Death and Denial in the Hot Zone

ZANGO TOWN, Liberia — In this small farming village, sinewy elderly men and women sit outside their thatched mud houses, with children scattered around. It is quiet and desolate. But one day in mid-July, in the town’s largest house, two women wail as they deliver news of death from a neighboring village: a young man, killed by Ebola.

The lethal virus has already arrived here too. According to Liberia’s assistant minister of health, Tolbert Nyenswah, 19 people from Zango Town have died. A few tested positive for Ebola and were treated in "case management centers" run by Samaritan’s Purse, an international Christian NGO. Yet many in Zango Town are skeptical of what they have been told. Some do not even believe Ebola has struck their community. They imagine the deaths were caused by something else or that health workers are killing patients.

A few weeks back, citizens of the town attacked a community health team that came to spray the area with chlorine, a cheap and effective way of killing Ebola, and tried to set its car on fire. Now a lone pink plastic bucket containing chlorinated water sits in the middle of the town, intended for people to use to wash their hands. No one touches it.

Henry Jallah, a 23-year-old farmer, recently lost five family members to illness, including his mother, an uncle, an aunt, and two of her children. He expresses his loss matter-of-factly and says that God is telling him to get on with his life. "There be no hope," he says. "So many people are dying."

Jallah says he has accepted the advice of Liberia’s Health Ministry to stay away from dead and sick people in the town, yet he is hesitant to believe it is really Ebola that claimed his family. He offers other explanations: poisoned drinking water as vengeance for a conflict over land, or some kind of curse. His family never took his aunt to a case management center, he says, because "some people say when you go over there, they can inject you — when you having the sickness, they inject you and kill you."

Liberia, along with its neighbors, Guinea and Sierra Leone, were once racked by war. Today, they are all facing a new and deadly crisis: Ebola, a virus that attacks organs and leads to fever, diarrhea, bleeding, and in most cases death, has swept across the countries and threatens to extend its reach. The virus, which cannot be cured but can be treated, can kill up to 90 percent of those who catch it. The overall death rate in the three West African countries is currently around 60 percent. Roughly 1,200 cases have been identified, the most ever in an outbreak, and some 670 people have already died.

On Friday, July 25, a case was confirmed in Nigeria, Africa’s most populous nation: A Liberian man collapsed at the Lagos airport and later died. Liberia, in which seven of 15 counties have identified cases of the virus, has announced that it is restricting public gatherings, shutting many border crossings, and opening testing centers at others. (One reason public-health experts think this outbreak has hit three countries and their urban centers simultaneously — a first in history — is due to porous borders. Often members of the same family living on different sides of a border cross to see one another, while other people border-hop to engage in commerce.)

Médecins Sans Frontières (MSF) Director of Operations Bart Janssens has called for a massive deployment of resources by regional governments and aid agencies to combat the outbreak. But it is unclear where these resources will actually come from. Liberia, which has identified 290 cases and suffered almost 137 deaths, has set up a new task force to address the situation, and a national operational plan will be released in the coming days. It will require $10 million to $15 million to be implemented, however, and the government has yet to muster the funding, according to Nyenswah.

Yet the biggest hurdle in stopping the spread of Ebola seems to be overcoming denial and fear in communities that are deeply suspicious of the government, the health-care system, and international institutions. This includes remote areas, which are relatively untouched by the government or have only experienced it in the form of force and coercion. But Monrovia, the capital, is not immune: In bustling Duala Market, 92 percent of people said they did not believe Ebola existed, according to a recent survey of 1,000 people conducted by Samaritan’s Purse. In fact, many in the capital initially viewed the virus as a hoax created by the government to generate and "eat money" from aid donors.

Often, too, people here view life events, including tragedies, through the prisms of religion and superstition. There is a Liberian saying that goes, "Nothing for nothing" — meaning, everything happens for a reason. Even Ebola.

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Over the weekend, in a community called Popalahun, in Liberia’s Kolahun district, residents staged a roadblock and attacked health workers traveling in a jeep. They smashed the jeep’s windshield and gashed its tires with a machete. Four Liberian health workers who were part of a team, employed by Samaritan’s Purse and tasked with collecting the body of a person who had died of Ebola, scrambled to safety in the bush. One who was beaten with a hammer managed to escape. Kendell Kauffeldt, the country director for Samaritan’s Purse, says his organization will be forced to cease outreach — that is, collecting patients and bodies from towns and villages. "We just cannot afford to put ourselves at that risk at this point," he says.

Similar attacks have occurred in Guinea and Sierra Leone. In Freetown, the capital of Sierra Leone, thousands marched at an Ebola treatment center this weekend following allegations by a former nurse that the deadly virus was invented to conceal "cannibalistic rituals" at the facility, a regional police chief told Reuters. (A local doctor also told the news agency that some health workers weren’t showing up for work because of "misconceptions by some members of the community.") MSF also had to evacuate a clinic in rural Guinea after attacks in April.

Back in Liberia, families in Monrovia have fought hospital staff to retrieve bodies of family members who have died. (Touching the deceased is extremely dangerous, given the virus’s contagiousness.) In one incident, people threw stones at Redemption Hospital in New Kru Town, a densely populated slum community, after the body of a woman who bled to death after giving birth was tested for Ebola. Also in New Kru Town, residents protested and stopped the construction of an isolation ward, meant to limit the chances of exposure to Ebola among health populations.

