Contracting out Ebola Hospital raises concerns in NGO community

MMU - Monrovia Medical Unit Ebola Training Tent - Monrovia, Liberia
Photo Credit: US Air Force (Maj. Adrien Adams) Oct 17, 2014

A slow moving, yet wide reaching crisis or catastrophic disaster event can easily overwhelm resources at the local and regional level. Resource management is a critical issue all emergency management agencies have. Preparation of logistics requirements for a wide variety of contingencies and events are analyzed, calculated and practiced. Gaps identified allowing crisis planners to document enhanced requirements and distributed for further consultation to all stakeholders, at all levels of responsibility. The volume of documents which chart and document each category of logistics support, for each type of disaster can accumulate into thousands of pages. At this level of planning, operations and command of resources often recognized during the real thing as hornets nest, stretched to the breaking point as the depletion of assets outstrip resupply of equipment and people available and what has yet to be anticipated. It is impossible to forecast every contingency that have the potential to occur once every 100 years.

In addition to local, regional, state and federal government response resources brought to a disaster zone, they can be augmented from every corner of a community including local, national and international NGO's. And if it is possible to establish, additional partners are sometimes right around the corner including community leaders, churches and the private sector. If the disaster is truly catastrophic, the United Nations and member nations offer assistance.

International assistance is a significant undertaking that entails complex planning and delivery roles that must be clearly understood. International experience is required to execute the mission and is paramount to achieve success. In most cases, several agencies or departments of the federal government are involved. The lead department is often resourced from the office of the Minister or Secretary of Foreign Affairs. In circumstances, such as broad coalition of international support, the United Nations is the lead organizer and resources are committed to the mission under U.N. responsibility and management. Navigating a disaster response inside the U.N. is a complex and difficult task depending on the nature of the event. The UN Office of Coordination of Humanitarian Affairs (UNOCHA) after decades of disaster responses has created an elegant and impressive response capability that has served the global community remarkably well and efficiently. Not every scenario has UNOCHA as the lead agency or Director of Operations. In some cases it might be the World Food Programme or World Health Organization. The participating government must be flexible and capable of working in multiple environments and do so with qualified personnel. In some cases, a donating nation may be approached directly by the government in need AND provide support services to other organizations such as WHO, or WFP simultaneously. U.N. agencies are always a work in progress. It isn't perfect either.

The mosaic of resources required for a response is immense, expensive and difficult to support. Each type of disaster requires different skillsets, equipment and expertise. It is not easily put into a template and put on a shelf until needed. Some elements are cookie cutter and can be simplified. Examples include aircraft specifications including payload, range and support requirements which can be factored into a response based on tonnage of cargo, flight distances and general planning information (airports, support services, technical requirements, etc.) that can be prepared in advance for any region of the world. Logistics templates can and have been designed and generated based on type of disaster and scale of response resources available or authorized for aid missions. Some agencies such as UNOCHA, USAID,  have prepared for multiple scenarios and update these plans regularly and are ready for implementation on a moments notice. It sounds simple. In today's world of computers, open data and access to technology, many argue that disaster planning should be a breeze. It isn't.

Most non-government organizations such as Save the Children, Oxfam, International Medical Corps, Doctors Without Borders/ Médecins Sans Frontières (MSF), IHS and many others are well organized, prepare for the worst and implement disaster response services knowing full well what kind of undertaking is before them, prior to deploying in the field. They understand the complexities involved in operating under difficult and some would argue, impossible conditions. In many cases, it is a collective effort working together to accomplish their goals. NGO's frequently deploy to the same disasters all over the world creating trusting and build lasting relationships. Along the way they find out what does and does not work in the field. There are still some rivalries between some of them, but certainly not all. Each are beginning to build new or revised operating procedures that take into consideration the strengths and weaknesses of each organization, creating improved operational capacity and expectations.

NGO's are not perfect organizations. Each has their strengths and specialized fields with burdens of flaws and weaknesses. Not all are welcomed in some parts of the world, including some UN entities and affiliated partners. Donors of NGO's are pushing for improved results and outcomes as funding is strangled during difficult economic times. As the complexity of a disaster increases the level of stress, performance and cost rise. There's never enough personnel, equipment, supplies or services.

