Faces of Ebola Supply and Logistics Response
Learning by doing – the design and construction of Community Care Centres (CCCs)
From the start, UNICEF’s Ebola response has had a strong focus on community. Intensive communication campaigns have awakened populations to the fact that Ebola is real, and raised awareness on each person’s responsibility to keep safe by avoiding contact and practicing good hygiene. Affected communities have been enabled by the steady pipeline of supplies from chlorine, soap, sprayers, gloves and other protective equipment to the different points in the community where people interact. At an October 2014 meeting of the UN Mission on the Ebola Emergency Response (UN MEER) in Accra, UNICEF was identified as the UN lead in the scale up of CCCs in Guinea, Liberia and Sierra Leone. CCCs are a facility where families can bring loved ones who have very early Ebola-like-symptoms before the disease is at its highest risk of spreading. CCCs are being built in consultation and with the participation of people and families that they are meant to serve, and reinforce in practice – that the end of Ebola lies in the strength of communities.
UNICEF completed the construction of 51 CCCs (428 beds) in 2014. 14 more are currently under construction.
Carlos de la Espriella is a construction specialist and city planner working for UNICEF in Supply Division, Copenhagen. In recent weeks he has been focusing on the design and construction of Community Care Centres (CCCs) – an essential component in the UN’s strategy to have 100 percent of Ebola victims buried safely and 100 percent of Ebola patients treated in isolation beds within 60 days by January 2015.
For Carlos, architecture is a deeply social endevour. “The design of a building is determined by the people who live in it and use it – how they live and how they interact,” he explains. In the case of CCCs, understanding interrelation of health workers with each other, with their patients, and the way the CCC site relates to the community, are critical factors that help shape a design aimed at saving lives. Before joining UNICEF five years ago, he worked on social housing and pro-poor urban planning in Colombia and Central America. In UNICEF’s South Sudan office upon the country’s independence, he was responsible for a nation-wide school construction project.
Isolation of the sick is key to interrupting virus transmission. CCCs are being built to provide care for loved ones who show symptoms of Ebola, without putting others in the household at risk. The standard design of CCCs includes two four-bed tents which separates patients according to whether they have “dry” symptoms like as fever and headache, or “wet” symptoms, such as vomiting and diarrhoea. The CCC staff, in full Personal Protection Equipment (PPE), are trained in testing and monitoring the sick. Patients with a non-contagious disease such as Malaria, are released back into the care of their family.
Installing a tent at the Mamasosaka CCC,Sierra Leone
Electrical power cables to the tent for patients showing dry symptoms in a CCC in Sierra Leone
One-way patient flow and humanising design
The risk of exposure to the Ebola virus becomes acute the moment an infected person starts to show “wet” symptoms. “An invariable consideration in the design of CCCs is the direction of patient and staff flow,” said Carlos. “Staff shouldn’t move from the “wet” to the “dry” area because that puts patients and colleagues at risk.”
One-way movement is non-negotiable. Imagining the multiple reasons why workers may have to go against the flow keeps Carlos and colleagues awake at night, proposing and analysing preventive solutions. For example, the “wet” area must have an access point to allow food and drinking water to be brought in, without a need to back-track.
Modifications from the original design reflect some of the most poignant consequences of the Ebola outbreak where families cannot touch their sick loved ones. At first, enforcing distance was envisioned as a two-metre wide trench between the CCC and visitors. But this has been replaced by double fencing that reinforce cautions about staying safe and healthy. “These are patients, not prisoners,” Carlos reminded.
The choice of building materials and furnishings has been influenced by the urgency with which countries need functioning CCCs, their temporary (six-month) presence, and the capability to dismantle them safely once the outbreak is over. Cost also affects the selection of materials. Local supplies are preferred over those that have to be airlifted. UNICEF-built CCCs contain water tanks, fencing and furniture that are all locally procured.
A non-negotiable in the CCC design is an even floor surface, gently sloped to allow quick and safe cleaning. While heavy-duty plastic flooring modules are available in Europe, the cost of freighting them by air to countries would be prohibitive. To keep costs affordable without sacrificing quality, CCC tents are raised on floors cast in concrete.
Adequate lighting is also a major non-negotiable. Supply Division devised a lighting-in-a-kit concept, where all the components of electrical lights needed by CCCs could be assembled and shipped. If quality components of this kit could be sourced within countries, Carlos anticipates that such kits could be locally produced in the near future.
CCC designs and country context
CCC design reflects the unique needs and resources that each country has available. Sierra Leone, which had a head start in construction, foresees care as delivered by trained men and women from the communities. Guinea envisages CCCs staffed with health workers. Liberia wants to use existing buildings for low risk (or “green”) zones while setting up the high risk (or “red”) zones in tents in adjacent open spaces.
Carlos emphasised that monitoring is a major part of the work plan supporting the implementation of CCCs. There is monitoring of the construction to ensure that specifications are followed. For example, compromises in distances between low and high risk areas could impede the movement of caregivers wearing bulky PPE. Monitoring also occurs on the operational aspect of CCCs, and compliance of caregivers with PPE donning and doffing protocols.