Samaritan’s Purse has halted the expansion of its case management center in Monrovia due to protests from the local community who fear illness. That facility, the main one in Liberia, currently has 20 beds that are fully occupied with confirmed and suspected cases. The NGO is looking to add another 60 beds, but it needs the government to negotiate with the community before it can do so.

"Right now we have no more space," Kauffeldt says. "When the next Ebola patient comes, there is nowhere to put them, and the worst thing that can happen is that patient goes back into the community."

"If we are still getting 90 percent deniability [of Ebola’s existence] in the hot zone of Monrovia, communication is not working," he adds.

Although there has not been violence, Kauffeldt says he is concerned about security. The gates surrounding the case management center are manned by unarmed police officers. The Liberian National Police force is currently developing a strategy to deal with violent incidents at hospitals, as well as when bodies of Ebola victims are being transported for burials, which must be done by specialists using body bags and chemical sprays — in violation of long-standing customs in which family members are responsible for washing and preparing corpses for burial.

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Compounding these problems, even when people believe Ebola exists, many are wary of hospitals because they believe the institutions provide poor care — a concern that existed well before the current crisis. To be sure, Liberia’s health-care system has improved since civil war ripped the nation apart; there has been a reduction, for example, in the under-5 child mortality rate. Yet Monrovia’s largest hospital, John Fitzgerald Kennedy Memorial Medical Center, or JFK, is nicknamed "Just For Killing" among locals because people go there with treatable diseases such as malaria and still die. There have been reports that, recently, health workers at JFK refused to treat patients suspected of having Ebola, even abandoning the facility’s emergency room. (The hospital’s Ebola ward has since been closed. JFK was "dangerous," according to Kauffeldt, as proper procedures for dealing with the disease were not followed.)

Ebola infections among doctors and health workers, in Liberia and elsewhere, have also raised fears about coming into contact with the health-care system. A leading Liberian doctor, Samuel Brisbane, who was working as a consultant with the internal medicine unit at JFK, died and was buried over the weekend. Another Liberian doctor has been infected and is currently undergoing treatment. Two Americans working to end the outbreak, including one doctor, have also tested positive.

Liberian health workers have complained about a lack of protection and equipment, saying it is limiting their ability to do their jobs and stay healthy. But Nestor Ndayimirije of the World Health Organization (WHO) says that part of the problem is inappropriate use of equipment. He says health workers, for instance, ran through a supply of 8,000 protective suits, worn when dealing with infected or potentially infected individuals, from donors too quickly because they were using them unnecessarily.

"Some don’t have the personal protective equipment, but this cannot explain the number of infections among health workers," says Ndayimirije, who witnessed and worked on major Ebola outbreaks in eastern and southern Africa in the late 1990s and early 2000s. There are currently 37 suspected cases among health workers in Liberia, and there have been 16 deaths.

The Ministry of Health says it is making an effort to speak to and further train hundreds of health personnel, including workers in counties that have not yet even registered cases of the virus. But this will be difficult, given that the country’s operational plan against the outbreak has yet to be finalized and financed.

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Despite violence, skepticism, and other obstacles, in Foya District, where Zango Town is located, the government and Samaritan’s Purse have had some success in working to raise awareness and provide treatment. On July 17, Liberia’s minister of health, Walter Gwenigale, and the nation’s chief medical officer, Bernice Dahn, held an emergency meeting in Zango Town to warn residents about the virus. Some people gathered to listen, if hesitantly.

Yet there are miles to go: Luana Korvah, a mental health clinician working for the government, estimates that the vast majority of people in Zango Town and the surrounding area do not believe the disease exists. And in Foya’s Ebola case management center, where white tents are sectioned off with bright-orange netting, shellshocked survivors of the virus admit they are worried about going back to their communities, uncertain as to how they will be met.

Harrison Sakela is one of them. Sakela was the nation’s first-known survivor of Ebola, which he contracted when his mother got sick after attending a family burial in Sierra Leone. His mother, father, and sister have all died, along with his 19-year-old niece and her daughter, who passed away in the treatment center while he was there.

"People believe that if you come here, they will give you an injection and put you in the body bag," Sakela says, echoing the words of Henry Jallah in Zango Town. "That what makes the fearness, and people are dying in the bush."

Saah Tamba is also worried. A young rice farmer who contracted Ebola after caring for his uncle in Sierra Leone, Tamba will be going back to his community after two months in the center. His body is frail, his brow furrowed, and his face strained. In his native Kissi language, he says he is uncertain whether his community, just 10 kilometers from the center, will accept him.

Randy Schoepp, who works for the U.S. Army Medical Research Institute of Infectious Diseases and is helping monitor a testing center outside Monrovia, says the "first line of defense" in the outbreak is communication. "There are reports of people hiding sick relatives and friends, and they die and then the people that are hiding them get infected and they die, and it just goes on and on," he explains. It’s a cycle that must be stopped.

Ndayimirije of the WHO says building trust in communities, including with elders and traditional leaders, is the key in the fight against Ebola. Without trust, fear and suspicion cannot be cut from their deep roots — and the work of helping a region overcome a devastating illness could drag on indefinitely. Making populations understand the disease in scientific terms is urgent, Ndayimirije says: "We must go door to door."