Wikipedia defines an NGO as;

A non-governmental organization (NGO) is the term commonly used for an organization that is neither a part of a government nor a conventional for-profit business. Usually set up by ordinary citizens, NGOs may be funded by governments, foundations, businesses, or private persons. Some avoid formal funding altogether and are run primarily by volunteers. NGOs are highly diverse groups of organizations engaged in a wide range of activities, and take different forms in different parts of the world. Some may have charitable status, while others may be registered for tax exemption based on recognition of social purposes.

NGOs are difficult to define, and the term 'NGO' is rarely used consistently. As a result, there are many different classifications in use. The most common focus is on 'orientation' and 'level of operation'. An NGO's orientation refers to the type of activities it takes on. These activities might include human rights, environmental, or development work. An NGO's level of operation indicates the scale at which an organization works, such as local, regional, national or international.

The term "non-governmental organization" was first coined in 1945, when the United Nations (UN) was created. The UN, itself an inter-governmental organization, made it possible for certain approved specialized international non-state agencies—i.e., non-governmental organizations—to be awarded observer status at its assemblies and some of its meetings. Later the term became used more widely. Today, according to the UN, any kind of private organization that is independent from government control can be termed an "NGO", provided it is not-for-profit, non-criminal and not simply an opposition political party.

One characteristic these diverse organizations share is that their non-profit status means they are not hindered by short-term financial objectives. Accordingly, they are able to devote themselves to issues which occur across longer time horizons, such as climate change, malaria prevention or a global ban on landmines. Public surveys reveal that NGOs often enjoy a high degree of public trust, which can make them a useful - but not always sufficient - proxy for the concerns of society and stakeholders.

By all accounts, disaster response NGO's fit the definition as described above. Support of their programs are often funded national governments and United Nations agencies such as World Food Program (WFP) or World Health Organization (WHO). The role and value of an NGO's in disaster response is their neutrality during response and recovery operations. NGO's follow local customs, recognize and respect indigenous laws and do not discriminate in how they deliver support aid. Some conditions do apply.

And like legal fine print in contract terms and conditions, there are numerous historical examples where NGO and International Government aid has not always been successful. Beginning with the 2004 Tsunami that struck Banda Aceh, Indonesia, a significant shift how international relief missions began. The use of the Internet, commercial satellite services and mobile phones allowed cooperation between multiple agencies, NGO's and foreign government assistance aid while working on the ground in extreme conditions in real time without having to attend meetings that could take hours to figure out where it was, let alone when. This was a time of monumental innovation in terms of technology, and mutual support services. International disaster management had entered a new era. These new capabilities evolved and were tested several times during subsequent large scale disasters including the 2004 Khyber Pakhtunkhwa, Punjab,Sindh, Balochistan and Gilgit-Baltistan floods in Pakistan and 2010 Earthquake in Haiti. During these two disasters, numerous lessons learned were collected, culminating into several critical reviews in how NGO's not only worked separately and together, but what important improvements were needed. The information age powered by the Internet generated new areas of accountability, forcing NGO's to opened up to ever increasing demands of transparency. Social media broadcast in real-time status every mistake and success in addition to recovery operations gaps and needs.

Typhoon Haiyan (Yolanda) was a global response effort that engaged every corner of the globe. It is still in the reconstruction phase and continues to this day. When the Category 5 Typhoon hit Micronesia, the Philippines, Southern China and Vietnam, it was the most devastating Typhoon ever recorded with winds speeds that recorded between 230 to 315 kmph, killing over 6,500 with over 1,000 still declared missing. The scale of the disaster and impact on the population triggered one of the largest disasters response operations in recent history. It is the largest international humanitarian military intervention recorded since the Berlin airlift in 1949 with over a dozen nations participating. Every major U.N. relief agency and all the major NGO's. The way in how disaster response aid had improved and developed with new techniques, process and delivery mechanisms. Military Navy, Air Force, Army and Coast Guard units filled valuable roles with direct non-integrated military to military operations as NGO organizations prepared long term recovery support to affected areas. At times, this technique ruffled some feathers as complaints of what supplies were assigned different priority than that of the donating military nation's aid supplies. Sharing information continued to be a significant barrier in an era where Open Data is considered to a necessity. Nonetheless, the disaster response capabilities implemented demonstrated continued emergency management improvements across every segment including communications, transportation & logistics, access to power, computer information tools and transparency.

