Voice

The Monster in the Sea

The Monster in the Sea

MONROVIA, Liberia — On the two-hour drive on the paved road from Monrovia, followed by nearly an hour of traversing the back-breaking bumps on mud-and-dirt roads, Frank Mahoney blasted Nigerian Afropop and American jazz from his laptop speakers. Between the cuts of music that Mahoney, a U.S. Centers for Disease Control and Prevention (CDC) epidemiologist, had amassed during his years tracking epidemics across Africa, he barked at and begged the callers on the other end of his cell phone, pushing them to find money, stop dangerous behaviors that could spread Ebola, and fix errors in papers due to be published soon. Also in the car was his CDC colleague, Terry Lo, and together we were headed northwest to a town called Jene-Wonde (“Jehn-ah Wahn-deh”), located close to Liberia’s border with Sierra Leone.

This trip had been prompted by Mahoney, who wanted to show Lo the dangerous Ebola outbreak unfolding in Jene-Wonde and check in on his crew of scientists and public health experts stationed there, working alongside local Liberians. Lo was intrigued because he had been embedding inside the Ministry of Health’s headquarters in Monrovia, working with a team of epidemiologists that’s trying to keep tabs on the epidemic. He was mapping Ebola cases against available treatment beds, showing that until the beginning of October, the numbers of patients all over the country well exceeded treatment space. But since mid-October, construction and staffing of hospital beds and new Ebola treatment unit (ETU) beds have been well ahead of patient needs in almost every part of the country.

Except in Grand Cape Mount County, home of Jene-Wonde, where the dangers of thinking Liberia’s epidemic is under control are obvious. Since late-October, Jene-Wonde and neighboring towns in the county have been fighting a desperate war with Ebola, which has reportedly swept through communities like a wildfire burning down a parched California hillside. On this November day as we drive west from Monrovia, Mahoney says the latest tally puts Jene-Wonde’s death toll at 17 — a big number for a small village, he insists.

About 90 minutes outside the capital city of Monrovia, the two-lane highway enters Bomi County and the landscape gets greener, denser, and more tropical. We pass large pineapple and palm oil plantations and cross the Nfar River. Mahoney turns off his laptop playing Ghana’s guitar hero Ebo Taylor when he spies a roadside shop, and he tells the driver to pull over so he can buy candy for the Jene-Wonde children. Once we enter Grand Cape Mount County, roadside signs declaring, “Ebola is Real!” become commonplace.

border

The border with Sierra Leone seems a vague entity, demarcated in the rainy season by a stream and now by a muddy, verdant gully over which spans a bridge. The small town at the bridge, Bo Waterside, has a border guard station, but the actual bridge has little more than a bar across it that impedes vehicles — a bar that over the summer denoted that both countries officially sealed their borders to keep Ebola out. On the Sierra Leonean side, a week earlier government officials told me that 90 percent of the long border is unguarded and encounters with guards are typically forgotten for a wink and $25. Although there is no evidence today in Bo Waterside of cross-border movement, it seems obvious that anybody determined to get in or out of Liberia would be able to do so, especially after dark.

Heading north along the border on a dreadful dirt road, we pass an empty Baptist seminary and eventually reached Jene-Wonde, where the population of some 700 souls is led by a middle-aged female chief named Chebe Sano. In the sweltering heat, Sano is supervising construction of an Ebola Community Care Center (CCC), which will be composed of three rooms, 12 beds, and a small walled yard, and will have its own well water. The CCC, which is nearly finished, is next to a clinic building that was erected four years ago. Together, the structures offer hope of bringing the town’s Ebola catastrophe under control, except for one thing: There are no doctors or nurses here to staff the facilities.

Mahoney greets three American CDC employees already stationed in Jene-Wonde who are advising the villagers and will eventually help run the CCC until the Liberian government can supply full-time health care workers. The remoteness of this place is clear immediately — no phones, no cell towers, no radio, and only long dirt roads that link Jene-Wonde to neighboring villages and, eventually, to the paved highway. Even the American CDC workers have no way to communicate with Monrovia unless they drive nearly an hour to get within range of a cell-phone tower. Ever since a 60-year-old schoolteacher from Monrovia died here on Sept. 3, spawning Jene-Wonde’s outbreak, the town has been cut off.

