Epilogue

From the 13th of August until the 2nd September I wrote 21 blogs to raise awareness about the Ebola outbreak in West Africa, particularly Liberia - one for each day of the incubation period of the virus.  In the time I have been writing, the number of cases of Ebola in Liberia, and the number of deaths, has more than doubled.  There is a greater need than ever for people all over the world to join governments of affected countries, international organisations and NGOs in taking action against Ebola.

The Liberia, Sierra Leone and Guinea Red Cross Societies are among the best placed organisations to make a difference, as they are known and respected by local people, and supported by hundreds of local volunteers who work in their own communities.  They have put the majority of their usual programmes on hold in order to throw everything that they have got at the fight against Ebola, providing vital personal protective equipment for medical workers, conducting safe burials, raising awareness and changing attitudes towards Ebola in their communities.

If you have appreciated reading this blog, please can I urge you to join others who have gone a step further and made a donation to the Red Cross' Ebola outbreak appeal - simply CLICK HERE to link to my online giving page where you can make a donation easily and securely online.

Thank you so much for reading, for caring, and for giving.

Rachel Ayrton

A Liberian point of view

Something that I have noticed while monitoring the Ebola outbreak in Liberia for the last 21 days, is that for all the ‘experts’ who are called upon to make public statements and reports, there is a distinct lack of West African voices.  People like me can make suppositions about what everyday life is like for people living with the threat and reality of Ebola in Liberia, but we can only truly understand this by listening to Liberians who are experiencing the outbreak first hand.

I am honoured that in this my 21^st and final blog post my friend Morris Saysay has agreed for me to interview him, to give us all an insight into everyday life in Liberia at present.  Morris is married and lives in Monrovia, the capital city of Liberia.  He works as an Operations Coordinator for an international NGO and in addition he is studying sociology and management at the University of Liberia.  He has asked me to emphasise that his answers to my questions are his personal opinions, and they do not reflect on the organisation he works for.

How has the Ebola outbreak affected life for people in Monrovia?

"The Ebola outbreak has affected every aspect of life for people in Monrovia and other parts of the country.  There is no free movement, the healthcare system has broken down, economic hardship has increased greatly and many people are living in fear."

"Currently, there is a state of emergency being enforced by the joint security and there is a curfew that runs from 9pm – 6am.  Military and other security personnel are deployed around quarantined communities and counties.  There is no free movement.   While many welcome the idea of quarantining infested communities to prevent the spread of the disease, there is criticism among many about the ways in which state security are handling the situation.  There have been complaints of mistreatment by security personnel in quarantined communities, especially West Point where there was a report of a riot between security forces and community dwellers that led to several people getting wounded and the death of a 15 years old boy who was shot and later died in the Redemption Hospital."

"Government, companies and humanitarian organizations have asked their staff to stay home. They are currently operating with essential staff only.  The problem here is that most of the people who work for government or at these organizations are services contractors who are paid on a daily basis. Sending them home means that they are left with no sources of income."

"The already poor healthcare system of our country is overwhelmed by the outbreak.  Doctors and nurses are not attending to patients visiting the hospital for fear of being infected.  At a result, many people have died from curable diseases.  There are instances where women in labour pain were not attended to and they lost both their lives and their babies’.  Government has set up a few treatment centers within Monrovia and other parts of the country but there are reports that those centers are filled due to influx.  For the fear of health workers not disposing of medical waste properly which might spread the virus, community dwellers are not allowing the Ministry of Health to set up Ebola treatment centers within their communities.  The Liberia National Red Cross, MSF and Samaritan Purse are all helping to boost government effort."

"The Ebola outbreak has increased the suffering of the Liberian people."

"Most Liberians are self-employed, they are either farmers or petty traders.  They produce vegetables and other agricultural products outside of Montserrado county, transport their goods to Monrovia and after selling their products, they buy rice and other goods that they don’t produce and take it back to their family.  This is a daily routine.  Now there is no free movement - you can imagine the difficulties lots of Liberians are going through."

What are people saying about Ebola?