In the future, it seemed clear that emergency management teams on the ground would continue to see significant improvements when a catastrophic event impacts a community, a large metropolitan city or an entire province covering thousands of square miles. Evidence suggests that cooperation and collaboration tools and services are dramatically improving how organizations can deliver effective and timely disaster relief. And then, Zaire ebolavirus infected a 2 year old boy in Gueckedou Guinea in December of 2013.

Ebola outbreaks in themselves are not unusual in Africa. Prior to 2013, between 1976 and present day there has been 9 outbreaks, 3 of those as regional epidemic events. The World Health Organization monitors the region in cooperation with local and national governments in all three nations currently affected, Guinea, Liberia and Sierra Leone. In all the previous 9 outbreaks since 1995, the fatality rate never exceeded 224. In the past twelve concurrent months, over 5,000 have died. This epidemic spread out of control before local resources could react to contain it. It is estimated over 15,000 are currently infected. The virus has a 70% mortality rate.

The international response was initially very slow, if not downright sluggish. There are several reasons why this occurred and are beyond the scope of this article. The World Health Organization upon recognizing the disaster activated every resource required in response. It engaged the International community including NGO's in support of the disaster across three countries that spans 170,000 square miles with a combined population of just over 20 million people.

According to the Center for International Disaster Information, 61 NGO's are engaged in Ebola Disaster Response initiatives, including U.N. Agencies. Not all of them are directly on the ground. Only three military organizations are on the ground; China, United States, and the United Kingdom.

10 International Government Foreign Assistance Agencies (USAID, UKAID, CIDA, etc) have also committed some or all of the following items;

• Personnel (Medical Staff, Logistics Support Experts)
• Financial support 
• Medical supplies (including PPE and Medical equipment)
• Airlift  and Logistics Support (Shelters, Supplies, Equipment)
• Technology (Communications, Computers, Devices, etc.)

In some cases, funding is being directed to NGO's already deployed. The United Nations also tracks funds donated by governments through the Central Emergency Response Fund managed by UNOCHA.

In addition to these assets being deployed, other institutions and organizations have contributed. These include the private sector that vary from large multi-national corporations to Foundations and small organized volunteer teams that span across the world. These include the Thompson - Reuters Foundation, Gates Foundation, Facebook, and many others. Informal volunteers technical also help through the United Nations such as Digital Humanitarians, Open Street Map, Crisis Mappers and the Standby Task Force. These services are critical in Ebola response efforts. Without them, the fabric of support weakens, threatening to tear the security blanket apart. According to the U.S. Chamber of Commerce, over 44.4 Million (USD) in cash or equivalents in equipment has been donated by U.S. corporations alone.

Private sector participation, in particular large corporate organizations, tend to engage in disaster response using one of two methods, direct funding to an agency or NGO (or blend of equipment and funding) or directly under the authority of a Government Agency such as USAID or their respective equivalents around the world. Using this model has significant advantages by offering support to a country in need without:

• Specific knowledge or expertise in how to deliver disaster relief
• Extensive knowledge of the area in need
• Understanding specific requirements, laws and regulations
• Exposure to unforeseen risks  and liability

It is one thing to help during a disaster on home territory, but supporting relief operations in a country that is facing an epidemic or where they have never been before would be irresponsible behavior by the company and potentially be damaging over the short and long term. Government agencies like CIDA, UKAID and USAID have worked with the private sector for decades, building unique disaster support mechanisms and forums to engage when assistance is needed. In most cases, Government agencies act as facilitators and managers for the response effort and direct how and where these services can be best used either through cooperation with another government agency or with the recipient host government. Corporations routinely operate under government oversight and management as required and necessary. DHL routinely acts as air transport agent for German Government aid delivery when military transports are not available and do so all over the world. Communications manufactures including Cisco, Motorola and Alcatel provide engineers, equipment and expertise as required, under the supervision of government oversight of their representative country and host nation.

In a disaster where infrastructure is severely damaged, civilian engineering company's are often contracted by governments (including the UN) to assist in rebuilding a region after an earthquake, flood or other catastrophic event. This process often takes months of planning and assessments prior to entering this phase of recovery. Depending on the type of disaster, it is simply not possible to allow or risk civilian engineering providers to enter a dangerous area. This gap is often filled by their military counterparts such as the U.S. Corp of Engineers, currently in Liberia.

