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MONROVIA, Liberia — Outside her six-room house in New Kru Town, one of this city’s largest slums, Esther Doe cradles her grandson while dressing her granddaughter at the same time. Clotheslines hanging between the mango trees in her yard are strewn with baby outfits, cotton lapa fabric and tank tops.
As she tends to the children, a team of “animators” — the term used by aid groups for employees who provide public education — speaks to Doe about Ebola. The animators, from Community Development Services (CODES), a local group that works with UNICEF, have painted blue crosses with the organization’s name on the walls of surrounding houses, marking the homes they have visited.
Like many Liberians, Doe does not fully believe that Ebola is real; she is suspicious of hospitals and health workers and the government. “Government saying this and saying that,” she says, asking if Liberia is expected to come to a standstill in order to end the outbreak. Nevertheless, Doe, like some people here, is starting to take note of public health messages.
New Kru Town is on the front lines of the fight against Ebola, a deadly hemorrhagic fever that in the past five months has swept across Liberia and two other West African countries, infecting an estimated 1,200 people and killing 729. This is the first time in the virus’ history that it has hit three urban centers (the others are Conakry and Freetown, the capitals of Guinea and Sierra Leone, respectively). Liberia has had to contend with rising tensions between residents and health workers, many of whom have died of the illness; a fragile health system shattered by years of civil war; and a government response criticized for being too slow.
On Wednesday, Liberian President Ellen Johnson Sirleaf unveiled new measures to stem the spread of the illness that many health experts are now calling a humanitarian crisis. The country’s security forces will oversee the closure of all of Liberia’s schools as well as provide surveillance at borders and airports and possible testing of passengers suspected of carrying the disease. All government employees except heads of ministries and agencies, deputies and other essential staff will be put on mandatory leave, and state buildings will be disinfected. Johnson Sirleaf’s administration is also advising people to stay away from public places and entertainment centers, and prohibiting large public gatherings and demonstrations. Three communities in Lofa, in northern Liberia, have been put under quarantine; only police and health workers are permitted to enter or leave. On Thursday, neighboring Sierra Leone declared a national emergency and instituted similar measures.
The new measures in Liberia were announced a day after a tense meeting of a task force of government and foreign donors. At the meeting, a top official for the aid group Doctors Without Borders told Liberian officials that the outbreak required immediate attention five weeks ago, according to one attendee who declined to be identified. At that same meeting, Samaritan’s Purse, a large international aid group, announced it would halt management of treatment centers in Monrovia and Foya, Liberia, because of an attack on the charity’s workers last weekend after they tried to collect the body of a person suspected to have died of Ebola. Policemen are currently deployed outside many health facilities to protect staff from attacks, which have grown increasingly common amid mounting fears that health employees are spreading the disease.
I don’t believe it! I don’t believe it! I haven’t seen an Ebola patient.
New Kru Town resident
In New Kru Town, a densely populated area made up of close-set houses built between old green trees and sandy roads and pathways, access to clean water and sanitation services is limited, making the area particularly vulnerable to the virus. Families pay between 10 and 20 Liberian dollars, roughly 10 to 20 U.S. cents, for a bucket of cold or hot water to bathe in cramped concrete toilet-like cubicles. There are few places to put trash and few functioning toilets.
Like many Liberians, Doe lacks an understanding of the disease. While the virus is thought to first spread to humans via fruit bats, human-to-human transmission occurs through contact with bodily fluids. Using a laminated chart during their visit to Doe’s home, the team from CODES lists Ebola symptoms — vomiting, constant diarrhea, headaches, sweating, vomiting blood and red eyes. The health workers instruct Doe in proper hand washing and food preparation, and tell her to avoid shaking hands with people or getting too close to them.
Doe tells the health workers she doesn’t know whether to let her children play outside. She is worried, too, about leaving her house and visiting public places like the “video club,” an informal movie theater where she sometimes sells cold drinks to make extra money. The animators from CODES offer some suggestions: Keep an eye on the children, they say, and store a bucket of chlorinated water nearby as a disinfectant.
