The perfect storm: how Ebola has taken hold of West Africa
They lay on beds without any mattresses – just the bare metal springs, covered by a cloth, if they had one. There were no medicines. The walls and floors were dirty and in places had fallen away completely. All this was apparently “normal”. These poor conditions had no connection to the sudden health crisis – things were always this way.
These words sound like one of the reports describing conditions in West Africa today, where the latest outbreak of the Ebola virus has killed thousands and is threatening tens of thousands more. But they actually describe the Africa of the 1970s, when the Belgian professor of microbiology Peter Piot first discovered Ebola haemorrhagic fever.
“Here I saw real deprivation, conditions that were truly shameful,” he wrote in No Time to Lose: A Life in Pursuit of Deadly Viruses.
About 40 years later, not much seems to have changed: a new and deadly Ebola outbreak has killed more than 2,600 and another 18,000 are in peril, in spite of the fact that the virus, although dangerous, should be easily contained.
Writing today in the journal Science, Piot describes the current situation as a “perfect storm”, involving dysfunctional health services, low trust in governments and western medicine, denials about the virus’s existence and unhygienic burial practices. He adds that a rapid international effort is vital.
While the current outbreak began in December 2013, it is only in the past two weeks that the developed world is seriously stepping up to confront the threat.
The US president, Barack Obama, said the epidemic represented a “threat to global security” as he announced his country was deploying 3,000 uniformed personnel to the region.
The United Nations has established the UN Mission for Ebola Emergency Response to coordinate its activities and to organise experts in Ghana, Guinea, Liberia and Sierra Leone.
However, the health systems in these countries have already crumbled under the strain, with hospitals closing and staff striking over unsafe working conditions.
Many of the field hospitals and Ebola treatment centres set up by Doctors Without Borders (known as MSF, from its French name Médecins Sans Frontières) are on mud tracks surrounded by fields. MSF has cared for more than two thirds of the reported cases.
Some hospitals and clinics are operating without reliable electricity or running water, while medical staff are forced to treat suspected patients with little or no protection. In some areas, the infection has resulted in the complete closure of most or all the health centres.
“In Sierra Leone, the health system is still recovering from the civil war, which ended in 2004 and resulted in many health workers fleeing or being killed and in the destruction of much of the health infrastructure,” says Oliver Johnson, the programme director of the King’s Sierra Leone Partnership, a collaboration between a group of London hospitals.
In rural areas, many of the primary health-care facilities lack reliable water and power supplies and have shortages of basic equipment and materials, such as rubber gloves. Poor infection control measures compound the problem, with some health workers becoming infected, which “led to a crisis in confidence among the others”, he says.
Bad roads and a shortage of ambulances also made it difficult to transfer patients for treatment and send samples to laboratories.
“All of these factors made countries in West Africa much more vulnerable to Ebola,” says Johnson, who is fund-raising to help his team fight the disease [visit his JustGiving page here].
Last week, Sierra Leone was put under a three-day curfew to allow health workers to find and isolate Ebola cases, because public mistrust has sent many cases underground, further spreading the disease. In Guinea last weekend, the bodies of eight missing health workers and journalists were found. They had been killed by villagers suspicious of their presence.
Johnson says some communities continue to hide cases rather than inform the government, and MSF has reported that its staff have been prevented from visiting some villages due to hostility caused by fear. An MSF outreach worker previously told The National that many people thought a diagnosis meant certain death so would rather not be diagnosed.
“The public have to believe Ebola is real, recognise the symptoms and be willing to be isolated in hospital if they are sick,” says Johnson, “and that requires good health education and trust in the government.
“We need doctors to work in the units and foreign medical teams to be willing to get involved in clinical care. Too many non-governmental organisations and agencies are keeping their international clinicians in meeting rooms or to do ‘site inspections’ rather than ensuring they actually get stuck in with helping Sierra Leonean colleagues.”
To this effect, Joanne Liu, the international president of MSF, delivered a stark warning to UN member states earlier this month: “We must also address the collapse of state infrastructure. The health system in Liberia has collapsed. Pregnant women experiencing complications have nowhere to turn. Malaria and diarrhoea, easily preventable and treatable diseases, are killing people. Hospitals need to be reopened and newly created.”
Obama responded to this plea and announced that the United States was sending the 3,000 troops. A US Africa Command is to be set up in Monrovia, Liberia, to run the operations to “facilitate and expedite the transportation of equipment, supplies and personnel”, as well as train up to 500 health-care providers a week. There will also be a new hospital funded by the US department of defence to care for health-care workers who become ill.
