Michael Edelstein was in Liberia in August-September as part of the Ebola outbreak response.
The scale of the current West African Ebola outbreak, which has killed more people than all other recorded Ebola outbreaks combined (over 3,400 as of 3 October), is not only the result of a slow and insufficient response from the international community. It is the result of decades of underfunded healthcare systems with no governance, the consequence of poverty, war, corruption and political instability.
Developed countries have the capacity to rapidly identify, isolate and monitor suspected cases and their contacts, as well as to safely treat sick cases, which will prevent ongoing transmission to members of the community or to healthcare workers. The case reported in the US on 30 September will likely infect only a very small number of individuals as a worst case scenario.
By contrast, in the affected West African nations, suspected cases remain in the community, infect relatives and healthcare workers and dead bodies lie in houses for days before they are collected. Entire families, sometimes entire communities, have been decimated. In addition, at least in Liberia, recent memories of the civil wars (1989-1996 and 1999-2003) and high levels of corruption have exacerbated mistrust in the government and fostered conspiracy theories, in turn decreasing population compliance with official advice.
At the beginning of the outbreak, rumours about the Liberian government and its international partners purposefully starting the outbreak, or pretending there was an outbreak in order to attract international funds, were widespread. As recently as September, the largest Liberian newspaper claimed the Ebola virus was manufactured by Western pharmaceutical companies and the US Department of Defense. When healthcare workers were collecting blood specimens from dead bodies, rumours about the government harvesting hearts to sell them started spreading. In order to demonstrate that Ebola was not real, one community leader licked a suspected case’s body. Both died, infecting several family members.
These anecdotes illustrate how deep government mistrust runs. Such lack of confidence has led to resistance to isolation, quarantine or infection control in the local population. The use of police and armed forces to enforce quarantine in some areas has further exacerbated antagonism towards government.
Even when the population is compliant, the weakness of the public health system compromises the response. There are not enough trained healthcare workers to manage the outbreak: In 2008 Liberia had 1.4 doctors and 27 nurses per 100,000, compared with 242 and 981 respectively in the US. When there are healthcare workers in local health centres, they often do not have gloves, aprons or chlorine to handle suspected Ebola cases. This is a consequence not only of lack of funds or resources, but also of the inability of the system to assess local need and distribute resources accordingly. In September, in one Liberian county, there were 60,000 pairs of gloves stored in a central warehouse, and none available in some health centres.
The Ebola crisis has also become an opportunity for healthcare workers, whom often are not regularly paid, to improve their working conditions. Healthcare workers have considerable leverage in the crisis, owing to high need and low availability. They use the outbreak as an opportunity to settle disputes over pay or working conditions that pre-date the outbreak, refusing to return to work until their conditions are met. This has led to closures of healthcare facilities, which affects population health beyond Ebola, as essential and emergency health services are not running.
The Ebola outbreak will eventually come under control, although it requires multiplying the scale of the response by a factor of ten at least. Beyond the immediate mortality and psychological trauma, there is a potential positive legacy. As part of the outbreak response, partner organizations, in collaboration with national governments, have trained healthcare workers, set up surveillance networks, built healthcare facilities, established infection control standards and improved the logistics and procurement of healthcare systems in West Africa. Public health capacity building is a requirement of the International Health Regulations, and these changes, as well as further capacity building, must be embedded in the healthcare system beyond the crisis.
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