“It is affecting us very much,” Austin Paul, a middle-aged resident, tells me. “We can’t go out of the area. Other villages will not allow us. We have no food, no trade; we eat just what we grow. We have no free movement. Everything is just Ebola now, no more care for anything else.”

JW CCC 2[1]

The town is spread out over two hillsides, bisected by a single dirt road that passes through a large, now-abandoned marketplace. Jene-Wonde used to thrive off the trade in this market, which was frequented by people who crossed the border from Sierra Leone to buy food and goods here. But since September the only buyers and sellers in the marketplace have been residents of Jene-Wonde, trading whatever they have grown or made with one another. Along the road are brick-and-mud houses, most of which have front porches and small yards. Children, chickens, and goats scamper about, girls stand in a stream washing laundry, and teenagers stroll lethargically, bored because all schools are closed until the Ebola epidemic comes to an end.

The quiet hides tragedy. Several houses are noiseless because every single person who resided within has died of Ebola. A local teen points them out: “That one there, this one here, across there.” And when a quartet of small children gathers around to stare at the visiting white lady, another teen says, “Orphans. Used to live there, in that empty house. Parents died. Orphans.”

Resting on one front porch, staring vacantly at nothing, is Imam Shagma Saleh, who barely notices his children pawing at him or the arrival of a foreigner. Five days ago, his wife, the mother of his four children, died of Ebola. “God carried her away,” Saleh says. His face is so strained by sleep deprivation and mourning that he looks like a man 20 years older than his 40-some years. As Jene-Wonde’s imam, Saleh instructs Muslims on appropriate burial procedures. He says, “Since the Ebola has started I say only let burial teams take the bodies.” “They will still go to Paradise,” despite forgoing traditional cleansing rituals, he insists. “God judges you by your deeds when you were alive, not by your shroud when you are dead.”

Thirty-year-old Ansu Annaseen sports soccer clothes and speaks semi-coherently, his train of thought drifting to fantasies of becoming a soccer superstar. He seems to be in shock, which makes sense given he has lost 10 family members to Ebola since September, including his wife, brother and sister-in-law, and four of his children. “I am a soldier on God’s Kingdom!” he shouts to no one in particular.

As of Dec. 18 the Grand Cape Mount district has lost 99 people to Ebola, most in and around Jene-Wonde. This town had officially lost 17 people to Ebola since Sept. 3 when we visited in mid-November but even a cursory head count reveals that a far larger number of people had suffered and died of the disease. Most of the sick and deceased, having gone untested for Ebola, were never entered into official records. I ask Chief Sano how many of her 700 residents have perished, and she shakes her head, saying only, “Too many.” Standing nearby, Paul, the middle-aged resident, does a quick calculation and tells me that if all the deaths the town has experienced since September are Ebola cases, the outbreak has already killed about 10 percent of the population. (The toll would grow far worse in the four weeks following my visit.)

A man standing close enough to hear Paul waves his hand at the newly constructed CCC and asks, “When this place is opened and it’s overwhelmed, what happens next?”

Redemption outside

It is that “what happens next” question that haunts epidemiologists Luke Bawo and Hans Rosling, who share a small office, along with two other number-crunching comrades, inside the Ministry of Health’s headquarters in Monrovia. Rosling, who is from Sweden, coined the term “monster” as a way to describe the danger he sees for Liberia right now. Although the number of new cases reported every day has dropped dramatically from the hideous highs of September, the Jene-Wonde outbreak shows that a single case is all it takes to spark an Ebola resurgence. Rosling drew me a picture to explain, first depicting a downhill slope of declining cases over time, heading to a zero point in the future. Horizontally beneath that slope he drew another line meant to depict the surface of a sea of deaths due to all causes, from heart attacks to car accidents, and, hidden within that, an Ebola monster.

