A months-long battle to bring West Africa’s Ebola outbreak under control has stretched medical teams to the limit, while mistrust in some communities has impaired prevention work and raised questions about the delivery of health warnings.
The outbreak, which was first declared in March in southeast Guinea, should have been winding down now, with cases reducing as controls take effect, said Armand Sprecher, a public health specialist with Médecins Sans Frontières (MSF) in Guinea.
Sprecher, who has worked on haemorrhagic fever outbreaks like Ebola and Marburg in places such as the Democratic Republic of Congo’s Western Kasai area, explains that outbreaks normally run their course and eventually die down because they are contained within a limited geographic area.
That looked to be the case in May with optimistic signs that the outbreak had already peaked, or was even over. But those hopes have since faded, with new cases being identified in Guinea, Liberia and Sierra Leone. At least 340 people have died of the disease so far in the three countries, according to the World Health Organization (WHO).
Ebola still a stranger
In Guinea, the worst-hit among the three West African countries, traditional burial rituals are still being observed despite the health hazards and many people are reluctant to be traced for medical surveillance (as a precaution for having come into contact with those infected).
Still, there are those who believe that the disease is due to Satan’s wrath or sorcery. Others think it is because of korté, or an evil spell cast by a witch, according to Mamadou Rafi Diallo, director of Guinea’s National Health Promotion Service.
According to Sprecher of MSF, people familiar with malaria or diarrhoeal disease understand the benefits of standard medical treatment at a local health centre, but their faith in medical methods “does not require abandoning a traditional health belief model”. Sprecher explains further: “I am pretty sure that people can hold both the belief that some illnesses – especially unfamiliar ones – are linked to sorcery, while others are amenable to medical therapy.”
It is a view backed by Barry Hewlett, an anthropologist at Washington State University, Vancouver, who has studied the influence of historical and cultural factors on a community’s response to Ebola. He suggests people seeing Ebola for the first time may accept medical and scientific explanations for its origins and impact, but will still be convinced that sorcery is at play. He stresses that all health education messages must be presented in a culturally sensitive way; if doctors and nurses discount local traditions and beliefs, they risk losing the trust and acceptance of those they are trying to help.
Changing the messenger?
Sprecher acknowledged that foreign experts may not be the best people to relay key messages, noting that “strange white people coming from far away are not always the people that are most trusted by rural populations in this area.”
Local communities may harbour a general distrust of foreigners, deriving from long histories of colonial exploitation, notes Hewlett. “People often believe that whites bring Ebola to do experiments, to kill Africans,” he said.
But local medical personnel say they too have problems convincing patients and those looking after them how they should act and what they should avoid doing.
For example, despite warnings by health workers and local authorities not to touch the body or bodily fluids of anyone, alive or dead, who is suspected of having Ebola, doctors say many families continue to care for their loved ones without proper protection.
Sakoba Keita, head of the Disease Prevention Unit at Guinea’s Health Ministry, said: “Health workers in the country… have experienced many difficulties on the ground because of hostility from citizens,” he told IRIN.
“The belief among some communities that Ebola does not exist also complicates the task, as does the refusal of people who have been in contact with a sick person to declare themselves.”
Hewlett points to the obvious dangers of ostracism and isolation faced by those suspected of having the virus. “You cannot travel; others may stigmatize you so that you cannot collect water or go to the market; people may stay away from your area.”
The outbreak that returned
These problems have come sharply into focus in Liberia, where new cases of Ebola have been reported in Lofa County in the north, which borders Sierra Leone, and in Monrovia.
A new case of Ebola was confirmed by health authorities on 30 May in Foya in Lofa County. The Monrovia cases came to light in New Kru Town district, a heavily congested part of the city on Bushrod Island.
Tolbert Nyenswah, the assistant minister for preventative services at Liberia’s Ministry of Health, has termed the fresh outbreak a “national crisis”.
“Our major concern now is how to curb the Ebola attack in the capital city,” Nyenswah emphasized, noting that high population density in areas like New Kru Town posed particular problems,
Nyenswah said the new cases were probably caused by an infected woman who travelled from Sierra Leone through Lofa County and into Monrovia earlier this month. While this has once again sparked some concerns about further cross-border spread, WHO maintains that no travel or trade restrictions should be put in place on any of the affected countries.
Health workers’ fears
The death of a hospital nurse, who had reportedly been treating an Ebola patient at Liberia’s Redemption Hospital on Bushrod Island, which serves the New Kru Town community, has raised strong concerns among health workers, many of whom say they are now afraid to report for work.
“What scares me is that the disease has no cure,” said Aaron Manner, a nurse in Monrovia. “More patients are coming into the hospital and we don’t know who is who. I am really, really scared. I am even deciding to quit my job for a while until the situation is put under control.”
Liberia’s Ministry of Health says that in light of the new cases, it has reactivated its national task force and recruited more volunteers to help with surveillance and sensitization campaigns. Liberia has also reopened its Ebola isolation unit.
In Sierra Leone, where 34 people have died of Ebola, fear has driven some residents from their villages. “Two of my friends from my neighbourhood died from Ebola and several others have contracted the disease,” said Cecelia Morris, who fled to the capital Freetown from her home district of Kailahun in the east of the country.
“But Freetown itself is not really safe. I just need to be careful about what I do.”
Medical teams overstretched
Sprecher said there was a pressing need for more outbreak control units to deal with the spread, particularly given people’s reluctance to travel long distances for treatment. But an expansion of control units requires financial and human resources – now stretched thin as the outbreak carries on well beyond its anticipated duration.
Many of the doctors and nurses sent to the field can only stay for up to a month at a time, before being rotated out.
“This is exhausting work,” Sprecher points out. “These people work very long hours. It’s extremely stressful, lots of patients don’t survive. The protective gear we wear is very hot. You cannot keep people in the field under those conditions for extended periods and expect them still to be healthy and working safely…
“If MSF had an unending supply of human resources, we would have more people working on health communication, social mobilization, infection control measures and contact tracing,” said Sprecher, “but we don’t, so more local resources would be very useful.”