18th August, 2014
By Mohammed M. Youssouf
Following the death of more than 900 people in West Africa from the worst outbreak of Ebola so far and with potential carriers arriving in the United States and Middle East, the international system has at last swung into action. The United Nations World Health Organisation held a two-day conference in Geneva, Switzerland, on 6-7 August to consider declaring a Public Health Emergency of International Concern. WHO officials are consulting on the ethics of endorsing the use of experimental treatments for Ebola after trial drugs were given to two US aid workers infected in Liberia.
Some oppose using this practice more widely. This is not only because the drugs are untested on humans and in short supply; the trials may divert efforts from the well-tried and tested methods of containing a familiar disease, albeit one globalisation has taken to a new scale.
During the US-Africa summit in Washington, Health and Human Services Secretary Sylvia Mathews Burwell met Guinean President Alpha Condé and senior officials from Liberia and Sierra Leone whose Presidents, Ellen Johnson-Sirleaf and Ernest Bai Koroma, had stayed at home to tackle the growing emergency. They sent troops to the worst-hit areas in the border regions to try to contain the spread of the virus.
Yet much more needs to be done if Ebola is to be contained. The head of medical charity Médecins sans Frontières (MSF) in Sierra Leone, Walter Lorenzi, described the outbreak as ‘unprecedented and out of control’. The immediate requirement, he said, was for more health-workers in the field with the right equipment to treat patients and protect the public. More than 60 health-care workers have died fighting the haemorrhagic disease in West Africa, further undermining the region’s grossly inadequate health services. Ebola’s rapid progression this year has highlighted the wider health service crises in Guinea, Liberia and Sierra Leone and now, Nigeria, where Health Minister Onyebuchi Chukwu said on 6 August that there was ‘a national emergency’.
From the start, the lack of medical equipment and awareness outside capital cities allowed the virus to spread rapidly. Local and foreign health staff quickly provided epidemiology and preventive measures but the virus quickly advanced beyond their reach. The lack of a coordinated information strategy in the three most affected countries – Guinea, Liberia and Sierra Leone – made matters worse. Instead, widespread misinformation and fear-mongering caused people to avoid health providers and reporting new infections to officials, a fundamental tenet of disease control.
A Sierra Leonean scientist working in north-east Sierra Leone for the US-based disease control specialists Metabiota, Professor Aiah Gbakima, said this had worsened the crisis. This reflected a bigger governance problem: the regional political elite’s neglect of remote rural areas. Ebola spreads through direct contact with a patient’s bodily fluids or through the preparation of victims for burial. Typically, it starts in remote rainforest villages which are easy to quarantine quickly.
The outbreak began in early February in the south-eastern forest region of Nzérékoré, capital of Guinée-Forestière, nearly 1,000 kilometres from Conakry. The government’s initial reaction was weak: it sent no medical team to the area, with its barely functioning clinics, until MSF launched an emergency response. It sent 24 doctors, nurses, logisticians and hygiene and sanitation experts, who set up an isolation unit for suspected cases in Guéckédou. The Health Ministry’s role was largely supportive.
By 25 March, the WHO reported that the four neighbouring districts of Guéckédou, Nzérékoré, Kissidougou and Macenta had become Ebola epicentres, with 86 suspected cases, including 59 deaths. By 30 July, the government had announced 472 cases, including 346 fatalities. The virus had spread to the centre and north-west, including some major mining districts. Conakry reported 91 suspected cases and 41 deaths.
Liberia had reported its first cases in Lofa County, close to Guinea’s epicentre, by mid-March. The Liberian elite also neglects its rural areas. The two initially confirmed cases in Lofa were said to be people who had caught the virus in Guinea and then moved to Liberia through the many unpoliced border crossing points. In early April, a hunter in Tapeta, Nimba County, tested positive. He apparently had no contact with anyone from Guinea and had never been there.
However, this made little impact in Monrovia. By 10 April, 26 suspected and confirmed cases were reported, with 13 deaths. Since some were in the Monrovia area, Parliament met and agreed a three-week Easter recess to allow members time to visit their constituencies and educate them about preventive measures. It was only on 15 April, about a month after the outbreak, that the government launched its first testing facility, in Kakata, close to Monrovia but several hours’ drive from Lofa and Nimba, which had more deaths.