Stabbing the paper, Rosling told me in his staccato, Swedish-accented English, “You see that monster? It is like — what do you call it in Japanese movies?”

“Godzilla?” I suggested.

“Exactly! That is it. Ebola is Godzilla, sitting below the surface of the sea, waiting to pop up. It is the monster. It’s whether Ebola dominates all deaths, or it is hidden among other deaths,” Rosling said.

And since the epidemic’s decline (which began in the first week of October), Bawo, Rosling, and the rest of the team have discovered Ebola cases and deaths hidden in that sea of “normal” mortality just about every day. Just as the reported 17 deaths due to Ebola in Jene-Wonde undoubtedly represent a gross undercount of the monster’s true toll, Bawo frets constantly about general illnesses and deaths in his country that are never tested for Ebola nor ascribed to the epidemic. On Nov. 13 they found 28 such hidden cases in a single day, all of them health care workers whose deaths over prior days had been incorrectly recorded. It’s painstaking work, scouring mortality reports from individual hospitals and county health offices, burial team numbers, laboratory testing results, and the employment information on all suspected Ebola cases and deaths.

Although Rosling is more than 15 years his senior, Liberian Bawo is the boss of Ebola number-counting. Walking with a limp from his childhood bout with polio, Bawo has toiled night and day for months, trying to make sense of the epidemic, project its future, and identify flaws in control measures. He concurs with Rosling that the virus lurks dangerously in his increasingly epidemic-fatigued nation, and he worries that even if new cases come down to zero, the nation’s porous borders with Guinea and Sierra Leone will continue to present danger for viral re-entry.

“We thought we were down to zero back in April — we couldn’t find any cases — but then the epidemic surged and overwhelmed us, “ 50-year-old Bawo reminds me. “There was a lull, 21 days with no cases. Everybody let their guard down. Then a Ugandan physician at Redemption Hospital [in Monrovia] got infected, and the minister of health called me and said, ‘We need your help to manage data.’ I had no idea what I was getting into. I read and studied about Ebola, and I thought in 40 days it will go away. But that did not happen with Ebola here — not like [in the past] in Uganda. And then this Liberian guy [Patrick Sawyer] exported the virus to Nigeria, and that woke the whole world up. Since then I have been working seven days a week, no holidays. I start calling all the counties at 8 p.m. until 10, maybe midnight. Catch a couple hours of sleep. And then up at 5 a.m. to prepare the [daily] situation report and have it ready to present at 9 a.m. It’s never-ending.”

Since the resurgence Bawo has created a tiny team of disease-trackers who have built the best epidemic-counting system in the Ebola-hit region. Over these months he has paid some team members out of his own paltry income, keeping their families fed until the government can provide funds and a payroll system to handle the missing salaries. Two of them, Mohamed Dunbar and Luke Nelson, finally got their first paychecks in mid-November, after more than two years on jobs at the Ministry of Health.

When a county fails to call in its case and death information, or numbers somewhere in the chain don’t make sense, Bawo burns the midnight oil, never venturing home until the puzzles are solved. Several times daily Bawo or another team member marches downstairs to the Ebola Command Center, where representatives of every Liberian, United Nations, and American entity engaged in the war against the epidemic sit, laptops and cell phones in hand, sharing news from the battlefront.

In September the epidemic utterly overwhelmed Bawo’s team members, some of whom slept in their cramped offices rather than drive home on dark streets lined with grief, even dead bodies.

In October, Bawo’s half-dozen disease detectors got help. First, in early August a man in faraway Sweden, made what he now calls his “great mistake.”

“If you want to blame somebody for this epidemic, blame me. It was my mistake,” statistician Rosling told me, speaking so earnestly when we met at Monrovia’s Royal Grand Hotel that his voice broke. Rosling is perhaps the world’s most famous statistician at the moment, a pop hero and favorite at places like TED conferences and wonky Silicon Valley gatherings. His Gapminder special software and the website that displays it is a serious yet highly entertaining look at the changes over time in health, wealth, and development around the world, sometimes delivered in speeches that feature Rosling swallowing a sword, just for the heck of it.