Others in New Kru Town are even more skeptical about the Ebola threat. As Doe and the health workers talk, her brother, 27-year-old Richard Koffa, who stands shirtless beside her house, interrupts the conversation. “I don’t believe it! I don’t believe it! I haven’t seen an Ebola patient.”
The animators start to engage him, explaining that people from New Kru and nearby neighborhoods have died from Ebola. (Nearly half of Liberia’s counties have recorded suspected cases of the virus, according to reports from the Ministry of Health. An estimated 170 people have died, 26 of them health workers.)
[Health workers] are turning away other people who do not have Ebola, and even those that have the disease are being turned away, and it is increasing the spread of the disease.
Liberia’s assistant health minister
But Koffa says he is unconvinced. Many here are deeply distrustful of the government, which they view as corrupt.
When the CODES workers start to explain what to do if someone may have been exposed to Ebola — take him or her to a health facility — they are met with irritation.
“At Redemption, if you have runny stomach, they [do] not treat you,” says Doe, referring to Redemption Hospital, New Kru Town’s main health facility.
She and Koffa cite cases of New Kru residents being turned away by health workers who are afraid of contracting Ebola. Their neighbors tell similar stories; another woman, Linda Nyanfor, sits on the stoop of her home nearby and recounts the story of a friend who she says was rejected from a clinic because of high blood pressure. Nyanfor says she thinks it is because the health workers believed the friend had Ebola.
The Liberian Ministry of Health has also expressed concerns about health workers turning patients away for fear they have the disease. In an interview, Assistant Health Minister Tolbert Nyenswah acknowledged that this is a major problem.
“A lot of health workers are getting infected, and they are afraid of getting infected,” he said. “They are turning away other people who do not have Ebola, and even those that have the disease are being turned away, and it is increasing the spread of the disease.”
They call this the Ebola hospital.
Deputy chief of security, Redemption hospital
On an afternoon earlier this week, Redemption Hospital is desolate. The mothers and other relatives who once milled about to bring food to their loved ones are gone, and there are just six security guards behind the barred entrance.
“There is only one patient in here,” says Sylvester Porte, the hospital’s deputy chief of security.
Fears of Ebola have driven both patients and health care workers away. Many of the city’s health workers have stopped showing up for work since the outbreak, and on Wednesday, three of the city’s four main hospitals were closed after medical workers at each hospital contracted the illness. Health workers have even been hesitant to go to work at the city’s main hospital, John Fitzgerald Kennedy Memorial Hospital, after the death last weekend of Dr. Samuel Brisbane, a high-profile Liberian doctor who worked there. St. Joseph’s Catholic Hospital was closed after its chief administrator and another employee contracted the illness.
In early July, a Ugandan doctor, Dr. Samuel Muhumuza Mutooro, died after contracting Ebola in Redemption from a nurse, Esther Kesselly, whom he was treating there. “They call this the Ebola hospital,” says Porte.
A recent attack at Redemption has also escalated health workers’ fears. On July 24 the hospital was flanked by police officers carrying plastic riot shields, stationed there to protect the hospital and health workers as they awaited the test results for a woman who died after potentially contracting Ebola. As her family waited to retrieve the body, says Porte, some community members threw stones at the hospital. Police were forced to evacuate health care workers, and the woman’s body was left at the hospital for four days before staff from the Ministry of Health buried it, according to the country’s chief medical officer, Dr. Bernice Dahn.
On Thursday in downtown Monrovia, a day after President Johnson Sirleaf declared emergency measures, it seemed some people were taking heed of the warnings. Men were selling water containers with small taps on the end, known as “Ebola buckets,” while women in green raincoats sold hand sanitizer. Some people on the sidewalk wore latex gloves or work gloves.
Benjamin Monroe, health communications specialist at the U.S. Centers for Disease Control and Prevention, said the Ebola outbreak, devastating in its own right, will further weaken Liberia’s health care system, which is just beginning to recover from a 14-year civil war.
"It’s a very dire situation, not just due to the scary infectious disease that captures headlines,” he says, “but just the routine day-to-day health care in this country is in complete jeopardy because of this.”