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Story Publication logo January 31, 2015

An Empty Medical Outpost Could Be the Future of Liberia's Ebola Fight


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To assist Liberia in containing Ebola, the US turned to its soldiers from Iraq and Afghanistan from...

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South African aid worker John Nel at an Ebola clinic in Liberia. Image by Cheryl Hatch. Liberia, 2014.

GRAND CAPE MOUNT, Liberia — In December 2014, an imam in the Liberian county of Grand Cape Mount decided that he could cure Ebola through prayer and the laying-on of hands. He traveled from village to village throughout the jungle along the Sierra Leone border, preaching and healing through ritualistic methods. Grand Cape Mount is home to much of Liberia's Muslim population, and the Islamic traditional healer found a receptive audience. In the rest of the country, public education campaigns have effectively put an end to rumors and practices such as this, but, with few radio stations or billboards, outreach in Grand Cape Mount relied on word of mouth, and the county was still a bastion of ignorance. By the end of the month, the imam and several of his family were dead, his village and three others were quarantined, and 49 new Ebola cases had been reported, the biggest flare-up in Liberia in months. At least five of the infected later died

The responsibility for saving as many of those people as possible falls to aid workers like John Nel, a South African project manager for the International Organization for Migration, the United Nations-charted intergovernmental agency that operates the Ebola treatment center for Grand Cape Mount. Nel arrived in Liberia in November, well before the local outbreak, and watched the U.S. military, in collaboration with the Armed Forces of Liberia, build his sprawling 100-bed isolation unit in the rolling hills of the rural countryside, a land of red clay, scrub jungle, and plantations growing neat rows of squat palm-oil trees.

But after the U.S. Army turned the facility over to him, Nel spent the next month making modifications and repairs. Rotting wooden tent floors had to be ripped out and replaced with concrete. The well was never established, forcing regular water deliveries from Monrovia. The tubing that carried chlorine solution throughout the camp was flimsy, not laid out according to blueprint, and split under pressure from the oversized gravel dumped on top. The shelter for a small lab for testing blood samples was constructed near the entrance to the treatment center, but the Dutch team to staff it had not yet arrived.

The facility was still not ready by Christmas, and throughout the outbreak caused by the imam, Nel watched Ebola case after Ebola case transported south, to isolation units in Tubmanburg and Monrovia. Finally, Nel's Ebola unit opened at the end of the year, and it was immediately flooded with patients. Dozens of suspected cases arrived at his door, though most with diseases other than Ebola. For a time Nel ran the busiest Ebola center in Liberia, but by mid-January, he was already down to only six confirmed cases: six patients housed in four cavernous wards, and a staff-to-patient ratio of approximately 30-1.

The story of Grand Cape Mount is the story in miniature of the Ebola crisis in Liberia. Traditional rites spread the disease, treatment centers were not available when and where they were needed, and once the infrastructure was finally ready to go, it was too much, too late.

And yet, as the Ebola crisis winds down, isolation units like the one in Grand Cape Mount will test the theory of the future containment plan for the virus in Liberia.

On Jan. 24, the World Health Organization announced that there are only five confirmed cases of Ebola remaining in all of Liberia. U.S.-built treatment centers are sitting mostly empty around the country, prompting criticism that the large international response was too slow to be of any real use in the fight. The facilities could still be of value, though, because they increase the Liberian government's capacity to deal with future cases on its own, and provide an opportunity to snuff out the disease locally before it has time to spread.

Since the first recorded case of Ebola in 1976 in what was then Zaire (now Congo), outbreaks in other parts of Africa had always been contained in the rural areas where they began. Monrovia was the first national capital and major city to experience widespread Ebola; the disease was imported from Lofa county on the northern border with Sierra Leone. Since the fruit bats of the West African jungles will always harbor the virus, the potential for the disease will remain in Liberia. Treatment centers like the one in Grand Cape Mount may soon be empty, but if they allow future flare-ups to be handled in the countryside, then they may wind up saving lives all the same.

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John Nel is not a medical doctor. "I'm actually an attorney," he said, laughing on a hot day in mid-January. "But the law is all about yelling at each other about money, and I prefer this."

After passing the bar, Nel quickly moved into project management, and in recent years worked for a private company that filled specialty assignments in conflict areas around the world. He last served as a subcontractor for the United Nations in Afghanistan, training the border police and local law enforcement. Nel is an organizer and a planner; it seemed to matter little to him whether he was coordinating the transportation of crime evidence in Afghanistan or Ebola-infected blood samples in Liberia. He's open about the financial rewards of working in a developing country, but insisted his prime motivation was to help his fellow Africans in a time of crisis. His foreign colleagues agreed; most are from Uganda and Kenya, and have worked on previous Ebola outbreaks.