In July, Rosling took issue with a World Health Organization assessment of the Liberian epidemic, believing it was vastly overblown, and fretted that, in overreacting to Ebola, more people would die of normal medical problems than of the epidemic, because regular health services would be closed to make room for Ebola treatment. By September, as the epidemic reached nightmare proportions far exceeding those seen in any previous epidemic since the original discovery of Ebola in 1976, Rosling knew his statements were dead wrong. A passionate man, mercurial and prone to crying out loudly over numbers the way normal people might shout at a football game, Rosling took his duty to correct an error quite seriously. He took a leave from the Karolinska Institute, kissed his wife farewell, and jumped on a flight to Monrovia, where he donated his time, setting up shop next to Bawo.

Further strengthening the country’s disease-detecting mission were specialists from the CDC, a smattering of academics like Johns Hopkins University professor Tom Kirsch, and soldiers from the U.S. Army’s 101st Airborne Division. One young soldier, 2nd Lt. Grant Demaree, marched me through the history of Liberia’s epidemic as told through statistics. Trained in nuclear physics, Demaree sees stories behind numbers, and the saga of Liberia’s success, he argues, is the story of stigma, trust, and community action. “They got teams out to educate people, village by village. They had to fight the stigma of Ebola, get past the fear. And simple thing — they moved labs next to ETUs, cutting the diagnosis time down from days to hours. That meant people got into the ETUs earlier in the disease process, and some got cured. So then the people didn’t see the ETUs as places of just death, and they started coming in” from remote villages to testing and treatment sites. In the counties closest to Guinea, from where the virus first entered Liberia, this process was already yielding positive results by late July, Demaree explained. Burials became safe, and villagers brought the sick into ETUs, which effectively isolated contagion.

But it has taken months to repeat those successes and behavior changes nationwide, especially in Monrovia. Rev. John Sumo has been in charge of social mobilization for the Ebola fight since the epidemic resurged in June. The Christian leader started his efforts by networking safe burial and hygiene messages through churches and mosques across the country. He realized he needed to build political support, however, so he started identifying key tribal chiefs around Liberia. And in his first formal meeting in Monrovia in July aimed at social mobilization, Sumo was stunned when President Ellen Johnson Sirleaf walked in: “She sat next to me! I was so surprised! The political will is there.” Following the meeting, Sumo says, Sirleaf went to parliament and told elected leaders that they had to leave the big city and return to their constituencies, mobilizing the masses to seek health care, shun contagious burial practices, and show support for Red Cross teams and ETU health care workers.

“Now the intensity was there, because of the president,” Sumo told me.

As the epidemic wound down Sumo urged the government to start paying some of the chiefs, “incentivizing them to keep the Ebola message going,” he explained. “We are beyond awareness now — it’s action we need.” In remote areas where cell phones don’t reach, Sumo wants a paid network of leaders to fight complacency, make sure that the populace doesn’t slip back into behaviors that spread the virus.

“We are under constant threat of retransmission due to normalcy,” Sirleaf’s political advisor Emmanuel Dolo explained. “This is the most dangerous phase. That monster in the water — he will pull us down if we let him. We need to change and strengthen our health care system. Now it’s only an Ebola care system. We have to rebuild it and make it sustainable by doing things with the patience of Job. We’re fighting a sinister enemy we don’t know.”

Moses Massaquoi was working for former U.S. President Bill Clinton’s foundation before Ebola resurged in Liberia. The Clinton Health Access Initiative has continued to pay Massaquoi’s salary, but since September he has worked full-time in the Ministry of Health, overseeing the search for Ebola-infected individuals and the bodies of the virus’s victims. His job, to be blunt, was to isolate potentially contagious individuals from the rest of the society.

The process begins at the treatment centers, where health workers take down the names and “addresses” — such as “after the bend in the river” — of every patient’s family members and associates who may have had physical contact with the sick. The ministry’s army of contact tracers are deployed to hunt every one of those contacts down, and monitor them for 21 days to be sure they do not develop Ebola. If symptoms arise, the contact tracers call the Red Cross or other ambulance services to have the ailing individual removed to an ETU, and widen their tracing pool to include family and friends of the new case.