The West Africa Ebola epidemic has created hardships that few could predict or forecast. This has created fears and the implementation of policy's many still do not understand why. In turn, emergency management resource planners are faced with limited access to available experts because of the perceived health risks and stigma attached. Some nations have prevented civilians from volunteering in any capacity, including Australia and Israel. These policies have had a chilling effect that has sent shock waves in and outside disaster management response community. On October 3rd, those that know MSF's modus operandi, this news did not sit well and publicly condemned Australia's actions to the point it refused Australian government financial aid. Peers cringed as Doctors without Borders lashed out at one of its biggest supporters over the past decade. Emotions run high when the largest NGO's on the ground in West Africa is operating around the clock in harsh conditions.

Australia's response was silence until last week (except in Canberra in Parliament where the controversy ignited fierce debate), when it announced on November 5th, that Aspen Medical, a global medical company based Deakin (Canberra), ACT had been awarded as sole source contract to construct, operate, manage and support a 100 bed Ebola Hospital in Sierra Leone. It will be responsible for every aspect of the hospital including medical staff. Upon learning this news, Antony Loewenstein of the Guardian Newspaper published an editorial suggesting the Ebola crisis had become a profit center for corporations. Company's supplying materials used in disasters have always had profit margins embedded into them - for over 50 years. This is not new and nor should it come as any big surprise. The scale and singularity of the contract may be unique, but not the awarding of a commercial contract for services required during a disaster.

Loewenstein asserts that NGO's could have delivered the same services for a lower cost. But when MSF refused any part of Australia's 18 million dollar aid package, it was rerouted to Aspen, and then adding fuel to the fire, the government added another 2 million. Even if we make the assumption that the extra 2 million is defined as 'profit', it is a slim one at best. In fact, it is likely Aspen will be lucky to break even, 18 or 20 million. Given the scope and scale of the project, where it is to be placed and the extent to which Aspen will be responsible for its operation, making a profit will be challenging. 20 Million for a hospital is relatively inexpensive. The U.S. is spending over 1 billion dollars, of which 700 million is for the construction and logistics support of 20 Medical Hospital units, each with 100 beds. These units will not include medical personnel costs required to operate them, but does include specialists and facilities to operate four medical labs, installed by a 22-member team from the expeditionary 1st Area Medical Laboratory unit.

There will be significant concerns the company has to address, despite past experience with NGO's and understanding the medical requirements;

• It has never operated in Sierra Leone
• It does not have an existing relationship with the Sierra Leone government
• It is in cooperation with the United Kingdom's aid program (who is in control?)
• Governance and oversight on the ground will prove difficult if Australia does not send government representatives to supervise the program
• It does not have a ready to deploy team in place with previous large scale disaster experience

But these barriers should not be reasons this experiment should not be attempted. In fact, it is long overdue. Privately operated companies have strong advantages that could serve them and the community well.

• Clear ownership of end to end responsibilities
• Streamlined project management, protocols and management systems
• Established procurement and service delivery organization
• Quality control mechanisms
• Cost containment (unless it is delivered on a cost - plus basis
• Knowledge transfer

Commercial vendors always have potential roles in disaster response. They have management skill sets that are desperately needed in some scenarios. It may have negative optics to many and it certainly has the potential to go wrong if mismanaged and terms and conditions (T&C's) are not clearly identified or transparent - one of Loewenstein's primary concerns. But ultimately the authority that is responsible, in this case, is the Australian Ministry of Foreign Affairs and Trade and ultimately, the Prime Minister. There can be little doubt this program will be under the microscope given the nature and type of disaster this is. Loewenstein also suggests that MSF believes this program will be inflexible and uncoordinated. It takes both sides to have that result. Non-profits have quarreled with each other, let alone the private sector over far less complex issue than this one raises. Many NGO's have learned valuable knowledge and expertise from the private sector and this should not be an area of friction that is put in place before it has a chance to be tried. 

We may learn very little from this particular deployment because Sierra Leone's Ebola epidemic is currently trending lower and has a lower infection rate than Liberia. In fact, by the time Aspen completes negotiations with the Australian government, gets clearance and agreement with the U.K. Government and establishes a relationship with Sierra Leone's, and builds the hospital, the need for it may have diminished or eliminated. The U.S. has already announced that it is not deploying all 4,000 military personnel to West Africa as originally planned and cutting it by 25% to a maximum of 3,000, of which 75% of those are now in theatre. 

