Ebola outbreak spotlights the limits of local and international response

The Ebola epidemic in West Africa is unprecedented. The deadly virus, which passes through contact with bodily fluids and causes severe fever, nausea and hemorrhaging, has not previously been reported in the region, and the current outbreak is the largest on record. Amid fears that infections are widening, the disease has been reported in Guinea, Liberia, Sierra Leone and Nigeria. Since the virus was first reported, in Guinea in March, 672 people have died out of the 1,201 Ebola cases identified, according to the World Health Organization.

There is no sign that the spread is slowing. Last week the virus was reported in Nigeria for the first time. Authorities said a symptomatic man was quarantined immediately upon arrival in Lagos after flying from Monrovia (he has since died). Between July 21 and 23 more than 100 new Ebola cases were reported in Guinea, Liberia and Sierra Leone.

Even front-line responders are falling ill. On July 25, a Liberian doctor infected with Ebola died. The chief doctor combating the disease in Sierra Leone died this week, and two Americans working with the aid organization Samaritan’s Purse in Liberia — one a doctor — have become infected. Of the first 70 Ebola-related deaths reported in Guinea, four were of health workers. While consistent with previous epidemics, illness and deaths among the few health workers available to treat patients is deeply concerning.

The epidemic has highlighted a lack of resources, preparation and infrastructure at both the regional and international levels. In the countries affected by the current epidemic, limited resources are constraining the response to the crisis. All three countries severely hit in the latest outbreak have poor health care infrastructure. In two surveys conducted by Afrobarometer in 2012 and 2013, a large portion of citizens in Guinea (77 percent), Liberia (52 percent) and Sierra Leone (48 percent) said accessing a public health clinic or hospital was difficult. Moreover, those numbers capture only the challenge of reaching a clinic — not the condition of the clinic and whether it is adequately staffed. These countries already struggle with serious health worker shortages. For example, Liberia has just 0.014 doctors per 1,000 people.

Consequently, in responding to the latest Ebola outbreak these countries had to rely on assistance from international agencies including technical expertise, equipment, supplies and medical personnel. But even international agencies are stretched; the medical organization Doctors Without Borders (Médecins Sans Frontières, or MSF) has called on the international community to provide more resources, repeatedly warning that it has reached the limit of its capacity to provide care.

The world, in short, is being told that it is not up to the task of responding to this epidemic. Closer study should provide valuable lessons for resolving the crisis and preventing future outbreaks.

People who are navigating the epidemic are — unsurprisingly — frightened, mistrustful and upset. Ebola is deadly and has no vaccine or cure. The context of weak public health care provision means people have limited experience with formal health care. In some areas the infusion of health workers from abroad (or domestic health workers from other parts of the country) has fueled rumors that the plague came with the medical personnel treating the infected. People are fearful and suspicious of medical staff working in clinics where they have watched many ill people enter and few leave. It doesn’t help that health workers must don head-to-toe protective suits. 

There are a number of other challenges complicating government response in the short run. First, the epidemic is spread out across multiple regions in the three countries severely affected and has required coordination across a myriad of domestic and international agencies. Second, without a clearly defined leader in global health governance, it is difficult for international health agencies to motivate domestic government responses. Third, because of the cross-border nature of the current epidemic, eradicating Ebola will be successful only if all the three countries — and international partners — respond effectively.

Border closures and the shutting down of hospitals underscore the governments’ inability to respond to the epidemic. Were the state better equipped to deal with the outbreak, anyone coming into contact with a presumed or confirmed case could be identified and isolated. The severe health worker shortage impedes capacity to do so.

Given the shortage of health workers, it is imperative that governments protect the few responders they have on the front lines. Failure to provide health workers with protective gear and adequate pay undermines the ability to curb the spread of the virus. The infection of health care providers reduces the number of personnel available to treat patients, but there are also follow-on impacts: Health workers will be wary of going to work, for example. For example, lab technicians went on strike in mid-July after the government failed to follow through on promised hazard pay for those working at Sierra Leone’s only Ebola-testing facility.

Governments cannot effectively ramp up their capacity to provide care overnight — particularly not during the throes of the worst Ebola epidemic. But they can improve their response by providing for those who are on the front lines and by shunning dramatic but empty gestures such as criminalization of health care avoidance or border closures.