Ebola Virus Disease Outbreak in Liberia

June 13, 2014, started as a usual hectic workday for me. After completing two cesarean sections in succession, and clinical rounds, I settled into my administrative duties involving meetings against the cacophony produced by the midday motorcycle traffic outside my office. I received a call from a junior colleague who worked in a public hospital in a mining concession run by the Chinese. Expecting his call to contain the usual exchange of pleasantries, I was startled when he described, in very stark terms, the situation at Redemption Hospital in the capital city, Monrovia. My colleague was particularly worried about his mentor, a general surgeon assigned at the Redemption Hospital to support the post-graduate residency training program in surgery.

Redemption Hospital, located in the sprawling slum of New Kru Town, is a public hospital with a 200-bed capacity.

“What happened at Redemption?” I asked? He said a staff nurse was ill and her care involved almost the entire hospital staff. In spite of the best available care from her co-workers, the condition of the staff nurse continued to deteriorate.

Make sure your essay is 100% unique

Our experts will write for you an essay on any topic, with any deadline and requirements from scratch

127 our experts are available
right now

Get custom essay

The surgeon, the most experienced of the team, explained to his team during clinical rounds one day, that from his experience working in Uganda, he suspected that they were dealing with something much more than they were treating their nurse colleague for. He dreaded to call by name what he suspected. However, soon that very day, news broke that the sick nurse had provided care for her sick relative who fled Lofa, then, the epicenter of the first wave of Ebola outbreak in Liberia.

The surgeon self-isolated few days later and called his mentee, the junior colleague with whom I had the conversation.

Two caregivers, from the same hospital at different points: the one fighting for her life being taken care of by her professional colleagues, and the other who was more knowledgeable about what they were suspecting, had now self-isolated.

Outbreak of Ebola Virus Disease in Liberia

In December 2013, the first cases of a febrile illness began to emerge in the forested region of Guinea, near the border with Liberia. These early cases were wrongly diagnosed as diseases that were common to the local settings. It was not until later that the World Health Organization (WHO) declared the outbreak of Ebola Virus Disease in Guinea.

Meanwhile on March 30, 2014, the first two cases occurred in Foya, Lofa County near the border with Guinea. By April 7, 2014, Liberia reported 21 cases and 10 deaths. The 10 deaths included three health workers in a trend that would be repeated throughout the Ebola Virus Disease outbreak.2 In Liberia, during the initial wave of the epidemic, health care workers were disproportionately affected with a high mortality rate among them and clinics and hospitals were shut down.3 Even before the EVD epidemic, Liberia only had 2.8 health care workers per 10,000 people – the global target is 23 per 10,000 (WHO 2007); and 51 physicians serving a population of 4.3 million people –even fewer than can be found in a single clinical unit at a typical US teaching hospital.4 Inadequate human resources for health was not the only problem the Liberian health care system faced. The fundamental problems that beset the health system are aptly summarized by physician- anthropologist Paul farmer, “ the region lack[ed] the staff, stuff ,space and system required to stop Ebola.”

In view of the stark lack of the require health care personnel, some caregiving responsibilities, by default, fell to family members.

Caregiving in the midst of contagion

Much has been written about the burden of disease and the burden of caregiving in the context of chronic diseases like cancer. In sub-Saharan Africa, the literature is replete with accounts of the burden of caregiving in settings of HIV/AIDS and Tuberculosis. However, there is a gap in the knowledge base concerning caregiving experiences in Liberia during the devastating Ebola Virus Disease outbreak. The Ebola Virus Disease outbreak occurred against a backdrop of a dysfunctional health care system and initial distrust and resentment from the general public to containment efforts6. People’s perception of care centers as places where the sick were only isolated and deprived of the necessary care created distrust and fear. Caregivers describe the need to care for sick relatives as a social obligation. Caregiving during the Ebola outbreak, could not be delayed, deferred, or delegated.

Instead, as Arthur Kleinman writes, “the caregiving was there to do, it had to be done.” To be able to effectively manage the next epidemic, it is important to learn the important lessons of caregiving, especially those that were not in tandem with the prevailing public health discourse. Thus, the results of the study will help to improve our understanding of caregiving during epidemics and how to leverage this knowledge in the improvement of the control of epidemic prone infectious diseases. The knowledge gained will better help harmonize public health messages with the moral and social obligations of providing care during future epidemics.

Closure of Health facilities

Closures of Health facilities and the Care Conundrum

In Liberia, health care workers lacked materials such as personal protective equipment and became infected themselves. This initial wave of shock and fear led to the closure of many hospitals. In succession as the major hospitals experienced cases among their health workers, they shut down, one after the other—Phebe Hospital in Bong County, Redemption Hospital in Montserrado County, C. H. Rennie Hospital in Margibi County and the St. Joseph’s Catholic Hospital in Montserrado County, to name a few. The wave of health facility closures presented a care conundrum that increased distrust of the health system. It is believed that most health workers were being infected in centers that lacked Infection Prevention and Control(IPC) standards and lacked IPC supplies and Personal Protective Equipment(PPE).

The health system was ill- prepared to handle the Ebola Virus Disease outbreak. The outbreak only exposed the cracks in the health system. The closure of major health facilities deepened the distrust of the population.