Just before Sept. 28, when Ebola peaked in Liberia, 40-something Massaquoi felt overwhelmed by his tasks, then as a physician manning an ETU post in Monrovia. “There were bodies in the streets. There were people queuing to get into hospitals. I was doing my rounds at the [Redemption Hospital] ETU, and I tried to encourage the nurses. And there was a huge queue of people who couldn’t get in and there were only three places inside. The triage nurse let the door open and everyone rushed in except those that were so sick they couldn’t walk. There was no respect for ‘suspect’ versus ‘probable’ versus ‘confirmed’ cases — everybody got mixed together. Your chance of coming out without Ebola, if you weren’t actually infected at first, were slim.”

Abandoned JFK 1

Strategically, all normal health care was stopped, and the country’s largest hospitals were converted to all-Ebola facilities. It was chaos and carnage. One by one, huge hospitals like Redemption, the John F. Kennedy Memorial Medical Center, SOS Medical Center, and ELWA Hospital were besieged by Ebola, and doctors and nurses were catching the virus and dying. Risky procedures, like emergency Caesarean sections for pregnant women or interventions for traumatic automobile injuries, involved too much blood to be safely handled, even by doctors wearing full personal protective equipment (PPE).

In the first week of October, the overrun hospitals were supplemented in Monrovia by a 150-bed ETU run by Médecins Sans Frontières (MSF, or Doctors Without Borders) and another ETU days later. And for the first time the bed space started to get ahead of the numbers of sick, and separating confirmed Ebola patients from those suspected of having the disease, to prevent patient-to-patient contagion, became possible. Among the first 106 patients admitted to the MSF treatment unit only 56 actually tested laboratory-positive for Ebola, showing that panic was driving many worried but uninfected people, or those sick with other ailments, into the cauldron of Ebola. Some hospitals, like Redemption, were shut down entirely.

In Monrovia and other urban centers the keys to getting Ebola under control, Massaquoi explained, were dividing up the ETUs so that “might be infected” patients weren’t bedded beside “dying of Ebola” cases, thereby contracting the virus, and mobilizing ambulance and burial teams to collect the dead. At the peak of the epidemic the government didn’t have enough PPE protective equipment for the ETU staff, so hundreds of people wound up untreated, laying in holding pens.

Today, with ETUs largely empty and the once-shuttered hospitals reopening for normal medical care, the challenge is to keep everybody safe — doctors, nurses, technicians, patients, visitors — while the Ebola monster lurks, invisibly. “We have tension between restoration of normal services and Ebola,” Massaquoi told me. “We need to reopen all the hospitals and siphon all patients through triage. Some might have Ebola-suspect symptoms — put them in a CCC located beside the hospital. And the rest go into general care.”

The game-changer in this scenario would be a rapid Ebola test that did not require a laboratory, something like a home pregnancy test. Suspect cases could be ruled in or out after squeezing a single drop of blood into a plastic well or onto a special piece of paper, which would in a matter of minutes change color if the Ebola virus were present. Although at least 19 such tests are in prototype testing now, according to the World Health Organization, development is taking far longer than hoped. So patients may wait hours, even a day or two in a CCC pending laboratory DNA test results.

So Massaquoi wants to shift his entire staff to what he’s dubbed Advanced Active Case Search to track down every single infected person in the nation. “We have more than 500 beds now, empty in Monrovia, alone,” he insisted. “So find the monster and bring it to those beds. Close the ETUs. And then be ready, in case the monster resurfaces, to give it an all-out response.”

It might be possible now because the army of contact tracers is finally getting paid. From September to early November thousands of contact tracers went unpaid, eventually striking with demands for back pay. Many of the angry workers I encountered in November claimed corruption was at the root of their missing salaries. In February Liberia’s doctors and nurses went on strike, also for nonpayment. And as the case of Luke Bawo’s epidemiologists demonstrates, hundreds of Ministry of Health personnel toil, remarkably, without receiving salaries owed them, and have done so in many cases for years.

