Gross governance errors led to Ebola epidemic

The U.S. military has arrived in Liberia to help manage the Ebola pandemic in West Africa. This effort is unfortunately too little and too late and will not reverse the original governance errors of isolating rural villages, alienating hospital workers, abandoning the sick, quarantining slums and understating the scale of infections. In fact, it is quite unclear whether the World Health Organization’s worst-case projection of 1.4 million cases of Ebola by January 2015 can be prevented.

While the tragedy in Dallas of a single Liberian traveler falling ill from Ebola after days of exposing others serves to alarm the American public of the threat, the incident has done little so far to hasten an adequate global response.

To this day, the threat continues to grow not only because Ebola is striking at the large impoverished urban populations of Conakry, Guinea; Freetown, Sierra Leone; and Monrovia, Liberia, but also because the disease continues to pick off the critical health workers who are necessary to combat the virus’ spread.

In the latest setback, Liberia’s chief medical officer, Bernice Dahn, has decided to quarantine herself after her assistant died of Ebola. Dahn says she is showing no Ebola symptoms of fever and weakness, but she will know for sure only after the virus’ incubation period of 21 days has passed.

Meanwhile, international assistance for the overwhelmed and now dysfunctional governments of Liberia, Sierra Leone and Guinea is arriving in a tardy, slight, hesitant fashion, despite the clear judgment of medical experts that the epidemic is out of control.

In addition to the military contingent the U.S. sent, Britain, China and Cuba are dispatching various small teams of medical workers. There is also a lone air shipment, sent by the NGO Direct Relief, of supplies needed to protect health workers and aid the sick, such as surgical clothing, plastic sheets, chlorine disinfectant and medications.

None of these efforts will answer the enormous scale of the crisis or resolve the problems that exacerbated it. The remedies applied so far of isolating, intimidating and propagandizing the at-risk populations are being repeated by the same authorities who watched the outbreak explode since spring.

1. Isolation did not work. For example, the three member states of the West African Mona River Association — Guinea, Sierra Leone and Liberia — ruled on Aug. 1 to impose a cordon sanitaire on the countryside of Sierra Leone. It quickly failed because the unprepared, uneducated armed soldiers maintaining the checkpoints were not given the means to choose between the ill and the well. They blocked everyone who was not in a vehicle with government approval to pass, such as journalists. In addition, villages where Ebola already struck were largely abandoned, despite children and farms to care for. Where did the villagers go? Likely to the homes of relatives in uninfected villages or to population centers such as the capital, Freetown.

In this fashion, with small villages emptying to larger ones and those in turn to Freetown to stay ahead of the illness, Ebola traveled to the slums of Freetown. This pattern was likely repeated in Liberia and Guinea.

In Monrovia the health centers quickly collapsed. When I spoke with Al Jazeera America’s Clair MacDougall in mid-August, health workers in Monrovia were refusing to go to work until the government guaranteed their families would be cared for in the event of their deaths. As of mid-September, Monrovia’s hospitals remained dysfunctional, without workers, supplies and plans to reopen.

2. Intimidation did not work. In August, the Liberian government ordered a quarantine of the vast West Point slum along the sandy coast of Monrovia. There was soon a shooting incident, when the unprepared armed forces were faced with a panicky population. The government of President Ellen Johnson Sirleaf soon reversed itself under international pressure, but public confidence in Monrovia’s leadership was finished.

The quarantine centers to which the sick were referred for help proved to worsen the crisis. Photographs from Liberia taken in mid-August showed centers were without equipment or workers; they were functionally no better than places to die. Those centers that were functional were overrun with the sick. 

The isolation centers were so appallingly managed that families made the risky decision to keep their loved ones at home to nurse them. This led quickly to families’ concealing the facts from their neighbors and from health workers, including the concealment of the dead as well, with families burying their relatives. The handling of the Ebola deceased is the most perilous time, because the corpse and everything it touches remain contaminated.

Sierra Leone’s most recent response to families’ hiding the ill and refusing to report the dead was to lock down the capital for days at a time, visiting every residence to make inquiries. This created an atmosphere of fear and persecution and also led to government inspectors’ exposing themselves to the homes of the ill and carrying the exposure to other residences in their rounds.

The U.S. military’s first challenge is to construct an isolation center outside Monrovia, Liberia, that can handle the demand. The WHO has recently opened a second clinic in Monrovia that was quickly overflowing with patients. The need in Monrovia vastly exceeds even these plans. When I spoke with sources in Monrovia in mid-September, I learned that not only the hospitals but also the isolation centers were turning away the sick at their doors. Wherever the infected go, whether in taxis, on the street, to rooms or corners, they spread the infection.

3. Official assessment of the epidemic did not work. Since the beginning of the outbreak in the spring, the worst response of all has been the WHO’s consistently upbeat and conservative estimations and advisories of the Ebola threat.

The first cases occurred in March in rural Guinea. The WHO said the situation was contained after six to eight weeks using the standard protocols of isolation, tracing contacts and added precautions by health workers.

But then cases appeared in rural Sierra Leone and Liberia, and by August the WHO was estimating the numbers for Guinea, Sierra Leone, Liberia and Nigeria at 2,127 infections and 1,145 deaths. These estimates were woefully at odds with those of workers for Doctors Without Borders and other aid groups, who guessed that these numbers needed to be tripled.

Even more alarming, in mid-August a WHO report issued weak travel warnings to people in the danger zones of the cordon sanitaire or in populations centers and to people traveling to and from the region: “WHO does not recommend any travel or trade restrictions be applied except in cases where individuals have been confirmed or are suspected of being infected with EVD [Ebola virus disease] or where individuals have had contact with cases of EVD.”

This deadly pattern of lowballing the number of infections and deaths while resisting a travel ban on all airports, roads and waterways continued into September: Estimates of the damage grew quickly, to 20,000 people at risk, then to 500,000.

At the same time, Doctors Without Borders reported that it was understaffed and overwhelmed and in emergency need of supplies for its staff and for the ill. “We’re running behind a train that is going forward,” said Joanne Liu, president of Doctors Without Borders, in mid August.

Nevertheless, the WHO continues to put the best face on the scale of the threat, insisting the worst-case scenario of 1.4 million infections by 2015 will occur only if the international community does not intervene.

A more candid and frightening report came from The New England Journal of Medicine, which presents the blunt warning that all the protocols now employed — isolation, health worker protection, handling of corpses, population education, international aid — must be improved “quickly or else there is the never before contemplated scenario that Ebola will become endemic in West Africa.”

Given the last two months of sloppy reporting by the WHO, bad governance in the affected countries and the sluggish response by the United States and the rest of the international community, there is no reason to believe that the necessary transparency, speed and scale of response is in place to avoid the worst-case scenario of collapse in West Africa.