The construction of CCCs are being made under extreme time pressure within the tightest of deadlines. Constructing and outfitting these centres is shared across different donors, agencies and NGOs, including UK’s Department of International Development (DIFD), USAID, Medicines sans frontiers (MSF), Save the Children, UNICEF, WHO and WFP.
Carlos observes that there has not been a lot of time for different agencies to share lessons learned and to brainstorm on innovation. But on-site opportunities such as visit to the WHO-constructed CCC in Port Loko, Sierra Leone, has been instructive in improving UNICEF CCC designs.
“In dealing with an emergency like this, there is not one solution that fits all,” said Carlos. “We are learning by doing.”
Integrity and rigour at UNICEF’s Conakry warehouse
Meet Saran Sidibé, UNICEF’s warehouse assistant in Conakry. She runs a very tight ship, managing 23 colleagues responsible for receiving the supplies, controlling the stock, processing the orders and ensuring proper delivery of the goods. The warehouse is the place of entry and exit for all UNICEF supplies. She considers it to be the backbone of the UNICEF Guinea’s supply unit.
Maintaining warehouse integrity is vital aspect in UNICEF’s supply response to the Ebola crisis. The volume of stock has increased ten-fold since March. With so much stock coming in every day: personal protection equipment, buckets, soap, chlorine, antibiotics – inventory control procedures are all the more essential. “If we bend on these rules, we will soon collapse and the supply unit will not pass the test of the Ebola epidemic,” Saran says.
Saran Sidibé (back row centre) and some of the warehouse team in Conakry, Guinea working hard to help fight the Ebola crisis.
A ten-fold increase in stock volumes arriving in the Conakry warehouse since March has required 15 new staff, tight inventory controls and strict new procedures, including checking the temperature of anyone entering the warehouse.
Every morning, Saran and her team clears warehouse space in anticipation of incoming supplies, and review existing stock. She works closely with the Ebola Emergency Response Operations team, ensuring the functionality of the warehouse and the readiness of her team. On the day of this interview, Saran and her team were busy supervising and monitoring loading of sanitation kits for Gueckedou in the south of the country, one of the prefectures hardest hit by the epidemic.
The exponential growth of warehouse operations has created some major changes in Saran’s daily activities: she’s had to add 15 new colleagues to her team – each of them aware of the strictly enforced hand washing and temperatures measurement of anyone entering the warehouse. Despite the stressful and unpredictable nature of the outbreak, Saran tries her best to ensure that her team work reasonable hours. Nevertheless, if often happens that they work late with long evenings at the airport, unloading and clearing supplies.
Sometimes Saran’s eight year old son asks why she comes home late at night, to which she replies, “I want to help Guinea get rid of the Ebola disease, so I help send supplies to where they will save lives. I want all the children of Guinea to be healthy, happy and have the best, just like you.”
Nothing left to chance – UNICEF Global Ebola Emergency Coordinator, Peter Salama, signing for a UNICEF t-shirt from the Conarky warehouse.
“I work very hard because I love what I do,” says Saran Sidibé (pictured), UNICEF’s warehouse assistant in Conakry. “We women must systematically be hired to replace the men because we are much more efficient and we deliver better results,” she adds with a laugh.
Read the French version of the story: Intégrité et rigueur au magasin d’UNICEF à Conakry
Protective Personal Equipment (PPE) standards and norms
Meet Nagwa Hasanin, Technical Specialist @UNICEFSupply (second from the right, in the dark red sweater). Nagwa is an expert on full body Protective Personal Equipment (PPE) which includes coveralls, hoods, surgical gowns and aprons. She speaks about PPE specifications, standards and norms in terms such as “viral penetration”, “minimum exposure pressure” and “reinforced material” – measures that are truly life-saving for frontline carers, health workers, and burial teams who depend on this layer of protection.
In this photo, Nagwa is with UNICEF colleagues from our office in Mekeni and staff at Panlap Community Care Centre (CCC) – one of ten eight-bed CCCs that recently opened in Bombali District, Sierra Leone. UNICEF is helping to build more like this one in the coming weeks. Nagwa has travelled to Guinea, Sierra Leone and Liberia where UNICEF is working with partners and governments implementing new approaches to community level care. Each country’s response reflects unique cultural and community contexts. Understanding the differences across variables such as the size of each point of service, number of workers, patient-time, and flow – is vital in identifying the correct level of PPE protection needed and quantifying demand across countries.
Nagwa is one of dozens of colleagues in UNICEF and other agencies who have worked with the PPE industry over recent weeks to integrate life-saving innovations into PPE manufacturing since the beginning of the crisis. We still face limited global capacity to meet immediate needs, and we know there is still a relatively long-lead time for the quantities required. The first ever aggregated global projection for a 6 month period showed industry that the demand for the key PPE component of coveralls would exceed 1 million per month, for the affected countries in different points of service by December 2014, representing an approximate 30 percent gap in supply based on current global production capacity.