By December of 2014, about 363 health care workers were infected in Liberia.8 The realization that ill-prepared and ill-equipped frontline health workers were at risk, increased fear amongst the already inadequate number of health care workers. By the end of the outbreak, it is estimated that Liberia lost 8% of its health work force to the Ebola virus Disease.

The closure of health facilities due to infection of health care workers, had the unintended consequences of placing care responsibilities squarely in the hands of family and other caregivers, who like health workers, were ill- equipped and not trained to handle this task. Closure of health facilities, coupled with placement of care responsibilities in the hands of family caregivers by default, led to a false lull in the number of reported cases because people were caring for their sick and burying their dead in secrecy.10 Finding those exposed to Ebola, those infected and their contacts was virtually impossible. Ebola treatment units were considered places of no return, to the extent that even desperately ill patients avoided them.

To understand the care choices these patients were faced with, we must first understand exactly what was responsible for the fact that at the onset of the Ebola crisis, there was a lack of public health infrastructure and lack of adequate clinical care capacity. Several historical antecedents are responsible for the weak state of the Liberian health system, prior to the Ebola Virus Disease outbreak. From its foundation, Liberia has been an impoverished country, entangled in a web of debt that has prevented substantive investment in health care delivery and other critical infrastructure. Furthermore, Liberia has been governed, until the 1980 coup d’état, by an elite class of settlers referred to as Americo-Liberians who relegated investment in health care delivery to the bottom of their scale of preference. Their governance has been characterized by inequality and neglect of the welfare of the majority indigenous people, including their health care. Their lack of investment in the health care delivery sector would come to hunt the country in the form of a fragile health system unable to withstand the shock of an Ebola outbreak.

Human Resources for Health

The emergence of Ebola in West Africa did occur in three of the poorest countries in the world. In Liberia, like other sub Saharan countries, the epidemic occurred against a background of abject poverty.11Three primary factors affect the human resources for health situation in Sub-Saharan Africa: the first is the increasing burden of disease that is increasing the workloads on health workers, second is the migration of doctors and nurses from countries that need them the most, and third is the historical underinvestment in human resources for health imposed by multilateral donor institutions such as the World Bank and the International Monetary Fund( IMF). In Liberia, the fourth factor responsible for the inadequate numbers of human resources for health is a devastating civil conflict. According to the WHO at the beginning of the Ebola Virus Disease epidemic, Liberia had 51 doctors prior to the epidemic to serve a population of over four million people. With physician-to-population ratio of about 1 per 100,000 people. This is one of the least in the sub region. The sub-regional average is 16.5 per 100,000. The situation was not always this way. For example, in 1973 there were 132 physician in Liberia when the population was 1.7million.

References

1. Baize S, Pannetier D, Oestereich L, et al. Emergence of Zaire Ebola Virus Disease in Guinea. New England Journal of Medicine. 2014;371(15):1418-1425. doi:10.1056/NEJMoa1404505
2. WHO Steps up Its Role in Health Emergencies. Bulletin of the World Health Organization. 2015;93(12):824-825. Doi:10.2471/Blt.15.031215.
3. LRB · Paul Farmer · Who Lives and Who Dies: Who survives? London Review of Books. https://www.lrb.co.uk/v37/n03/paul-farmer/who-lives-and-who-dies. Accessed May 25, 2018.
4. Mitman G. Ebola in a Stew of Fear. New England Journal of Medicine. 2014;371(19):1763-1765. doi:10.1056/NEJMp1411244
5. Farmer P. Diary. London Review of Books. October 23, 2014:38-39.
6. Fauci AS. Ebola — Underscoring the Global Disparities in Health Care Resources. New England Journal of Medicine. 2014;371(12):1084-1086. doi:10.1056/NEJMp1409494
7. Matanock A, Arwady MA, Ayscue P, et al. Ebola virus disease cases among health care workers not working in Ebola treatment units–Liberia, June-August, 2014. MMWR: Morbidity & Mortality Weekly Report. 2014;63(46):1077-1081.
8. World Health Organization. Http://Apps.Who.Int/Ebola/Ebola-Situation-Reports. Accessed May 25, 2018.
9. Evans DK, Goldstein M, Popova A. Health-care worker mortality and the legacy of the Ebola epidemic. The Lancet Global Health. 2015;3(8):e439-e440. doi:10.1016/S2214-109X(15)00065-0
10. https://www.nytimes.com/2014/12/30/health/how-ebola-roared-back.html.
11. Fallah MP, Skrip LA, Gertler S, Yamin D, Galvani AP. Quantifying Poverty as a Driver of Ebola Transmission. Bockarie MJ, ed. PLOS Neglected Tropical Diseases. 2015;9(12):e0004260. doi:10.1371/journal.pntd.0004260
12. Chen L, Evans T, Anand S, et al. Human resources for health: overcoming the crisis. The Lancet. 2004;364(9449):1984-1990. doi:10.1016/S0140-6736(04)17482-5
13. Tankwanchi ABS, Özden Ç, Vermund SH. Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile. Kruk ME, ed. PLoS Medicine. 2013;10(9):e1001513. doi:10.1371/journal.pmed.1001513.