"What we are hearing from many quarters in Monrovia is that government lacks the capacity to combat this disease.  And besides, there is a lack of trust in the government and citizens are afraid that any resource that comes in will not be used for the intended purpose.  Others believe that the government is hiding something.  They don’t believe that it is because of the Ebola outbreak that the government declares a state of emergency and deploy military in Monrovia and other parts of the country."

Have you been affected directly in any way?

"Yes the situation has affected my day to day movement, both my study and business."

People say that fear and denial are the biggest barriers to containing the outbreak. Do you agree?

"Yes I do agree fear and denial are the biggest barriers to containing the outbreak.  During the early stage of the outbreak, major deaths occurred amongst healthcare workers due to the lack of personal protective equipment (PPE).  At a result, doctors and nurses abandoned the hospitals for fear of their lives.  Up to present, many have not returned to work.  Because many people do not trust the government and are wary of corrupt government officials going with impunity, they think that this is a scam from government to misuse tax payers’ money.  There are still some, because of their faith or traditional belief, that deny the virus exists."

What do you think is needed to bring the outbreak under control?

"In my opinion, vigorous awareness is the first step.  And this should be led by humanitarian organizations supported by the government.  Reason being, the people lack trust in the government.  There are credible humanitarian organizations that have gained the trust of the people over the years; they will be more easily accepted by the communities than government workers.  If possible, in addition to testing the body temperature of people traveling from one county to another at checkpoints and borders, fast track testing centers should be set up in communities and hospitals to test and quickly isolate those with Ebola cases from those with other illness instead of treating every illness as a suspected Ebola case.  Health workers should be provided with personal protective equipment, logistics and properly trained in standard operating procedures with regards to how to handle suspected Ebola patients.  Lastly, the country needs the help of volunteer doctors from the international community to help fight this outbreak."

If you would like to support Liberia to fight Ebola, CLICK HERE to visit my fundraising page and donate to the Red Cross Ebola Outbreak Appeal.  This is a quick and effective way of getting money quickly to the people who need it most.  Thank you for your help.

Standing in the gap

“Rarely will anyone die for a righteous person—though perhaps for a good person someone might actually dare to die.”

If you were to ask me would I be willing to die to save someone else’s life, I would probably say it depends.  If it was a child, someone innocent who has had little opportunity to live, maybe I would.  If it was someone I loved very much, then probably.  If it was someone with an exceptional ability make a difference in the world, perhaps.  I would either act on instinct born of love or compassion, or I would have to make an assessment of whether I thought their life counted for more than mine – taking into account my desire not to inflict grief on the people I care about.

There are people who regularly put their lives at risk for the sake of other people whose value they never assess – mountain rescue, life boat crew, fire fighters, the military … this kind of bravery, where a person puts him- or herself between another person and harm, is an awesome thing.  Of the many challenges health workers face and sacrifices they have to make, usually dying for their patients’ sake is not on the list.

In Liberia alone, 147 health workers have contracted Ebola (confirmed, probable and suspected), and 95 have died.  That is between 8 and 9% of the total number of cases and deaths in Liberia.

These are people who would have been highly unlikely to contract Ebola outside work, and who by providing good medical support increase Ebola patients’ chances of survival by 10-15%.  They are also people with homes and families who rely on them, who go to work to do a job as many of us do, in order to provide as well as in order to do good.  By helping to give their patients the best possible chance of survival they have paid the ultimate price.  Barrier nursing techniques could prevent infection of health workers, but where the right equipment or procedures are not available, or where the health worker did not know it was Ebola they were dealing with, some have put caring for their patients above their own safety.

I am thankful that there are people like that in the world.

The Red Cross are providing more protective equipment in order to protect health care workers in Liberia and elsewhere in West Africa.  You can help them – click here to donate to my campaign supporting the Red Cross’ Ebola outbreak appeal.

