Departure of many Western development workers has weakened the understaffed health systems.
When people started dying of Ebola in Liberia, Clarine Vaughn faced a wrenching choice: Should she send home, for their own health and safety, four American doctors working for HEARTT, the aid group she led there? Or should she keep them in the country without proper supplies or training to fight the virulent, contagious disease, which was already spreading panic?
After much agonising, Vaughn, who lives in Liberia, pulled the doctors out and cancelled plans to bring in more. The African physicians and nurses left behind told her they understood, but felt abandoned. They said, “We need you guys here,” she recalled. Since then, Vaughn has wondered if the American doctors might have made a difference, and she asked the aid group AmeriCares to help. It sent in a planeload of supplies that landed in Monrovia, the Liberian capital.
The departure of many Western development workers from Guinea, Liberia and Sierra Leone, the West African countries hit hardest by Ebola, has further weakened the region’s understaffed health systems at the very moment they are facing one of the gravest public health crises ever. Liberia, population 4 million, has fewer than 250 doctors left in the entire country, according to the Liberia Medical and Dental Council. Seven doctors there have contracted Ebola, and two of them have died.
“The locals’ seeing this mass exodus of expatriates has contributed to the sense that there’s an apocalypse happening and they’re in it on their own,” said Raphael Frankfurter, executive director of the Wellbody Alliance, which provides clinical services in a diamond-mining district of Sierra Leone bordering Guinea, where the outbreak began.Frankfurter, too, sent his four American volunteers home for fear they might fall ill. They left behind 160 national staff. “It’s certainly not in line with our values, because it’s just such a glaring inequality,” he said. But “it’s a very scary place to get sick right now.”
As an array of international organisations, wealthy countries and charitable groups gear up to provide desperately needed resources to fight the outbreak, the absent doctors and volunteers are a reminder of the daunting practical obstacles. Many African health workers battling Ebola are contracting it themselves. At least 170 workers have gotten the disease, according to the World Health Organisation, and more than 80 have died.
Those sickened include Dr Kent Brantly, an American now recovering in an Atlanta hospital after receiving ZMapp, an experimental drug. Three Liberian patients received ZMapp on Friday, according to Tolbert Nyenswah, a Liberian assistant minister of health and social welfare. The patients signed consent forms stating that they understood the risks of the untested drug and waived liability for any adverse effects.
The doses had been flown into Liberia after appeals from President Ellen Johnson Sirleaf of Liberia to President Barack Obama and senior US officials. Its arrival last week lifted morale and “raised the hope of everybody,” Johnson Sirleaf said. The situation, however, was volatile. On August 16, several hundred people in an area of Monrovia known as the West Point slum broke through the gates of a former school that had been converted days earlier into a holding centre for people with suspected Ebola.
Samuel Tarplah, 48, a nurse running the centre, said Saturday evening that the protesters wanted to shut it down. “They told us that we don’t want an Ebola holding centre in our community.” He said the intruders stole mattresses, personal protective equipment, even buckets of chlorine that had just been delivered. “They took everything.”
Fear is complicating the huge increase in aid that is needed: food for people in areas that have been cordoned off; laboratory supplies to test for the disease; gloves, face masks and gowns to protect health workers; body bags for the dead; bedsheets to replace those that must be burned. Airlines have cancelled flights that could have carried in such supplies, despite assurances from the WHO that properly screened passengers pose little risk. Positions on aid rosters remain unfilled.
Hundreds of workers for Doctors Without Borders have fought the outbreak since March. The group’s president, Dr Joanne Liu, said there was an acute need for materials as well as for more human resources on the ground - and not just experts and bureaucrats, but also the kind of person who is ready to “roll up his sleeves.” “What we have to keep in mind is we are facing today the most devastating and biggest Ebola epidemic of the modern times,” Liu said. “There is fear, there is a front line, the epidemic is advancing, and there is a collapse of infrastructure.” A more muscular effort to fight the outbreak began lumbering to life over the past week.
Tight time pressure The newly appointed UN coordinator for Ebola, Dr David Nabarro, wrote in an email that he had his “head right down working through some extremely challenging stuff under tight time pressure.”
“All of us are going to have to perform in an outstanding way over some months,” Nabarro added in a phone interview. “For many, the image is fearful to a degree that it makes it very hard indeed for them to do anything other than think about their safety and the safety of those they love.”
The WHO’s sole in-house Ebola specialist said he was following his doctor’s advice to take the week off work. His colleagues drew up plans to coordinate the international effort and recruited employees from other agencies to help with data management and field work. With commercial flights dwindling, the UN's World Food Programme began an air service for humanitarian workers on Saturday. “The virus is spreading, and we’re all suddenly realizing we need to do more,” said Denise Brown, the agency’s emergency coordinator for the crisis.
The agency studied whether food stockpiled in the region for refugees fleeing a military crisis in Central African Republic could be moved to help people in what Brown called “hot zones.” But planning was complicated by the refusal of some countries to receive ships that had stopped at ports in Guinea, Liberia and Sierra Leone, she said. And the movement of food from domestic stocks into quarantined areas stalled as the World Food Programme and WHO sought ways to keep transporters safe and to ensure that deliveries did not cause people to congregate, risking further transmission of the disease.
Dr Marie-Paule Kieny, a WHO assistant director general, said that while it was “important to limit the movement in and out of the hot spots,” there was an urgent need to provide food and drinking water in communities cordoned off by the military to “make sure we don’t add a humanitarian disaster on a difficult health problem.” Kieny has begun cataloging available doses of experimental drugs and vaccines in preparation for a September 4 meeting on their possible use and testing.
UNICEF staff at a supply depot in Copenhagen are working to mobilize medical treatments, burial supplies, and millions of bars of soap and disinfectants for use in homes and health centers, many of which lack basic sanitary supplies.
The director of the Centres for Disease Control and Prevention, Dr Thomas R. Frieden, said the CDC had sent 50 experts to help local governments keep track of where people are getting sick and set up emergency operations centers - a challenge, judging from a Liberian Health Ministry report that in the hardest-hit area of the country, the County Surveillance Office has no computer for data management.
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