When Epidemics Mask other Epidemics
Don't do this at home
When people find out that I just returned from Liberia, they no longer communicate the fear of posture and look that they used to. Last November, dear friends would laugh nervously and say things like, "You didn’t really just get back from Liberia did you?" Despite reassurances that I was the International Rescue Committee's (IRC) Ebola advisor not Ebola provider, my own Taiwanese father suggested that Thanksgiving was not a big enough occasion to justify the flight home.
There are two current and competing perspectives regarding the Ebola epidemic in the U.S. and in Liberia. Here, the conceit is that the epidemic is over since the topic is off the popular news channels. Indeed, Liberia is now 16 days without an infection with 42 days defined as a country being Ebola free. The U.S. Navy and Army troops of medical personnel and testing equipment headed stateside a month ago. NIH research projects are in peer-review. A week ago at JFK airport, the surveillance system was strong enough to know that I had traveled to West Africa despite me stopping over in London and Scotland for three days-- Impressive. But later it was hard to locate the CDC representative to do the mandatory health screening and when she was found, the official spent more time asking me whether it was worthwhile for her to go to Liberia, than understanding the work I do and how it relates to Ebola infection risk. "I've always wanted to travel there," she said, "I heard it's beautiful."
African Union Doctors from Ethiopia and Nigeria filling some of the human resource gaps at Redemption Hospital
Meanwhile in Liberia and Sierra Leone, the health systems and the international partners who support them still operate as if in the middle of an Ebola epidemic. Ebola Treatment Units (ETU) still stand distributed like well-organized villages across the country populated by massive numbers of heath care workers and support staff. The two public general hospitals that have opened use the same Ebola screening tools developed when there were 1,000 cases a week. This means, women who have fever during delivery of a child will deliver on the street. This means a man bleeding from a car collison will be deposited outside the emergency room but not be allowed to come in. In the hospital, providers are taught to interpret the ministry mantra of 'safe and serve' as prohibitions on use of diagnostic equipment like stethoscopes, justification for doing cursory physical exams and rationale for not entering care notes in the medical record at the patient's bedside.
The disconnect on what needs to be done to transition West Africa out of emergency response to everyday response plays out in inefficiency and lives. Liberia has 500 vacant ETU beds with the ability to scale within a week to 1200 ETU beds but only 50 now-filled public hospital beds in the whole country. The two open public hospitals in Monrovia, where half of the country’s citizens live, don't have enough doctors and nurses because staff are still working for the NGO's in the empty ETU's. Ebola tests take almost 24 hours to run because of a decrease in testing capacity which is 'expensive' though an increase in ability to test is needed to reassure health care facilities that it is okay to see sick looking patients with malaria, pneumonia, diarrhea. The hospitals have abundant personal protective equipment (PPE), which incidentally mean $100 every time you put on a suit, but are short on antibiotics, IV fluid pumps, pulse oximeters and oxygen. Incidentally in 2010, the per capita health expenditure in Liberia was $16 a year.
There are about 4,100 dead in Liberia from this Ebola epidemic. This is an astounding scary number and more from all other world Ebola epidemics over the virus' 40 year history on this early. But over the past 9 months, assuming a hospital can save half of the patients that come, which even in Liberia is a gross underestimation, there were about 9,000 mothers who died with their babies during childbirth and 18,0000 children less than 5 years of age, who were lost due to acute infectious disease. This does not even consider the pathologies afflicting men. This also does not consider the consequence of shattered outpatient childhood immunization programs. In only three weeks, I watched in Liberia one baby die from pertussis and another of tetanus. The pertussis I had never seen before. There was a local outbreak of measles in the community with no ability to isolate the cases.
Whooping cough. This patient will die.
The IRC and MSF are currently among the few NGO's assisting the Liberian Ministry reopen its public medical care facilities. We need help. We need national medical staff to return and therefore for our NGO sister organizations funded to run ETU's to nevertheless release them. We need international health experts to propose then oversee infection screening and control practices that balance risk with the need to actually touch patients. We need the NIH and CDC to create and maintain local health facility Ebola testing capacity for patients who show symptoms consistent with Ebola but who likely do not have Ebola, but to prove exactly this point. All hands are needed on deck as Liberia had many problems before the Ebola crisis, which will only be solved with an adjusted dare I say brave approach.
The Liberia worth saving. With Famatta, daughter and Augustine.