How to spend $490m in six months

It’s reassuring to know that someone has a plan.  A few days ago the WHO released their Ebola Response Roadmap with the goal of stopping Ebola transmission within 6-9 months in affected countries, and preventing international spread.  It’s sobering to see what financial resources, human and organisational capacity is going to be needed, but more so to observe the assumption that the outbreak is going to get quite a lot worse before it gets better, and that already in some areas the number of cases may be 2-4 times the number we know about.

Let’s take a look inside …

Objective 1: “To achieve full geographic coverage with complementary Ebola response activities in countries with widespread and intense transmission.”

Key Milestones: “Reverse the trend in new cases and infected areas within 3 months, stop transmission in capital cities and major ports, and stop all residual transmission within 6-9 months.”

Focusing on Liberia, Sierra Leone and Guinea, this means caring for Ebola patients in purpose-built treatment centres with full infection control measures, laboratory diagnosis facilities, contact tracing and monitoring, supervised burials, and engagement with communities.  Areas with intense transmission will be continuously identified and monitored, and the interventions will be significantly stepped up in these locations.  To limit national spread, where there are ‘containment areas’ (quarantined communities) this means ensuring that basic services such as primary health care, psycho-social support and food are provided.  Public gatherings should also be deferred.  To limit international spread, there will be exit screening at all major land, air or sea borders and no Ebola sufferers will be allowed to travel unless by medical evacuation.  There will also be an effort to cover the gaps in essential services such as health care, education, water and sanitation, food, and protection.  An investment plan to strengthen health services in the longer term will be developed, as well as a fast-track training programme for health workers.

Objective 2: “To ensure emergency and immediate application of comprehensive Ebola response interventions in countries with an initial case(s) or with localised transmission.”

Key Milestone: “Stop all transmission within 8 weeks of index case.”

In countries like Nigeria, and now Senegal, where there has been a first case (known as an ‘index case’) and perhaps some transmission on a relatively small scale, emergency health procedures should be instigated, including the establishment of an emergency operations centre and plans for coordination and communication.  Ebola response protocols must be followed, including isolating patients in a designated treatment centre, accessing diagnostic capacity, contact tracing/monitoring, safe burials and good public communication.  Again, international spread must be prevented by forbidding travel by Ebola-sufferers.

Objective 3: “To strengthen preparedness of all countries to rapidly detect and respond to an Ebola exposure, especially those sharing land borders with an intense transmission area and those with international transportation hubs.”

Key Milestone: “Full Ebola surveillance preparedness and response plan established in areas sharing a land border with an Ebola-infected country and at all major international transportation hubs within one month.”

Neighbouring countries are most at risk of international spread because of porous land borders (that’s how Ebola got to Senegal), and transport hubs (as we have seen in Nigeria) are also vulnerable.  All countries should be prepared – by providing travellers to affected areas with information, ensuring an isolation facility is available along with arrangements for diagnosis and contact tracing, if needed.  Countries with a land border should also provide the population with accurate information about Ebola and how to prevent it, begin active surveillance for any clusters of unexplained deaths (particularly near borders) and put in place means of managing travellers at major land crossings who show signs of fever.  International travel hubs also need to be prepared to manage passengers with unexplained fever.

None of this comes cheap – a budget of $490 million (£295.3m) is projected for a six month period.  Hard to fathom, isn't it?  Money isn't everything though – the plan also identifies the need for 3170 national staff, all in skilled or semi-skilled roles, and 410 international staff, in Liberia alone.  Finding those people will not be straightforward.  I can’t help thinking had this level of coordination been put in place earlier, things might never have got this bad.

Then there are the things that the budget doesn't include – such as the costs of supporting essential services to be provided in the worst-affected countries, and the costs of health systems recovery and strengthening in these areas.  Who, I wonder, is going to take care of that?

For the keenies, the full Roadmap can be found here: http://apps.who.int/iris/bitstream/10665/131596/1/EbolaResponseRoadmap.pdf?ua=1

The anxiety of the uninfected

About a week after I returned from Liberia I got a cold. It started with a headache - a classic early Ebola symptom. Being perhaps a little run down after an intense period of work and travel, it hit me hard, and I felt exhausted and weak. The thought crept into the corner of my mind, what if I have Ebola?