The country has so far committed more than US$175 million (Dh642.76m) to address the crisis.
However, despite all the investment in health from both domestic and international sources in recent decades, much of the health care in West Africa remains in a dire state.
Twenty eight per cent of the World Health Organisation’s budget this year was earmarked for the African region. Reaching about US$1.1 billion, it is the largest amount allocated to any of the six WHO regions. Many of the Ebola-affected countries already rely heavily on not just foreign money but also skills. There are dozens of missionary groups running hospitals and clinics, particularly in rural areas, manned by western medical staff.
Tom Carr has been the executive director of International Health Care Foundation African Christian Hospitals for a decade and has spent most of his life working with non-profit groups. The group is involved in eight facilities and treats 100,000 patients a year in countries such as Nigeria and Ghana. It was set up in the 1960s when traditional rulers in Abia State in Nigeria asked some American missionaries working there to call for assistance to build and run a hospital.
Carr says that while there are some very “talented people” working in government facilities, there is often a shortage of medicine and supplies. “Government facilities, no matter how good they are … cannot keep up with the demand for services,” he says. Wealthier people can afford to pay but “the non-profits of faith-based facilities take up a lot of the slack at the other end”.
One of the biggest changes in health infrastructure in recent years, he adds, is the introduction in some countries of national health insurance schemes.
“This has been a blessing and a curse. It is a blessing because it gives more people access to care but they are often grossly underfunded. Some of our clinics at this time are behind six months in receiving funds due to them from these national health schemes,” says Carr.
“It is hard to operate even on a non-profit basis when it is so difficult to be reimbursed by the government for the care being provided.”
The group also runs a sponsorship programme to help academically qualified students who lack the financial means to get a health-related education. The students then agree to work in the faith-based hospitals for as many years as they are sponsored. “Seven or eight” doctors at the group’s biggest hospital in Nigeria are sponsored students, he says. Carr believes a “brain drain” of some of the best and brightest in the medical field was another major challenge.
“I see a lot of African students who come to the US and Canada so they can ‘get an education so they can go back and help their countries’, but in the end they like life more in the country they study in, or they marry someone from that country, so they never go home after all. It is an enormous loss for their countries.”
In her speech to the UN, Liu urged more countries to help fight the disease rather than implementing measures to prevent the arrival of an infected patient in their countries. “Only by battling the epidemic at its roots can we stem it,” she said. “It is your historic responsibility to act.”
What is needed more urgently are people and skills on the ground, backed up by each country’s “logistical capabilities”, she said.
In terms of priorities, Liu selected four key areas – expanding isolation centres, deploying mobile laboratories to improve diagnosis, establishing air bridges to move people and equipment into West Africa and building a regional network of field hospitals.
It has become obvious since the outbreak began in 2013 that the health-care infrastructure in West Africa is nowhere near good enough to cope. There are too few isolation facilities and too few mobile laboratories to diagnose people quickly.
In Monrovia, experts say that an additional 800 hospital beds are needed and patients are being turned away because there is no space. “Every day we have to turn sick people away because we are too full,” says Stefan Liljegren, the MSF coordinator at the Ebola management centre in Monrovia.
“I have had to tell ambulance drivers to call me before they arrive with patients, no matter how unwell they are, since we are often unable to take them.”
Because of the limited numbers of flights in and out of Liberia, equipment is arriving on traditional wooden boats, with cardboard boxes carrying incredibly precious cargo balanced precariously on the thin slats. Most of it is destined for treatment centres run by NGOs.
Much of the world’s attention has been focused on the western doctors who contracted the virus while volunteering in Ebola-affected countries. Three of the most notable cases were Dr Kent Brantly, Nancy Writebol, both American missionaries, and the British nurse, Will Pooley. All three were flown out of West Africa and treated successfully with an experimental medicine, ZMapp.
But while these three cases have received a huge amount of attention, the deaths of hundreds more have gone relatively unnoticed.
In fact, MSF estimates that more than 150 health workers have died from Ebola, and many, many more are too afraid to go to work.
For these people there is no plane waiting to transport them to a state-of-the-art facility in the developed world; they were forced instead to rely on the local services.
“Journalists come to film staff in exotic yellow hazmat suits, to photograph tanned, exhausted expatriate aid workers, and then they go home and tell the story of the poor Africans and the brave foreigners who came to save them … No one is asking where the rest of the response is,” says Ella Watson-Stryker, an MSF health promoter in Sierra Leone.
