and crowded housing, open sewers, and no running water; very limited health care, communications, and transportation infrastructure; poor food availability and distribution; and cultural burial practices, lack of education, and fear.
Here is a survey of the situation on the ground in various countries as seen through the eyes of the WHO and workers from various humanitarian NGOs with operations in the region. The situation is changing rapidly, and this reflects circumstances as of late October 2014.
Liberia’s health care system was very limited in resources and personnel before the current Ebola epidemic. Malaria and measles are common. There is about one doctor per 100,000 people. Many Liberians live in a state of poverty with day-to-day food insecurity.
As of late October, over 4,600 cases of Ebola had been confirmed in Liberia. The numbers are almost certainly much higher due to fear, resistance to going to the hospital (which is widely perceived as a death sentence), and other cultural traditions (and superstitions) often misunderstood by Western NGO and health care workers.
In Liberia, improvised contact tracing teams were formed only after Ebola had spread widely. Poorly trained former students or shopkeepers often lead these teams. There could be tens of thousands of contacts scattered across slums like New Kru Town, a small peninsula with 20,000 to 50,000 residents. This is an area with mosquito infested open sewers, shared toilets, crowded and inadequate housing of sheet metal shantytowns, and limited access to potable water.
A recent article in the British Journal Lancet reviewed the situation in Montserrado, a densely populated county in Liberia that includes the capital of Monrovia. There is a rapidly closing window of opportunity to bring this disease under control according to senior author Alison Galvani, a Professor of epidemiology at the Yale School of Public Health.
By December 15, there could be over 170,000 Ebola cases in Montserrado. If in place by October 31, adequate numbers of hospital beds and health care workers could prevent nearly 98,000 of these cases; if this scale of aid was delayed to November 15th, only about 54,000 cases could be avoided. This is in the Montserrado region alone, and does not reflect cases nation wide.
Unfortunately, there is little likelihood that the estimated needs for hospital beds and doctors, nurses, and technicians will be met anytime soon.
There is a need for 4,800 hospital beds nationwide. The rapid detection of new cases and monitoring of those exposed needs to increase fivefold. There is great need for personal protective equipment safety kits for families treating those ill at home due to a lack of hospital beds.
In mid-October, the WHO estimated there were 620 Ebola hospital beds in Liberia, only about 20% of the nearly 3,000 beds planned. Much of this effort towards increasing hospital beds and isolation clinics comes from US aid (much of the engineering and building being done by the US military). There are plans for seventeen 100-bed facilities in Montserrado, the region of Liberia that includes the capital, Monrovia. It is unclear at this point just how soon these facilities will be completed.
While some scientists questioned the accuracy and validity of projecting such numbers in a rapidly spreading epidemic, most agree that the number of cases is almost certainly underreported. This research published in The Lancet suggests that the western and international response has been inadequate to limit the spread of the illness before it becomes much larger in scope and increasingly difficult to contain.
The World Health Organization (WHO) by late October confirmed 5,230 cases of Ebola in the country, with about 1,500 deaths. In the capital, Freetown, the cases have risen from one or two a day to about 30 cases a day, expected to at least double by early December.
The British have plans for building 100 bed hospitals in about two months. In comparison, at Connaught Hospital, British Doctor Oliver Johnson and others converted a wing of the hospital to a 16-bed isolation unit in 5 hours. During a 3-day national lockdown last month, Mayor Henry Bangoura of Freetown led a team that developed a 100-bed clinic from an old police training camp.
The WHO feels that Sierra Leone needs about 4,800 hospital beds by November. Even with the British plans for 700 beds, there is a tremendous shortfall in hospital beds now and into the near future. The two to three months planned for these 100 bed hospitals is not rapid enough to prevent thousands of fatalities from this deadly disease.
Dr. Johnson, quoted in the Washington Post, said:“I would rather have 40 NHS [National Health Service] volunteers on the frontline fighting this outbreak today than 400 in January when it may be too late.” He and others feel that what is needed is a massive effort immediately, with a strategy towards quickly developing dozens of smaller isolation clinics of a dozen to 20 beds.
While many decisions are made in offices of various nations outside the region, some see health care workers and officials for some NGOs as patronizing. Many volunteers come in for a month-long tour and then are gone.
There are hopes of obtaining help from experts in Uganda and other African countries that have experience from previous outbreaks of the disease. These regional experts would perhaps have a greater sensitivity to the cultural beliefs and traditions than Western NGO or volunteer workers. This could improve educational efforts and methods of monitoring and isolation that would be more acceptable to the local population.
The Ebola crisis has made other aspects health care more severe. Malaria is on the rise, and many going untreated as resources are going towards Ebola related treatment. Subsidies for contraceptives have been greatly reduced, and some fear a rise in illegitimate teen pregnancies. Women are having babies away from hospitals. Acute malnutrition rates of children under five are expected to double. Some expect increased deaths from these causes will greatly increase as limited resources are shifted towards Ebola.
Western non-governmental agencies, such as Médecins Sans Frontières (MSF), the World Food Program (WFP), and Oxfam, have had a long presence in much of region affected by the Ebola virus.
The World Food Program (WFP) has been involved in feeding over 350,000 people in Guinea, a country that had a high level of poverty and food insecurity long before the Ebola epidemic began there in December 2013. This has led to a need of greatly expanding their programs beyond providing basic food supplies.
The WFP is being called upon to help construct health care facilities and assist with transportation and communications in areas with poor infrastructure. WFP engineers were in the process of building four 100-bed clinics, along with help from the WHO and MSF. These activities are well beyond their mission of food programs and distribution to fight child malnutrition. Some areas of Guinea had a chronic rate of 40% with child malnutrition before the Ebola outbreak.
What is greatly feared is the outbreak seems to be spreading into regions of the country not previously affected. Reported cases tend to come in waves, and officials report they are now in their third wave of increasing cases that seems to be rapidly expanding.
WFP’s Guinea director, Elizabeth Faure says the WFP is being forced to expand well beyond its core mission of feeding some 350,000 people. Only about $51 million has been received of $120 million needed. This has led to closing of many of its outreach centers, leading to a severe setback in any progress made in fighting child malnutrition in recent years.
While Guinea had an initial response that was more effective than in Liberia and Sierra Leone, this third wave of Ebola cases suggests limiting the spread of Ebola in the country is far from over. As in the countries of Liberia and Sierra Leone, the long-term impact on the overall health, welfare, and economy of this country are going to be severe, and likely to get much worse before things improve.
Other West African Countries with Ebola
In Nigeria, where there were 20 confirmed or probable cases of Ebola in July, tracers created a list of 894 contacts of the patients, and isolated and monitored them. Health workers conducted 18,500 face-to-face visits. This was possible largely due to about 50 workers from the WHO providing assistance. In late October the country was declared Ebola-free.
Senegal had isolated cases of Ebola in the summer, but is now considered to be free of the disease.
The spread of the virus into Mali with the death of a two-year-old girl in late October is of serious concern. Due to the 21-day incubation period before symptoms of the illness are present, it is too early to tell if this will develop into a major spread of the illness in Mali or be quickly limited as it was in Nigeria and Senegal.