Ebola: The Overlooked Sexually Transmitted Disease

Ebola virus disease infected close to 26,000 people in Guinea, Liberia and Sierra Leone, killing more than 10,000, according to the World Health Organization (WHO). Over a year into the epidemic, cases are still being reported in Guinea and Sierra Leone, while Liberia was declared Ebola free by WHO on May 9, 2015, thus becoming the model for effective Ebola management and containment. However, it is evident that Liberia cannot fully enjoy this freedom from Ebola until her neighbors are also declared Ebola free. The porousness of the borders between these countries makes this a difficult feat.

Humanitarian aid groups have criticized WHO for not recognizing the epidemic early enough. In response, efforts to combat Ebola focused on promoting culturally appropriate, safe and dignified burials, managing information, case identification, contact tracing, infection prevention and control (IPC) and health systems strengthening (HSS). Gender based violence was not considered in prevention measures to halt Ebola transmission. Making this link to Ebola is critical because of reported increase in gender based violence overall. It is documented that Ebola virus remains in the sperm and breast milk of survivors, for up to 90 days or longer, indicating that the virus is sexually and maternally transmitted. Aid agencies distribute condoms to men who recovered from Ebola, disregarding reported failures in adherence to "don't have sex for 3 months." Even with precautionary messages about risks, women remain vulnerable to the sexual exploits of men in general, particularly in traditional African societies. This escalates their risks of Ebola virus disease (EVD) through sexual contact, just like the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). EVD like HIV/AIDS, is a sexually transmitted disease.

Two weeks before the outbreak was officially announced in 2014, my colleague, Dr. Lynn Lawry, of Overseas Strategic Consulting Ltd, headquartered in Philadelphia, conducted an assessment on gender based violence (her specialty) in Sierra Leone. Her assessment included interviews with ordinary Sierra Leoneans, judges and lawyers, police, members of secret societies and tribal chiefs. Secret societies, in the African context, are akin to brotherhoods and sororities in developed societies, though emphasizing tribal or ethnic customs. Tribal chiefs are recognized heads of specified clans, communities or tribal dynasties. Dr. Lawry learnt from community members that legally, adult women cannot be raped because of a bride price, cultural dictates and, in many cases, women are presumed to "provoke the attacks"---they are provocateurs, in other words. Although a bit more complicated, the logic is that an adult married woman loses the right to say no to sex with her husband.

Regarding evidence in rape cases in Sierra Leone, "passive consent" as described by one lawyer, is a method for determining whether or not a woman consented to sexual intercourse. "Passive consent" per this description, occurred in cases where the situation may have led to consent such as, a woman "having drinks with the man, being in a bed with him and talking to him....thereby creating a situation where he would assume that no was not really a no." With reference to a boyfriend/girlfriend relationship, the explanation was that, if the woman had sex with the man on previous occasions, that too was "passive consent." Therefore, "she cannot come to a court claiming rape because she set a precedence of sexual consent in the past." Affected governments, the United Nations and WHO, have yet to recognize gender based violence and its impending role in EVD transmission. Despite evidence of better case management, case identification, contact tracing and treatment, as modeled in Liberia, new EVD infections are likely, as the cycle of violence against women continues and as more men surviving EVD have inclinations towards sexual interactions. Liberia had gone twenty eight days without new EVD cases and no one in treatment, when in March 2015, a woman, whose only exposure was sexual relations with her boyfriend, an Ebola survivor, contracted EVD and died within a week. This case raised the alarm of EVD as a sexually transmitted disease, a fact not previously addressed in the West African epidemic. The emphasis was on NO physical contact as a means of prevention and, rightfully so.

With women being more affected by violent acts and sexual assault, the world and booming Ebola experts must understand the potential role gender based violence plays in this epidemic, especially now, with the raining season spanning from May to October. Being forced to stay in close quarters due to torrential rains, boredom and frustration may provoke sexual assaults on women. Coupled with EVD, sexual violence impacting women will pay a recurring role in this and future epidemics.

The link must be made between gender based violence, women's lack of empowerment and Ebola. The chain of infection must be broken, or human resources in country will diminish. If you lose all of your doctors, nurses and other health care providers, rebuilding or strengthening a health system will be futile. Policy makers must recognize that.

Lynn Lawry, MD, Overseas Strategic Consulting Ltd is a major contributor to this article on gender based violence in Sierra Leone.