How Not to End a Plague

MONROVIA, Liberia — Liberia’s first experiment with urban quarantining amid the Ebola epidemic began last week in West Point, one of the poorest, most densely populated, and ethnically diverse communities in Monrovia, the country’s capital. On the morning on Wednesday, Aug. 20, West Pointers woke up to find that they were cordoned off from the rest of the city by a makeshift barricade made of wooden tables and concertina wire and manned by armed police officers and soldiers. They panicked — they had no idea how they would tend to their business, when they would eat, or how they and their families would receive medical treatment. No one informed them of what was to follow. When the town commissioner, the presidentially appointed official in charge of West Point, Miatta Flowers, attempted to escape with her family from the quarantine zone, outraged residents of the ramshackle seaside slum rioted, clashing with the police and army troops who had been dispatched to ring them in. Their commissioner seemed to be abandoning them, making a getaway while leaving them trapped.

From the outset, the quarantine project was destined to fail. The sheer size and population of West Point, which sits on a peninsula next to Monrovia’s mainland, were stumbling blocks. The outcast township — made up of ex-combatants from Liberia’s brutal civil war that ended in 2003, marginalized youth, and migrants from Guinea and Sierra Leone — is one of Liberia’s most complicated communities. Consent for a quarantine was neither won nor sought from residents, including community leaders; health organizations working to help the government fight Ebola did not endorse it either. Making matters worse, many people who live in West Point do not understand how Ebola is transmitted and distrust the government, which has become synonymous with deception and corruption for many Liberians.

There was, in short, a glaring lack of knowledge and communication surrounding the quarantine — as there has been throughout the crisis of health and governance that is the Ebola outbreak in Liberia. Already, more than 570 people in the country have died of the virus; nearly 1,000 have been infected. The number of cases is only expected to rise.

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The idea of quarantining communities had been in the works for weeks. On July 30, the president’s office issued a press release about quarantining, in which the Liberian government specified several areas that would be cordoned off, among them communities in Lofa County, Upper Caldwell, and Tubmanburg city, all poor parts of the country. But a second version of the release that was sent out several hours after the first one backtracked, claiming that "several communities are being considered to be quarantined" and "when these measures are instituted, only health care workers will be permitted to move in and out of those areas. Food and other medical support will be provided to those communities and affected individuals." (Italics are the author’s.)

Rumors swirled for weeks about which communities would be targeted, and the government consistently failed to explain how it would decide which communities and how quarantines would actually operate. This lack of clarity fomented fear in Monrovia. Ultimately, the government’s decision to quarantine West Point, according to President Ellen Johnson Sirleaf, was in response to an attack on a holding center for suspected Ebola patients that served patients from West Point and neighboring towns; both people and the mattresses on which they had slept — which authorities worried might be carrying the virus — were released into the community.

When security forces were deployed to evacuate Flowers from West Point, some residents hurled rocks, and others unsuccessfully attempted to escape. Three male youths were wounded when security forces opened fire, and community members say others were injured. Images of 15-year-old Shakie Kamara, one of the three, whose right shin was split open to show blood, muscle, and bone, flooded through the media. Shakie bled to death later that night in a hospital where he was reportedly left untreated. The military initially denied that he was shot, but the chief medical officer at Redemption Hospital, where Shakie was taken, said bullets were involved — and they were in the two other youths as well.

The military took Shakie’s body away, according to one report. He was buried on Monday without an autopsy. The minister of defense, Brownie Samukai, has backpedaled on his claim that Shakie’s injury was caused by barbed wire and has admitted that lethal force was used. "The Armed Forces of Liberia have not been issued any orders to shoot to kill anybody out there at this point in time," he said in an interview with FrontPageAfrica, published Tuesday, adding that a government board of inquiry had been set up.

According to a statement to the press by Karin Landgren, the head of the United Nations’ operations in Liberia, Johnson Sirleaf has said that "under no circumstances will lethal force be used again." Johnson Sirleaf herself also insisted in an interview with Katie Couric that there was no "anarchy" in West Point, and she chastised the international media for "spreading false rumors." The situation was "calm," she said. But when she walked through West Point on Monday to meet Shakie’s mourning family and other West Pointers who complained about the conditions of the quarantine, she did so with a bulked-up security detail wearing helmets and sunglasses; some of them were armed with AK-47s. "Open the gates!" one sweaty young man in a red football shirt yelled.

To be sure, tensions in West Point had calmed some since the angry outbursts at the beginning of the quarantine — but the reprieve will almost surely be short-lived. The reckless and fatal use of force riled the beleaguered community, already distrustful of the government, and the Liberian Ministry of Health has struggled to provide food, water, and medical treatment to roughly 80,000 residents under quarantine. When food rations were handed out by government workers on Aug. 21, community members stood pressed together, sweating on one another while police in padding and armor held the line, striking unruly members of the crowd with canes. Health workers dipped the fingers of community members in blue ink before handing them food — a contradiction to the government’s message that citizens should stop shaking hands and touching other people to avoid contracting Ebola. With the residents of West Point under such duress and confusion, it is easy to imagine violence reigniting once more.

The West Point quarantine has shone a spotlight not only on the government’s miscalculations in a specific instance, but also on its failure to communicate with and win the cooperation of its citizens throughout the Ebola crisis. Indeed, the government’s unilateral actions and lack of foresight have mostly created fear and suspicion, precipitating other dangerous incidents.

The holding center that was attacked in West Point, for instance, was set up unannounced by the Ministry of Health. Not long into its existence, a mob, many members of which were suspicious of the outsiders working there and some of whose members were convinced that Ebola is a government ploy, ransacked the facility. They set 17 suspected patients free and hauled — in addition to mattresses — clothes, cups, and medical items out into the community.

These manifestations of fear are not helped by Liberia’s struggling health care-system: Some of the patients at the holding center came there because other facilities were overcrowded. Most hospitals are now closed or woefully understaffed, meaning that even people who go to them seeking treatment are not likely to receive it. Often, medical workers lack sufficient equipment and medications with which to assist people. Many workers, too, have already been struck down by the virus.

In another example of poor planning and outreach, in early August the government dumped the bodies of 37 suspected Ebola patients in a community called Johnsonville, a rural locale just outside Monrovia. As with the holding center and the quarantine, residents were not consulted on the action. Some rough-cut graves jutted out from the soil, while some body bags were left floating in swampy water. A sad display of wooden placards, with the names and ages of the dead written in thick black marker, was placed a few meters away.

Johnsonville residents, many of whom do not understand how Ebola works but feared that their water supplies could be contaminated by burials, became aggressive. They threw rocks at a large excavator used to dig graves and demanded that the bodies be removed. The military was deployed to control the situation.

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Médecins Sans Frontières has described the outbreak in Monrovia as "catastrophic," and the World Health Organization has predicted that the epidemic could last another six to nine months. The death toll continues to rise, and the virus has spread to new counties. A comprehensive and coordinated plan has yet to be developed. But the incidents in West Point, Johnsonville, and elsewhere underscore the government’s greatest failure: communication. Unless it can secure the consent, trust, and cooperation of its people, it will not win the battle against Ebola

In what would turn out to be the final hours of the failed holding center in West Point, before the mob attacked, Daniel Dahn, a tall man with deep bags under his eyes, sat inside a dark room in the building with his four young daughters. The family had voluntarily gone to the center after Dahn’s wife had died.

"We are frightened," he said, his face illuminated by a small flashlight. Like so many Liberians, he did not know what to do — and the government has yet to provide meaningful, even lifesaving guidance that might help.