Conquering Ebola and safely restoring normal health care will demand paychecks be processed.

Liberia’s health payroll is so complicated that when physicians went on strike in February President Sirleaf marched into Miatta Zenabu Gbanya’s Ministry of Health office and demanded an explanation. After an hour of talking Sirleaf through the system the distraught president told Gbanya it was simply too complex to explain to the angry doctors, much less to the nation, as a whole. When Gbanya walked me through the system my head was spinning after an hour.

In a nutshell, blame the civil war, and well-intentioned humanitarian and foreign aid groups.

During Liberia’s two civil wars (from 1990 to 2004), the entire national health care system collapsed. All medical services were provided either by private doctors on a fee-for-service basis to those able to pay, or by outsiders giving free care. The outsiders — such as the British government’s Department for International Development, the U.S. Agency for International Development (USAID), MSF, World Vision, and a host of other faith-based missions — paid local staff and ran their health operations as they saw fit. Nobody complained about the lack of government-run services when bullets were flying.

When Sirleaf was elected in 2006 she was not happy with the state of medical affairs, as it left foreigners deciding the health care fates of her people. So in 2008 the Ministry of Health created the Health Sector Pool Fund — a unique financing system that pools donations from wealthy countries, humanitarian groups, and the NGOs that once ran the country’s hospitals. The goal of the Health Sector Pool Fund is to give the nation of Liberia control over its own health care system. Gbanya has run the fund since 2013, which is supported by all of the nation’s health donors and NGOs except the U.S. government. The United States cannot, under congressional edict, put taxpayers’ money into pooled accounts, so USAID and other bilateral partners fund programs directly, but in tandem with the policies set by the fund. And the United States has a seat on the fund’s board of directors, along with other major donor nations and U.N. agencies.

Since 2008 the Health Sector Pool Fund has received $65 million, Gbanya told me, which was a tidy sum, but not enough to cover all of the salaries once paid by the civil war-era NGOs and donors. Even when combined with direct-to-Ministry of Health support from the U.S. government, World Bank, and Global Fund to Fight AIDS, Tuberculosis and Malaria, the net was insufficient to cover payroll and operating costs for the country’s health programs — and that was before Ebola slammed Liberia. Throughout 2014 Gbanya has held out her tin cup, begging for alms from Britain, the United States, and a variety of major donors to cover salaries, purchase medical supplies and protective gear, buy gasoline for ambulances, and keep the medical system functioning. All the while, she has had to reform the Ministry of Finance, forcing transparent accounting that satisfies the board of the Health Sector Pool Fund and gets paychecks to ministry employees — including that army of contact tracers.

“We were dealing with a tough workforce that was dissatisfied” before Ebola, Gbanya explained. At every health facility and ministry office some workers, like Luke Bawo, were getting paid while others, such as his epidemiologists, were not — the same was true in every hospital and clinic in the nation. “The challenge stems from existing imbalance in payment among people that work in the same positions. Ebola adds on top of that. And then you have people saying, ‘You want me to put my life at risk, but you have to pay me.’ So it was tough to get people to work,” Gbanya said. If Liberia were to put every single health worker employed under the old system, plus to newly hired Ebola workers on full salaries, “We would need about $300 million, right now,” she concluded.

Against that financial background, with the Ebola virus still lurking in most of the country, Bernice Dahn, deputy minister of health, is trying to restore the nation’s health services. During the epidemic thousands of children have missed immunization doses, the entire society has been without check-ups, women have given births unattended by skilled midwives or doctors, and an atmosphere of fear has overwhelmed every aspect of medical care.

“The public is afraid to access health care. There is no confidence in the system. The people are afraid they will end up in an ETU, and we see a huge drop in admissions for fevers, of all kinds,” Dahn told me in a quiet conversation in her tasteful office. “Health care workers are also selecting patients out of fear. If anything resembles Ebola, they walk away. So there is fear on both sides.”