Before passing judgement, Australia's contract with the private sector should be welcomed, observed and analyzed with an open mind. 

How Social Media is destroying Ebola disaster response support - Part II

The Ebola crisis affecting West Africa has created new challenges in how to respond. Governments and Disaster response agencies are not in uncharted territory. This is not the first time Ebola has impacted the region and likely not the last. What is new is the speed in which information and demands are now placed upon them to act in a 7/24/365 social media hungry environment.

Social media's power to distribute a specific or broad message is indisputable. It is the lowest cost distribution method and mechanism available anywhere in the world. It is a proven network. Social media has achievements in and around disaster environments span across the globe from Haiti to New Zealand. From New York to Tacloban City. Internet connected platforms have enabled multiple types of social media applications to support and aid in the recovery during disaster.

In Sierra Leone, Liberia and Guinea, each government has pushed forward with policies to invest in public safety programs. All three nations are under-developed with high rates of illiteracy, significant levels of corruption, fragile economies, civil war, ethnic conflicts and distrust of the west and everyone else outside of the continent. Social media's use inside all three of these countries is limited and only beginning to be understood.

No two epidemics act alike because of terrain, ethnic composition, population densities and cultural acceptance of warnings and alerts. As a result, policies and risk analysis vary, both in terms of disaster preparedness and capabilities to respond with local awareness and acceptance. As we repeatedly stated, those looking to technology to be the solution and answer are in for a rude awakening. To defeat Ebola, the effort becomes one of direct intervention and does not paint a bright picture of success from any perspective. But it can be done as Nigeria has proven.

Use of Technology and social media's during a disaster has evolved over the past 5 years, playing an important role in detection, response and recovery. But there are limitations. In some cases, coordination of social media sensors can support potential detection models across a wide area. But if sensors such as tweets, facebook posts and Simple Message Service (SMS) are not widely available, detection using analytics proves to be difficult implement.

Internet access and its use by the public in the affected region is not as widespread as people think it is. 85% of the population in the region lives on less than $1.00 a day. The populations in all three affected countries do not own mobile phones or have access the internet for information. It is true that infrastructure is improving in all three nations (Guinea in particular), the reality remains, usage is dramatically lower than most understand or recognize. As we mentioned (and linked) in our previous article, the infrastructure is also limited by the total bandwidth available.

There are three important areas we often find significant obstacles. Policy, services and education. Disaster management is a complex, yet elegantly simple organization. In West Africa, the management of resources and assets, is frequently limited or in some cases, not well understood as to their effectiveness and value. Preparedness policy begins at the community level. But such policies are only possible when the community is willing to adopt them. Liberia and Guinea in particular have suffered through decades of civil unrest and war. These historical scars cannot be understated. The impact on communities and the cultural impact in all of them are open wounds that have not yet healed.

The measurement of how well a community is trained and capable of responding varies is rarely publicly disclosed for review. Each village has taken care of their own people for generations without interference or concern. It only when a mysterious disease flares up that the community is stunned in disbelief as shock hits the community with catastrophic consequences. This epidemic will be one of the longest in recent African history, marking the one year anniversary this coming December (2) when a young boy, Emile Ouamouno died in Gueckedou Prefecture in Guinea died along with 20 others in the same village. News of this was never reported on Social Media. And when it did begin to publish references, it reported that the first cases were first detected in March, 3 months after it actually hit. It would be another 7 months before social media would make Ebola a household word around the world. But when it did, it exploded everywhere else around the world but not West Africa.

New England Journal of Medicine presentation tracing Ebola index patient in Guinea.

International news media outlets are not out on the front lines outside of the capital cities Monrovia, Freetown or Conakry every day. Those journalist that venture out into the country including the BBC, do not risk staying for long periods of time reporting eye witness accounts. The result is limited information with few facts. Local media in some areas is non-existent and television is a luxury outside of the capital cities.

Filling the news and information vacuum to varying degrees are the NGO's and UN agencies. But their news accounts are not receiving the same attention as CBC, CNN, BBC and other internationally recognized broadcast organizations. They must also respect local laws and regulations, often limiting the level of details they can release. Most NGO's have maintained their focus on helping those affected. Given the nature of this disaster, the World Health Organization has done a remarkable job in ensuring information is freely available to any agency or organization that needs it. Real-time information sharing and distribution on the ground remains a challenging problem to overcome.