“They don’t question why, after five months of talk and more than 1,500 known deaths, the epidemic is still raging. They don’t ask where is the money donors are pledging, where are the boots on the ground?”
Given the high numbers of local health workers who have died, it is not surprising that there is a growing concern about working with Ebola patients.
Earlier this month, nurses from one of Liberia’s largest hospital went on strike demanding better protection. John Tugbeh, a spokesman for the nurses at John F Kennedy hospital in Monrovia, said they had not been given any protective equipment and they would not return to work until they were properly prepared.
Meanwhile, there have been several international funding pledges since the outbreak began. Earlier this month, the European Commission announced a €140m (Dh660.86m) package. The Bill and Melinda Gates Foundation said it would spend $50m fighting the disease. The African Development Bank Group has pledged $210m in total, with $60m going to the WHO.
However, the WHO and UN have come also under fire. In a recent opinion piece in The Washington Post, the World Bank group president Jim Yong Kim and Paul Farmer, an American anthropologist, said if these agencies worked effectively, then Ebola could be beaten.
“The virus could be contained and the fatality rate – which, based on the most conservative estimates, exceeds 50 per cent in the present outbreak – would drop dramatically, perhaps to below 20 per cent.”
But people on the ground say the fight is not just about hospitals and clinics. The information infrastructure is just as important as the physical infrastructure, argues Tarry Asoka, a Nigerian health consultant who spent five years working at the UK’s department for international development advising on health care in West Africa.
Asoka lives in Port Harcourt, the capital of River State, Nigeria, where he is part of a team working on a health development plan for the country.
Last month the WHO announced Port Harcourt’s first confirmed Ebola case. It arrived in the city through an infected man who was under quarantine in the capital Lagos, but fled to seek treatment. The doctor who treated him at a hotel then became the city’s index case – the first case in that region – and later died.
Before he died, but after he treated the absconder, the doctor performed surgery on at least two other people and continued to treat patients at his private clinic. He also hosted a party to celebrate the arrival of a new baby.
Asoka says even with good hospitals and clinics, if the public awareness is not there the disease will continue to spread and the health system in general will remain in a poor state. “For the first time a public health emergency has started to engage the population itself. There is a responsibility on them to be able to take care of themselves. People need to be informed and look after themselves as part of the health infrastructure.”
He estimates that in the past two months the Nigerian government has spent on health goods and services what it would usually spend in a year. Investment in even the most basic things such as hand sanitisers or temperature sensors will have a lasting impact, he says.
“It is a good thing. It’s shifting the infrastructure as we know it of clinics and hospitals, to have a level of goods and services that are now going to be a permanent feature of the health services.” Using the example of a visit to his local church with his wife, Asoka demonstrates how public attitudes towards basic health and safety are changing.
“They were worried about how the Holy Communion – which is usually served in one cup and everybody sharing it – was going to be done. They modified the practice by serving the Holy Communion in disposable plastic cups.
“And I’ve been to a bank this morning to do some business transactions and I have to wash my hands, somebody has to check my temperature before I go into the bank.”
Echoing others, Asoka is critical of the role big organisations like the WHO have played in his country. “All the talk for a very long time of making WHO an effective donor has not happened. Whatever funding WHO gave has gone on salaries and one or two things, so they don’t have money to do any operations.”
Asoka says the money his own government has spent in the past decade has not been spent wisely. “The money goes into having fancy kitchens in hospitals, with consultants and doctors trained. They put the money into building facilities without thinking how people will access the service in terms of cost.
“After many health authorities have finished paying salaries, there is nothing to run the hospitals and so they have to depend on out-of-pocket payments from the patients. So if an average patient gets malaria and he needs to buy a course of anti-malarials for $10, high poverty and low income levels mean many people can’t afford that.”
Johnson, of the King’s Sierra Leone Partnership, agrees that some long-term opportunities could arise from the response to the epidemic. “I worry that NGOs will build a parallel infrastructure outside of the government health systems: separate facilities, financial systems, supply chains et cetera, that aren’t sustainable and undermine the government system.”
However, if properly planned, he says, the funding and expertise could be funnelled through the government system to help refurbish buildings, buy new equipment and provide extra training, which would leave a lasting legacy. “Only then will we ensure that an outbreak like this can never happen again.”
Mitya Underwood is a senior features writer for The National.
Updated: September 25, 2014 04:00 AM