Emergencies preparedness, response

Ebola in Liberia: misery and despair tempered by some good reasons for hope

Much-needed offers of relief offer hope for desperate families and their ill loved ones

Ebola at 6 months

The Ebola outbreak in Liberia, where case counts are increasing exponentially, is by far the most worrisome. Last week, 113 new Ebola cases were reported over a single 24-hour period – easily breaking records at all outbreak sites. Fourteen of the country’s 15 counties have now reported cases. Throughout the country, very few treatment beds are available for the management of Ebola patients.

The number of reported cases, although the highest of all outbreak sites, vastly underestimates the severity of the outbreak and the way it has ripped apart the very fabric of traditional West African cultural and social life.

Health services overwhelmed

The true number of deaths will likely never be known, as bodies in the notoriously poor, filthy and overcrowded West Point slum, in the capital, Monrovia, have simply been thrown into the two nearby rivers.

Liberia has only one academic referral hospital, the John F Kennedy Medical Center in Monrovia. The hospital was severely damaged during the years of civil war; floods and electrical fires are frequent. As in Sierra Leone, some of Liberia’s “medical giants”, working at that badly equipped hospital, became infected with Ebola virus disease and died.

The capacity to deliver basic health services has been diminished for many treatment and emergency needs, whether arising from infectious diseases, a chronic condition, or a road traffic injury. Highly successful programmes that promised to end or significantly control several ancient and debilitating tropical diseases have been disrupted; the future of these programmes is, for the moment, uncertain.

The high season for malaria transmission is under way. Stocks of antimalarial medicines and bednets have been depleted. Some experts estimate that the number of deaths from malaria may soon surpass those from Ebola virus disease.

Development stopped in its tracks

In Monrovia, key businesses have shut down and the once-bustling markets are now short on some supplies. Food and fuel shortages deepen the misery and suffering of large numbers of people. Work done by the World Food Programme, with its unparalleled logistical capacities, is deeply appreciated by the government and its people.

Prior to the outbreak, Liberia was recording some of the most acute declines in maternal and child mortality anywhere in sub-Saharan Africa, demonstrating just what the Ministry of Health and Social Welfare can achieve under more favourable circumstances. Tragically, that trend is now moving in reverse.

Two anecdotal observations help illustrate the severity of the situation.

The head of a WHO emergency assessment team, Dr Rick Brennan, describes delivering a baby in Liberia as “one of the most dangerous jobs in the world.” As learned from recent experiences, some pregnant women in that country are infected with the Ebola virus, but neither they nor their doctors are aware of their infection. WHO is aware of several obstetricians who isolate themselves when they leave the wards, foregoing any contact with families, neighbours, or friends.

According to staff at Médecins Sans Frontières (MSF), one of the most emotionally-wrenching jobs is that of guarding the gates at the organization’s overflowing treatment facilities in Monrovia, where desperate families and their ill loved ones must be turned away in large numbers every day. MSF staff are then left to watch, helplessly and hopelessly, as patients die, alone and without dignity, on the grounds beyond the locked gates.

New signs of hope

Some much-needed good news arrived yesterday when the Island Clinic, supported by WHO, UNICEF, the World Food Programme, and USAID, opened its doors. Long awaited and badly needed, this dedicated Ebola treatment unit has 120 beds, with 30 beds in a triage area, a design feature that improves safety for patients and staff. It greatly augments Monrovia’s existing and woefully inadequate 240-bed treatment capacity.

WHO fully funded the Clinic and handed it over to the country’s Ministry of Health and Social Welfare. As the head of WHO’s Liberia office, Dr Peter Graaff, noted, “More than one hundred construction workers laboured three shifts, every day and night, over the last three weeks to get the clinic ready.”

A line of grateful patients and their families was waiting when the doors opened yesterday.

Later this week, the United States Government, through its Centers for Disease Control and Prevention, will be setting up a new laboratory. This additional capacity means that suspected cases will have diagnostic results within four hours to guide their admission to the Clinic or transfer to another health facility.

Working with the Government

Staff in the WHO country office, and response teams deployed under the GOARN umbrella, collaborate closely with the Ministry of Health and Social Welfare, which is making a heroic effort to keep schools open and at least some essential health services flowing.

Another government priority is to extend Ebola community care to more rural areas so that patients, and the families who are caring for them, have support for safer and better treatment near their homes.

Gradual, then likely dramatic, improvements can now be anticipated.

The government of Liberia, WHO and its Director-General, Dr Margaret Chan, wholeheartedly welcomed last week’s US White House announcement of a monumental scaling up of support to Liberia and other affected countries in West Africa. Many believe this announcement heralds the kind of transformational change that can let all partners in the Ebola response get a grip on the outbreak and turn it around.

Work on the construction of a planned total of 17 new treatment facilities, supported by US military troops, began almost immediately following the announcement. US engagement further includes the training of around 500 health care personnel each week. Apart from supporting more treatment capacity, such training will create badly needed jobs as the rate of unemployment in Liberia continues to rise.

UN Mission for Ebola

WHO also welcomes the decision, announced at last week’s emergency session of the United Nations Security Council, to immediately establish a special UN-wide Ebola mission, modelled on UN peacekeeping missions.

Known as the United Nations Mission for Ebola Emergency Response, or UNMEER, it relieves WHO from some burdensome and time-consuming tasks, like creating air bridges and transporting essential supplies and medical personnel.

So freed, WHO can step up its constitutionally-mandated functions during public health emergencies. For example, data collection and reporting urgently need improvement, as do the assessment and management of risks. WHO is further freed to concentrate on streamlining laboratory requirements, ,increasing the number and safety of facilities providing state-of-the art supportive care, and getting more of its hand-picked doctors and other medical personnel deployed under the WHO GOARN umbrella. As just one example, psychologists are increasingly needed as an integral part of medical teams.

In addition, other major public health initiatives, prioritized by the government and disrupted by the outbreak, need to be put back on track with WHO support. For example, Liberia’s health officials know how to reduce maternal and child deaths, but need support from partners to do so again.

Incoming personnel

The much-needed transformational change in outbreak response capacity is further supported by the generosity of the governments of Cuba and China.

Cuba’s President and Minister of Health are sending 165 doctors, nurses and other staff with deep experience in the management of emergencies in sub-Saharan Africa. Additional deployments of Cuban medical staff will be announced soon.

China is despatching an entire 59-person mobile laboratory team, bringing badly needed expertise in clinical care, nursing support, diagnostic work and epidemiological investigations.

Though the team will deploy to Sierra Leone, anything done to reduce intense virus transmission in neighbouring countries indirectly aids outbreak control in Liberia. The new team augments the 115 Chinese doctors already working in affected West African countries.

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