Training local volunteers is the top priority by NGO's and the World Health Organization. The International Medical Corp, Gates Foundation, and local medical agencies are continually upgrading and themselves learning how to effectively train local medical aid workers. This cannot be achieved using the internet or even locally based cloud services and distributing it across the national wireless networks because of limited bandwidth and device access costs. The required training to use such services is also a significant obstacle. Knowledge transfer (train the trainer) is not always easily conveyed in a classroom. In some remote villages, it is ignored or considered a low priority or worse, not spoken of. The process that has proved most effective in the education of the locals has been to go into the field and educate directly one on one, a time consuming task that proved successful in neighboring Nigeria that traced and investigated every case early in the Ebola outbreak. Social media tools or other internet services did not play a role.

Social media and access to the Internet is currently not worth the investment to spend significant resources and efforts as local preparedness capabilities, management and planning is not possible without other essential services being implemented. When the outbreak was first detected, there continued to be the belief that communities could survive the Ebola outbreak because community leaders and the population were not equipped to understand the impacts or the implications to their families or those that live nearby. Prior to support by W.H.O. involvement, disaster planning and education was not recognized as a critical element in any phase of the Ebola outbreak. Complicating matters further are local conditions including asphalt paved roads and lack of capable airport facilities (storage, hangers, security) and the use of aircraft to support emergency operations and associated logistics in remote areas.

Early emergency response operations throughout West Africa were entirely ad-hoc. Access and use of local health clinics was limited and not widely trusted after years of civil war and local ethnic conflicts. It should be clear that the use of social media would not have made a difference when the Ebola outbreak first occurred given the current state of each country's communications capabilities. Social media would face significant resistance even if it was widely available with propaganda denouncing it. Today in all three countries, each has responded with improved Ebola response plans, dramatically improving the odds of the epidemic being contained. It is going to take a sustained on the ground approach to defeat Ebola. It will require a significant increase in medical support staff willing to volunteer and go to West Africa with the necessary support teams to back them up. Funding this will cost hundreds of millions of dollars. This is where the international community can leverage Social Media and play a key role as it did during Typhoon Haiyan.

Social media combined with wireless communications for emergency response programs are an important tool in Africa's future. Together they can deliver critical knowledge covering a spectrum of a diverse cultural audience. There is acknowledgement that there will be technical and fiscal deployment limitations. Liberia's average literacy rate is 60%, Sierra Leone; 35.1% and finally Guinea at 41%. In a strange twist of fate, despite a better literacy rate, Liberia has more cases of Ebola than Sierra Leone or Guinea.

With so many health workers initially infected and dying, a thorough review was initiated. It was discovered that workers were not following procedures. Masks and gloves were not always were being handled (removed) in the correct sequence by healthcare workers resulting in contact with the virus as some workers would touch their faces while still wearing their gloves. Such transparency has improved accountability and retraining. Governments recognized that in implementing transparency, trust is built and does not negatively affect them long term. Social media's reaction was swift as this information was tweeted and retweeted and posted on Facebook and Reddit around the world. Because of the lack of local internet availability, the criticism and hype was not read and did not affect morale like it did when a similar accident occurred in the Thomas Eric Duncan case in Dallas Texas. As news broke and criticized the medical team including the nursing staff, the response by the nursing union was swift and blasted the Texas Health Presbyterrian Hospital and CDC. It only got worse as two nurses were infected, one of them being allowed to travel. Social media wars broke out (especially on Reddit, Quora and Twitter) with nobody winning and more than a few losing both credibility and trust.