Nel is in his mid-50s and of average build, with thick glasses, a salt-and-ginger beard, and short, thinning hair on top. He wears a royal-blue baseball cap branded with the USAID logo to protect his scalp from the sun. That logo is everywhere: on shiny new Toyota Land Cruisers, on every bit of white tarp that skins the walls of his facility. Locals scavenge scraps of that tarp to sew into bags to store charcoal, so the USAID logo is in nearly every Liberian home as well.

During a visit to treatment facility one recent morning, Nel was generous with his time but rushed. A general with Liberia's U.N. peacekeeping force, nationality unmentioned, was scheduled to arrive in a helicopter before lunch. In the yard outside the fence of the Ebola ward, armed Nepalese soldiers in baby-blue hats sat wedged in battered white U.N. pickup trucks, ready to pull security for the VIP visitor. This is the face of the Liberian Ebola response: international, intergovernmental, non-governmental, contracted, subcontracted.

Nel's Ebola treatment center is in Sinje, a cluster of cement homes and palm-frond shelters along the main paved road in Grand Cape Mount. Sinje is not the largest town in Grand Cape Mount, not by far, but it is located near the geographic center of the large county. As repairs to tent floors and water pipes continuously delayed the opening of the Ebola center, Nel had time to refine the protocols and flow of his facility, establishing four Ebola wards: suspected, probable, and then two separate tents for confirmed cases, dry and wet. They installed elaborate spray-down facilities and a closed-circuit television, so doctors in a safe room (outside of the contaminated area where they would be forced to wear full protective suits) could use video cameras to zoom in to examine patients. Nel thought he was ready for anything. He wasn't.

Just hours after the Sinje center opened on Dec. 29, it received its first patient, an 18-month-old girl. An ambulance dropped her off and promptly left, and for a moment Nel and his staff were completely unsure what to do. The girl was terrified, and following standard protocols — wearing the full Tyvek suit and rubber gloves and goggles and face shield — would only make matters worse. How would they comfort her? How would they entertain her, keep her within the containment area, all alone? Nel had made lots of plans, but none involved caring for a solitary toddler.

"We didn't know what to do," he told me, "but then one of our local Liberian nurse aids — she's an Ebola survivor — she said, 'I'll take care of her.' And she took off her suit, and just had her light scrubs on, and she picked up the girl and hugged her and played with her and cared for her all by herself, right there in the confirmed ward.

In time they would learn her name (Nel asked we not use it for privacy's sake), and shortly thereafter they found her young mother, Isatu, in the Island Clinic, an Ebola treatment center just north of Monrovia. Isatu was transported to Sinje so the two could be together.

"We have enough resources," Nel said, when I asked him about the challenges he faces. "Our biggest issue is duplication of effort." Education campaigns are ongoing, still teaching, "Ebola Is Real," but while the villages closest to the main road are visited several times, the more inaccessible communities on the rough dirt tracks are never reached. The struggle is to convince locals to drop off their sick early. If Nel's health care workers can see patients within two or three days of contracting the disease, there is a much better chance they will survive. The public education campaign may be working; Nel receives all sorts of patients now, including a man in a coma who has meningitis.

Like a castle on a hill overlooking a medieval cluster of hovels, the Ebola treatment center dominates the hamlet of Sinje. Ebola is big business here. There are as many vehicles at the Ebola treatment unit as in the rest of the village combined. Nel's clinic employs 180, including 158 Liberians making $800 a month — an eye-poppingly large sum of money in a country with a per capita GDP of $400. An influx of foreign cash has created entrepreneurs in Sinje. Gasoline and bananas and day-old bread are available every morning. The modest guesthouse I slept in was only constructed in November, to meet the demand of the visitors the treatment center would generate. To see Ebola's opposite potential effect, one need only travel 45 minutes down the road, to the town of Bo on the Sierra Leone border. That international crossing has been closed for seven months, and the residents there only tell stories of financial ruin, as their trade-based economy has been virtually eliminated.

Meanwhile, Nel is in negotiations to begin accepting patients from Sierra Leone. There are 54 border crossings nearby, and only five of them are official. Families live on both sides of the Mano River, know where the fords are, and cross daily for food and work. Protecting the capital, Monrovia, first involved setting up Ebola wards in the far-flung counties of Liberia. In the future it could mean reaching out past the borders, to stop an influx of patients before they start. Ebola came to Liberia from Guinea, and as President Ellen Johnson Sirleaf said in December, "Full eradication will not be secured until the whole region is free from Ebola.

I checked my watch at the end of my time together with Nel. His appointment with the U.N. general had come and gone. Nel had been stood up for a second time. He didn't seem particularly bothered, though. He was happy because later that afternoon they would release Isatu; her daughter would soon follow. Nel's first patients are also his first survivors. The staff at the Sinje center celebrated and began an impromptu parade as Isatu left the hot zone, received her official survivor certificate, and marked her palm print on a wall with paint.


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