Author: PLOS Medicine

Mark J. Siedner of Harvard Medical School and John D. Kraemer of the O’Neill Institute for National and Global Health Law, Georgetown University, discuss the impact of the delayed global response to the Ebola epidemic.

On August 8, twenty weeks after the first suspected cases in what has become the worst hemorrhagic fever outbreak in history, the World Health Organization’s (WHO) Director-General declared the epidemic a public health emergency of international concern (PHEIC). The announcement, which signals that an epidemic constitutes a sufficient public health risk to member WHO States through the spread of disease, will ideally motivate financial and logistic support to the countries most affected. But after nearly 1,000 deaths, and for a disease where a relatively simple and coordinated public health response has extinguished prior epidemics, many are left wondering, “what took so long?”

An integral part of the WHO mission, mandated by the International Health Regulations (IHR), is to protect member states from international public health threats. The IHR were revised in 2005 after the SARS outbreak to improve responses to epidemics in an increasingly globalized world. Among the IHR’s central components is commitment from high-income countries to build capacity to prevent public health emergencies, and to provide assistance during active ones. The IHR task WHO with promptly identifying emergencies by declaring PHEICs to sound the proverbial alarm.

Timeline demonstrating course of Ebola epidemic including cumulative suspected cases, deaths, and notable events during the period (Source: CDC).

By most accounts, the criteria to declare a PHEIC were met months ago (Figure 1). The outbreak quickly made public health impact with its rapid pace and case fatality rates above 50% and by disproportionately affecting healthcare workers. It became an international epidemic five days after the first cases were reported when it spread from Guinea to Liberia. The epidemic is also unusual because it represents the first hemorrhagic fever epidemic in urban areas, where poverty and population density exacerbate disease spread. Only nine days after Guinea notified the WHO of the outbreak, Senegal closed its land borders with Guinea. By the end of May – 10 weeks before the PHEIC declaration – the epidemic raged on in Guinea, gained speed in Sierra Leone, and reemerged in Liberia.
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Liberian medical student Gondah Lekpeh gives us his perspective from the front lines of the Ebola outbreak.

On July 22 of this year, the Liberian Minister of Health informed us and the world that the Ebola hemorrhagic fever outbreak in our country is out of control. This disease is caused by the deadly Ebola virus, and the fate of infected individuals is death in 90% of cases.

The announcement followed more than a month of efforts by the Ministry of Health to contain and eradicate the virus. The Ministry is doing what it can, but with the weak health care system because of the lack of human and other resources, the Ebola outbreak has caused the system to break down. The disease continues to directly and indirectly take away lives. Indeed, our relatives, colleagues and friends are perishing daily and our survival as a people is unpredictable. Either through natural selection some will survive, or we will all be extinct. As I was writing this, a childhood schoolmate of mine, a nurse, just died this morning after contracting the disease at St. Catholic Hospital while treating a patient about two weeks ago.

Here in Liberia, the virus is spreading like wildfire, devouring the life of everyone along its path. Limited health resources, ignorance, stigmatization, denial, and cultural burial rites are fueling the spread of the disease. Ebola cases are reported in ten of the fifteen counties in our country. I do not have the space and time to elaborate on how ignorance, denial, stigmatization as well as cultural practices are spreading the virus. But regarding limited health resources, here is the tip of the iceberg. As part of control measures, everyone was advised to call the Ebola response unit for safe transfer of suspected cases and disposal of corpses from communities in and around Monrovia. There are two ambulances to transfer suspect cases to isolation center and two burial teams for Monrovia. These teams are overwhelmed and it takes about two to three days to respond to calls from communities. The relatives of suspected cases end up transporting the patient in a commercial vehicle, thereby contaminating themselves. The remains of suspected cases who died at homes spend days before the burial team can arrive. Moreover, there is only one treatment center in Monrovia. The isolation center is full to capacity and suspected cases are reportedly turned away. When will the spread and death of Ebola stop in the wake of limited resources? I do not know. But I know for sure that contact tracing is not possible and we are overstretched and exhausted.

Besides Ebola directly killing here, others are dying of treatable conditions due to closure of health facilities. Most health facilities in and around Monrovia have been closed for the past three weeks. This followed the failure of most health workers to show up on duty after the death of their colleagues. They fled due lack of equipment as simple as gloves to protect themselves. At the beginning of this week, some of these health facilities reopened. But activities currently at these hospitals are limited to training of staff on precaution measures. I do not know the fates of those with treatable conditions other than Ebola. Where the obstetric emergency cases are being managed? Where are the hundreds of children who usually present weekly at John F. Kennedy Medical Center under-five ER with diarrhea and severe dehydration and severe malaria complicated by anemia, hypoglycemia and seizure, seeking care? I do not know. But I know there are numerous corpses in homes in and around Monrovia which have overwhelmed the burial teams.

The Ebola virus is like a merciless rebel determined to annihilate his weak and feeble enemies (Liberians). Help! Help! We are drowning in the sea of Ebola.

About the author: Gondah Lekpeh is a fourth year medical student at A.M. Dogliotti College of Medicine in Monrovia, Liberia.

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