It has been suggested the news has not negatively affected the sums of money and supplies being donated and if anything, increased. We have noted several spikes in social media on the subject of the need for increased donations of reusable rubber gloves. As we posted in our previous article, social media has tweeted about these mistakes and errors and it has not helped improve conditions and the need for additional health care volunteers.  The spread of fear has drowned out several initiatives asking for increased medical volunteer support. We did not imply in our article that emergency disaster relief will not improve or should be halted, Social media users have. By retweeting news of quarantines, visa cancellations and the suspension of humanitarian aid, often adding (requoting) negative commentary (i.e. that it should become policy, or agree with total ban, quarantine or worse in some cases), the kind of publicity and information spreading around the globe has not been one of positive support and response. Reddit posts fill gigabytes of data center space with rumors and false information. Australia's Attorney General's Department of Emergency Management has raised similar concerns when using Social Media and published a white paper on the subject that is appropriately titled 'All that I'm hearing from you is white noise' (Social Media aggregation in emergency response)

Transparency does not indicate that all contingencies can be solved immediately or accepted by the public using social media. The messaging has been clear and more support is needed. But it will not be effective in West Africa. Even if it was, it is drowned out by all the negative media attention. In fact, there is evidence that social media usage by the global community eliminates the positive messages being published. Reddit's Ebola's posts are in the thousands. An early session tried to educate the world about Ebola using Reddit. It was positively received, tweeted and engaged. For every one positive post, hundreds cast doubt on U.S. policy and trust of government agencies, including the CDC. It can be an effective tool to educate the public and challenges a local community face. It certainly is not helpful to those in West Africa.  If social media was widely accepted and available in the Mano River Union (MRU basin, it could convey information quickly in its own cultural ways and customs;

• Ebola's 5 W's; Who, when, where, why and what
• Public Support initiatives
• Improved detection and response
• Distribute knowledge in real-time
• Spread support instead of fear

Local Sierra Leone Poster: more powerful than a Tweet: Photo Credit: BBC (http://www.bbc.com/news/magazine-28583051)

Most of the social media activity has occurred outside West Africa. We stated in our previous post that some governments are now halting humanitarian aid resources and services (Israel and Australia) to West Africa and reviewing (Canada) immigration visa's. It has been suggested that we were;

• Blaming Social media creating fear
• Social media influences foreign policy

In fact we did not suggest that this was the case at all. We left out of the article, on purpose, specific details and what these implications could be. Social media is a world of information that cascades in all forms edited to 30 second sound bytes or less than 140 characters. Users of social media increasingly use it learn about global news and events. What we have said was that social media user tweeted about these news stories in millions of tweets. User reactions to events then followed one of three courses of action:

1) Repost to their friends and followers

2) Add opinion and commentary (true and false stories)

3) Do nothing at all 

Social media can be a useful tool to gauge public opinion and sentiment. It is also an important platform governments and agencies use to debate and react  - if they wish to do so. We did not implicitly imply that Australia, Canada, Israel or any other nation have made foreign policy decisions regarding support for Ebola by analyzing social media behavior. We certainly left the door open to suggest it was possible, however unlikely. But it should not be automatically discounted that such activity is not being heard by politicians and making an impact. Chances are, it is. What we don't know for certain is the level of influence and what specific trends and events tip the scales one way or the other. Imagine how easy it is to make that assertion in 140 characters using Twitter. The millions of tweets, blogs, Reddit posts are influencing other users of social media. There have been past cases where political leaders and its members, agencies and private organizations have made decisions based on social media blowback and reversed course.

All we had to do in our article was clearly state our opinion on how social media could impact government policy. We decided, intentionally, not to do so and gauge reaction. It did not take long and was short and to the point. Responses ranged from "hogwash or it is a stretch". Emails included that we had lost all sense of reality. Others posted in response that social media is very effective in West Africa and pointed out that wireless services were available everywhere and all that was required was to used it more and could turn the tide. Using Topsy's analytical tool is one of many available to analyze social media behavior and the potential impact in West Africa.

Users post news about Canada's halting of Visa applications from West Africa

News of Canada's shipment of experimental Ebola Vaccine to World Health Organization did not gain wide acceptance or distribution. 

Ebola Quarantine news spreads faster and over a longer period of time

Public finally spreads some good news as Facebook announces Ebola Donation program and only 800 tweets, drops like a cliff soon after. Other users tweet announcement (5-18,000) Facebook's Twitter account fails to even mention the announcement on the day it was released.

Social media's usage since the start of the Ebola outbreak has mainly been one of negative news. West Africa's exposure to the Internet is still in the early stages of adoption. It cannot yet effectively utilize its power compared to other countries. The populations of all three countries must improve access to education resources and technology to enable self determination and more importantly, the ability to be resilient in the face of disaster. Other regions across the continent prove West Africa can catch up with its neighbors as illustrated in this CNN report How Africa Tweets. 