Then on 1 July, Samuel Muhumuza Mutoro, a Ugandan surgeon at the John F. Kennedy Hospital in Monrovia, Liberia’s largest, died after being diagnosed with Ebola. He had been drawing on his experience in Uganda’s outbreak in 2012 to treat patients in Liberia. Nurses are often poorly trained and JFK had little equipment: even protective clothing was in short supply. On 26 July, a prominent Liberian doctor and JFK’s main expert on Ebola, Samuel Brisbane, succumbed to the virus.
The next day, the charity Samaritan’s Purse announced that an American doctor, Kent Brantly, was in quarantine at Monrovia’s ELWA Hospital with Ebola. He was sent to the leading Centre for Disease Control and Prevention in Atlanta, USA.
A week earlier, Patrick Sawyer, a Liberian working for Arcelor Mittal and the Finance Ministry, flew to Lagos, where he died. His sister, who lived with him in Monrovia, had already died of Ebola before he boarded the plane. A Nigerian nurse who treated him in Lagos later died.
On 27 July, a community in Lofa took the bodies of Ebola victims from the makeshift hospital to give them traditional burial. In a reminder of the widespread distrust of central government, they burnt a government ambulance, which they thought had brought them the disease. On 30 July, Johnson-Sirleaf declared a state of emergency, deployed security officers to quarantine areas of infection and sent all non-essential state employees on 30-day leave. By that time, WHO had reported 391 cases of Ebola, including 227 deaths.
Ebola struck Sierra Leone in late May, over two months after the first deaths in Guinea and Liberia. On 26 May, the WHO announced that in addition to one laboratory-confirmed case, the authorities were investigating four deaths in Kailahun District, adjacent to Guinea’s Guéckédou region and Liberia’s Lofa County. Gbakima and his team were testing for Lassa fever, believed to be endemic there. His initial impression was that some of the Ebola cases were a particularly virulent strain of Lassa. This was disproved after more tests and just as Ebola hit Kailahun, overwhelming the limited health facilities there. The main government facility for viral and related diseases is at Kenema Government Hospital, over half a day by car on an atrocious road from Kailahun.
Sierra Leone’s leading virologist, Sheik Umar Khan, and a handful of trained nurses were based at the Kenema hospital yet the government made no effort to move him to Kailahun. Ebola patients were instead driven by ambulance from Kailahun to Kenema. Many died, so people began to view ambulances and the hospital as bearers of death.
MSF set up an emergency clinic in Kailahun in June but several nurses had already died in Kenema. By early July, over a dozen health workers, nurses and drivers in Kenema had contracted Ebola and five nurses had died. They had not been properly equipped with biohazard gear of whole-body suit, a hood with an opening for the eyes, safety goggles, a breathing mask over the mouth and nose, nitrile gloves and rubber boots.
On 21 July, the remaining nurses went on strike. They had been working twelve-hour days, in biohazard suits at high temperatures in a hospital mostly without air conditioning. The government had promised them an extra US$30 a week in danger money but despite complaints, no payment was made. Worse yet, on 17 June, the inexperienced Health and Sanitation Minister, Miatta Kargbo, told Parliament that some of the nurses who had died in Kenema had contracted Ebola through promiscuous sexual activity.
Only one nurse showed up for work on 22 July, we hear, with more than 30 Ebola patients in the hospital. Visitors to the ward reported finding a mess of vomit, splattered blood and urine. Two days later, Khan, who was leading the Ebola fight at the hospital and now with very few nurses, tested positive. The 43-year-old was credited with treating more than 100 patients. He died in Kailahun at the MSF clinic on 29 July. President Koroma had flown to Kenema two days earlier but he did not go to Kailahun, where Khan was hospitalised.
On 31 July, he announced new emergency measures, including deploying troops to quarantine the worst affected areas. Religious leaders had criticised him for not taking the Ebola threat seriously. By 3 August, Sierra Leone had over 600 cases, the highest in the region, with 252 deaths. Ebola had spread across the country, even to Freetown. Sierra Leone also accounted for most of the 60 health workers killed by Ebola by 30 July.
•Youssouf is Manager Poverty Reduction & Social Protection Division (OSHD1), African Development Bank, Côte d’Ivoire, Tel: | + (225) 20202110 (Office), Email: [email protected]