Dahn has a deep personal understanding of this fear. In September her assistant’s family perished from Ebola, one by one, and then the colleague died. Fearing she might have caught the virus from her assistant, Dahn placed herself in quarantine for 21 days.

The workers are also fearful — justifiably — that the payment system will be even worse for normal medical care because, Dahn explained, all of the donors have earmarked recent funds for Ebola care, only. So while she might be able to meet the payroll of her army of Ebola workers, Dahn cannot guarantee that the average OB-GYN or pediatrician, surgical nurse, or lab tech will get their paychecks.

For those willing to show up for work without guaranteed salaries – which, remarkably, is the majority of the unpaid medical workforce — the ongoing presence of Ebola means each interaction with a patient, or lab samples of patients’ blood, could be life-threatening. So Dahn is overseeing efforts across the public and private medical sectors to define personal protection standards for every single medical procedure.

I liken Liberia’s health care moment to the impact a Florida dentist had on the practice of health in the United States in 1993. David Acer was an HIV-infected dentist who unwittingly passed his virus onto six clients, all of whom died of AIDS, as did he. The Acer case was enormously controversial at the time, given that HIV infection was then a death sentence. Remarkably to young Americans today who are accustomed to their dentists wearing gloves and masks while working, neither was the norm before the Acer case. Fear of HIV spread in health settings spawned a long list of hygienic improvements in American medical and dental practices.

In Monrovia, John Mulbah chairs the Liberia Medical and Dental Council, as well as the Department of OB-GYN at the University of Liberia. The dignified, elderly physician sported a University of Michigan tie when we met in his stifling-hot office — a symbol of past travels in the United States, he said. He is leading physician efforts to redefine the standards of care in Liberia, in the Ebola era. Topping his list of concerns are obstetric procedures.

“When the civil war ended, Liberia was a very dangerous place to be pregnant,” Mulbah told me, noting that improvements in health care made by the Sirleaf government had improved maternal survival rates. In 2013 some 994 women died for every 100,000 births — by global standards a dismal number, but a vast improvement over the wartime 1990s when maternal mortality exceeded 1,100 deaths per 100,000 births. “But now, thanks to Ebola, we are back to square one,” with 1,072 maternal deaths per 100,000 childbirths.

Anecdotally, Ebola infection during pregnancy is the most dangerous — nearly all pregnant women die when infected, often miscarrying at the time. And for OB-GYNs and midwives, handling the bloody birthing process is fantastically dangerous. Two of Mulbah’s OB-GYN faculty members have died in such circumstances of Ebola. So “paramount” to resumption of medical services is infection control. Mulbah and his staff are deciding with Massaquoi’s ministry team what sort of protective garb doctors and nurses must wear for every obstetric and gynecological interaction, from routine pelvic exams all the way to emergency Caesarean sections — for 657 hospitals and clinics.

“We have to be able to say, ‘You are a scrub nurse. This is what you need to wear.’ All deliveries must be handled wearing three pairs of gloves, one long, elbow-high pair. If you are the anesthesiologist in an emergency Caesarean section, what kind of PPE should you wear?” Mulbah detailed.

In the end, like every health professional I spoke with in Liberia, Mulbah bemoaned the absence of a rapid diagnostic test that could within minutes tell doctors which patients carried Ebola.

In the absence of such a test, Liberian health professionals hope that the country’s Ebola monster can be beaten back to the nation’s borders. But the porosity of those borders leaves the nation uneasy and vulnerable. Just as the Acer dentist case signaled a new era in American health care standards, forcing all dentists, doctors, and nurses to simply assume their patients might carry HIV and protect themselves accordingly, so Liberia’s health care workers must, perhaps for years to come, assume Ebola lurks in their patient population. Sadly, the Ebola virus is far more contagious, and numerous in the blood of symptomatic patients than is the case with HIV.

In the end, Liberia’s future hinges on the government’s ability to convince its populace to remain vigilant, even as the fed-up people sense the end of the monster is nigh.

Photographs by Laurie Garrett.