF, Baylor, Infectious Diseases Institute and others joined, I started to see results,” Batiibwe. “The workforce was bigger and it had health workers who had previously managed Ebola.”

Though chaotic, Batiibwe remembers how the first two weeks helped them build systems and that would eventually lead to less panic. “Even when more patients came, we knew what to do, and the teams in the field were making sure the suspected cases got to us on time,” he said. “We went from having patients arriving to die in hospital in September to mid-October, to having no deaths later in November.”

On the 12th of November, WHO’s Tegen told media that only five cases had tested positive for Ebola that week and that the previous three weeks had seen a sharp drop in the number of cases.

In Kampala, where a large treatment centre had been set up, Bbosa said that there weren’t any patients. “By mid-November, there were 300 unused beds at the National Referral Hospital alone in anticipation of a rise in patients, but there wasn’t any new case,” he told VICE World News.

On the 11th of January, Uganda and the WHO announced the outbreak was over after no new cases had been detected since late November. 

Ultimately, the WHO reported 142 confirmed Ebola infections, 55 deaths and 87 recoveries; CDC reported an additional 22 probable deaths from undiagnosed cases and over 4000 contacts traced. The final numbers are a long way from the initial estimates of over 500 deaths that were predicted at the outset of the outbreak.

The programmes have since shifted to the discharged patients who, the team on the ground recognised, still needed support. Alongside aid organisations such as USAID, the health ministry has since established Ebola survivor programmes.

"There are clinical issues that remain once you are discharged," Dr Sarah Page, the USAID Global Health Security Agenda Advisor, explained. "For many survivors, they experience headaches, joint pain, and sometimes you can have the virus persisting in breast milk and semen.”

Uganda’s survivor clinics continue to do rigorous 72-hour mobile testing of breastfeeding mothers and support infants who have been weaned. Not to mention the emotional support programmes monitoring survivors’ mental health.

Today, while the survivor monitoring continues, finding patient zero is high on the agenda. Dr Amy Boore, CDC Director of Global Health Protection, said that the world hopes Uganda will be the first country to deliver this critical news that has eluded every Ebola outbreak. Many studies are going on for now, with suspicion being placed on an animal reservoir. "We don't know which one, but Uganda's Ministry of Health is leaning in hard with the Wildlife Authority as well to up the game with ecologic studies," she says. "They are pretty determined this time around to answer that question, and if they do, they will be answering it for the world."

She commends the country for quickly differentiating between the Ebola variants. “Uganda is one of the very few places on this planet that could have identified the Sudan species,” she adds.

Emmanuel Ainebyoona, the Health Ministry’s Spokesperson, added: “Uganda has been a good example within the African continent to the extent that some other countries have had their samples tested here. The whole response lasted less than four months, contrary to the doom the articles in some foreign media had predicted.”

The UN has been equally complimentary. “I congratulate the government, health care workers, and the people of Uganda, for your leadership and dedication, which have enabled this Ebola outbreak to be contained in less than four months,” the Director General of the WHO, Tedros Adhanom Ghebreyesus, said in a video message last month. “Even in the absence of approved vaccines and therapeutics for this specific Ebola, Uganda was able to use proven public health tools to contain the outbreak.”

“We commend the Ugandan government in leading efforts to put a swift end to the spread of the Sudan ebolavirus which spurred the outbreak, the US government said in a statement. “A major accomplishment in such a short time.”

In the end, Boore gives most of the credit to the people of Uganda. “Everything that Ugandans do, they do with absolute effort; people do not reserve energy till the end,” she told VICE World News. “The story of Uganda and Ebola from 2000 until now is inspirational.”

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