Our goal was to ignite discussion around a series of issues

• Social media can have an impact, individually and globally. 
• Headlines published in social media have limits
• Africa's use of social media is in an early stage of development
• Social media still has significant hurdles to overcome
• It cannot easily integrate into all disaster scenarios
• Still lacks adoption and acceptance of SMEM standards

Is our Headline accurate or inaccurate? 

The answer is both. Key indicators are missing and likely never to be made public, including data sets which track detailed donation information allowing it to be compared it to social media behavior. It might illustrate and correlate positive and negative affects. The United Nations Office for Coordination of Humanitarian Affairs (UNOCHA) has donation data, but only publishes totals contributed by each nation or organization and does not break out by dates when donations are made and by what regions. The same applies to Red Cross Agency the world. Most do not publish total funds raised for specific initiatives until year audits are completed. Nor do they publish fund raising and break out the financials into daily, weekly or monthly statements. The Red Cross is not required to do so in any jurisdiction we are aware of. Such statistics would be a key piece of evidence to determine social media's influence. Marketing and advertising 101 suggest positive messages help and negative ones do not. Sometimes both help, regardless of its message.

Augmenting financial donations in support of a conclusion are volunteers and professionals who registered to help. Tracking stats; when they applied, when hired, processed, deployed and returned home. Inconsistent messaging or negative news stories posted are not going to help. When there is a conflict or disagreement in policy on the international stage, it is going to attract social media attention and spread. It not only gets notice, but acted upon. Reaction may not have the same initial explosion social media distribution like a Category 5 Typhoon. Some stories are very subtle in comparison.

U.S. United Nations Ambassador Samantha Power made that clear in October how the U.S. feels about the lack of international response to support the Ebola crisis in West Africa, in condemning the current levels of response. The BBC story version was tweeted 194 times on the day of the story and disappeared. Or so one might believe. The story of Ambassador Power's condemnation was distributed by over 300,000 different news media outlets, blogs and social media sites, then again tweeted using various different headlines. Politicians and their use and interaction with social media should not be under estimated. Political parties routinely use polling data, whom in turn analyze social media every hour of the day, week and month. Social media's influence is rising, particularly when joined at the hip with news organization editorials and links. It often becomes an explosive combination winding up on the front page of the New York Times, (article tweeted 100,710 times) American Press (Obama Authorizes for Ebola the call up of the National Guard Reserves if necessary: tweeted 1,247,695 times), Wall Street Journal (WSJ / NBC Poll finds wide support for Quarantining Health Workers). 

Do we not think people answering these polls are not influenced by what they read using social media stories and commentary, let alone what they tweet in response? Should we also believe that politicians are never influenced by opinion polls? 

Listed below are some answers to both sides of the question. In the end, the goal is engage you the reader, to determine how social media can be used more effectively and the challenges that lay ahead.

Yes, headline is true:

• Social Media is a measurable barometer of public opinion
• Negative Social Media messaging outweighs positive messages hurting participation in support of the region
• Facts are often diluted, inaccurate or not fully explained
• Negative sentiment tends to detract on the ability to support response and delay urgently needed resources
• Resources directed to counteract false information
• Negative and repeated news stigmatizes West Africa today and in the future

No, headline is false:

• Social Media cannot be held responsible in the court of public opinion
• What you cannot access, cannot influence
• Leaders are not directly influenced (.....except when....)
• Fear, Uncertainty and Doubt are not quantitative with sufficient evidence
• Social Media trends change daily, weekly and monthly; the crisis is forgotten

In conclusion, you have to decide if social media is affecting the Ebola crisis and response and what changes (if any) should be made.

We invite you to follow our archives of curated articles collected from most major media outlets from around the world about the Ebola crisis in our CDM magazine powered by Flipboard. All of the links used above are in our magazine. Learn more about Ebola, technology and social media services used in Crisis and Disaster Management. We welcome your comments and thoughts below and not just on the websites that link to this article. 

In Part III of our Ebola coverage, we will look at how Social Media has impacted U.S. public opinion, where there is a strong belief, that a clear and present danger to the country's National Security exists because of one death in Dallas, Texas. We will try to avoid using a sensational headline. 

A challenge that may be difficult to resist.

To read Part I of this series, click HERE.