Being a rational sort of gal I knew this was intensely unlikely. I was in a 'low risk' category. High risk people are the family of Ebola sufferers, medical workers and aid workers in affected communities or treatment centres. As a foreign visitor who had never knowingly come into contact with a sick person, I could only have contracted Ebola by touching someone or something contaminated with an Ebola patient's bodily fluids, then eating, rubbing my eyes or nose or touching a broken area of skin before washing my hands. I didn't honestly believe this had happened.

But it was just possible ... so how far should I go in taking precautions? Should I sleep in the spare room and keep my husband away? Should I refuse entry to my home when my friend visits with her 11 month old baby? Should I try not to touch my young niece and nephew? It's easy to be logical when it is only your own health at stake, but the thought of putting loved ones at risk bred a gnawing anxiety.

I'm just one person with access to good information sources - so I carried on as normal and checked my temperature regularly for my own peace of mind. But what happens when you multiply that nagging doubt, that hypothetical guilt, to a whole population? Only a minority may be acutely affected by Ebola, but no one is untouched - the whole of West Africa is on edge.

Treatment

The human body is an amazing thing.  We’ve studied it for centuries, and still there is so much that we don’t understand.  Its ability to heal and regenerate itself must be one of the most intriguing things about it - in film and television this is often exaggerated and described as a superpower (X-Men, Heroes …) but the truth is we are all capable of self-regeneration – just not instantaneously!  Something that I didn’t know before my husband specialised in intensive care medicine is how much our most high-tech medical interventions rely on the body’s own ability to heal itself.  Notwithstanding antibiotics to kill bacteria and so on, fundamentally what intensive care offers is the skills, drugs and technology to support failing systems in the body, keeping it going and buying it time to repair itself, or not.

No matter where you are in the world, in the absence of any cure, the treatment for Ebola is supportive care.  Its purpose is to keep the patient alive as long as possible to give the immune system the time it needs to mobilise its response, which will be new and specific to the virus that it is up against.  That is why there has been some benefit in previous outbreaks in using serums to treat Ebola – that is, extracts from the blood of Ebola survivors that can be injected into Ebola sufferers.  Their blood contains the antibodies that the immune system has generated, which gives the recipient’s immune system a head start in working out what to do about the viral invasion.  The body is capable of eliminating Ebola – we just don’t know how.

In Ebola treatment centres in West Africa run by MSF or in hospitals, this supportive therapy focuses on the basics of life.  They are kept hydrated, and their oxygen status is maintained.  This keeps their blood pressure as stable as possible.  Since their immune system is otherwise occupied they are susceptible to other infections, and these can be treated.  Beyond that, all we can do it watch, and wait – but the time that this supportive treatment buys a patient can make the difference between life and death.  MSF estimates that early treatment can improve the chances of surviving Ebola by 10-15%.

Of course, what would really buy Ebola patients time is access to the full works of intensive care support – invasive ventilation, powerful drugs (inotropes) that modulate blood pressure and heart contraction, haemofiltration (like dialysis) to replace non-functioning kidneys, one-to-one nursing … Not only would this give the immune system time to work its magic, but even for those who did not recover, their death would be far less traumatic.  As soon as it became clear that the patient was deteriorating into severe multi organ failure, they would be anaesthetised and ventilated, so as well as receiving other treatments to give them a chance, they would not suffer.  The trouble is, this comes at a cost.  In the UK, a bed on intensive care costs on average around £2000 per night – so that would be £28,000 for just one patient with two weeks of Ebola.  It also requires a consistent and safe supply of a wide range of drugs, lots of nurses, complex equipment that requires a specific skill-set to operate, even amongst doctors, a lot of clean water and a reliable electricity supply – you can’t very well provide life support where there is a risk of a power cut.  Too bad it’s not countries that can afford it that get Ebola.

'Fear will be your enemy'

Everyone who is parent to or otherwise spends time with a girl under the age of, say, 13, will know that when fear grips you, bad things can happen.  Especially if you are an ice-wielding princess struggling to control her powers (even if you don’t have any children as an excuse, I still recommend the film ‘Frozen’ as a heart-warming if cheesy use of 108 minutes).  In Liberia, the main reason the Ebola outbreak is not under control is the potent combination of fear, denial and distrust.  We often think of fear as irrational, something that causes senseless action.  It might be tempting to read events like families hiding cases of Ebola in their homes, patients running away from treatment centres, or communities rioting to escape a quarantined area, in this way.  But I think that if we can put ourselves into the position of a person behaving in this way, we can begin to see the logic, consistency and good sense in their actions – and the challenge to change perceptions that the Red Cross and others playing their part in the outbreak response face.

Of course, we’re all a little bit scared of Ebola – it’s a terrifying disease.  Even when we read news articles (or even blogs) about places over three thousand miles away, it still causes us a little anxiety knowing that there are diseases like that out there.  But Liberians have other reasons to be afraid.

Many people in Liberia have had very little contact with Western-style medicine.  Access to health care is very poor in Liberia, and during the civil wars it was virtually non-existent.  Alongside this, there is very poor access to education, particularly in rural areas, for the poorest people in the population and for women, so there has been little opportunity to learn of the benefits of modern medicine.  Rather, people have always relied on traditional healing, including both the use of herbs and roots, and magical interventions, in order to address their ailments.  Many people have rarely or never faced a situation where they have had to trust Western medicine.  Then a relative falls sick with a fever that looks just like the malarial fever that everyone has had at some point in their life.  They are taken away by strangers in strange suits to a medical facility.  Then, their condition worsens, and they die a terrible death like nothing anyone has seen before.  From that perspective, you might be forgiven for thinking, at best, that Western medicine is ineffective, or at worst, that someone has maliciously tortured and killed your loved-one, either directly or through some malevolent magic.  In order to trust someone or something, you need to believe that it is competent to do what is needed, and that it is benevolent to do it.

Then there are the measures that the government is taking to contain the outbreak: road blocks, quarantining communities, soldiers going house-to house to find families who are hiding cases of Ebola in their homes.  This would be intimidating for anyone, but Liberia is a post-war country where most of the population has experienced these things before.  Now I'm not saying these measures are wrong - you would have to ask a Liberian living in the country to make that kind of assessment, I'm in no position to judge the pros and cons of the government's actions.  A Ugandan friend tells me that a tough approach from their government has previously prevented Ebola outbreaks from spreading in his country.  Still, imagine what it is like to have a soldier force his way into your house when the last time this happened, people were screaming, gunshots were being fired, there were bodies in the street and children running into the bush to hide. Houses looted, young boys kidnapped, women assaulted and many people arbitrarily executed. There is a real danger of retraumatising a population with a lot of bad memories.

Survival is a daily challenge for the majority of Liberians, over 60% of whom live below the national poverty line.  Recently, the prices of staple goods such as rice and drinkable water have rocketed by 80%.  The main commercial hub of Monrovia is the Waterside area,  and 70% of traders who serve this economic centre live in the quarantined community of West point,  which had been barricaded for at least three weeks to contain instances of Ebola in this one of the poorest and most densely populated areas in the country.  Add to that the restrictions in cross - border and cross - country trade, and the supply of rice and water, the essentials of life, is in serious jeopardy.  People who already live on the edge of survival cannot afford these price increases - as a Liberian aid worker pleaded on CBC news,

"We need food, we need water. We're not just fighting Ebola here, we are fighting hunger too."

Trust is something that we badly need in order to cooperate with other people without unbearable anxiety.  In order to trust, whether that is medical workers, the government, NGOs, traders of basic commodities or other citizens, people come from a place of vulnerability and uncertainty about how they will be treated. Drawing on past experiences, cultural background and the advice of influential others they assess whether they expect a favourable outcome to arise through trusting. In order to trust, they must make a leap of faith, accepting their vulnerability and acting as if the outcome will be good even though they don't know whether this will be the case. Trust could not be more relevant and essential to Liberia, and it is in the balance in this crisis. A lot hinges on the successful management of the outbreak.