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Posted on Tuesday, 21 April 2015 13:32

The fightback against Ebola

By Billie Adwoa McTernan and Patrick Smith in Monrovia Photos by Francis Kokoroko for The Africa Report

At a cemetery in Congo Town relatives have painted the graves of their loved ones for Decoration Day. Photo© Francis Kokoroko for The Africa ReportA week before an unexpected last case, Liberia had first reached zero Ebola in early March, thanks to community activists, a nationwide information campaign and tens of thousands of volunteers working alongside government and foreign medical help. Now it's time to look at the lessons learnt.

In the back room of a modest house in the St Paul's Bridge area of Monrovia, Beatrice Yardolo sits with her husband, Steve, and their family on a Saturday afternoon, waiting for President Ellen Johnson Sirleaf.

Ebola actually exposed to what extent people are inhumane when it comes to issues of corruption

The previous day, 13 March, Johnson Sirleaf had flown in from yet another trip to the US, where she spoke to President Barack Obama and lawmakers about the devastation that Ebola had wrought in West Africa.

Her decision to visit the Yardolo family had particular resonance, as this area was one of the worst hit by the virus in the capital. Many local critics accused the government of a laggardly response to the Ebola outbreak as the death rate exploded in the capital city last August.

Since then, thanks to community activists, determined action from government and foreign medical help, the worst is over.

Liberia had reached zero Ebola in March, but its health officials were still keeping their wary eyes on a spate of new cases in neighbouring Guinea and Sierra Leone.

The target date for all three countries to be declared zero Ebola by mid-April looks highly ambitious.

Yardolo was Liberia's last known Ebola patient to be discharaged – she left a Chinese-built Ebola treatment unit after testing negative on 5 March. "I have a new love for life," she tells The Africa Report. But her relief at surviving the deadly virus was tempered by the grief of losing two sons and a daughter to it.

She told us that she contracted the virus from her 22-year-old daughter Amanda, who died from it after she was misdiagnosed with appendicitis. "I was in direct contact with her, taking her to the bathroom, bathing her," Yardolo explains.

A week after Amanda's death, Yardolo began experiencing symptoms and she was taken to a treatment centre. "There were some other patients there. There was a man on the bed next to me. When he was discharged along with two other ladies, I was lonely. That night I didn't sleep well. I was afraid."

Social stigma

Yardolo's story shows the bravery and resilience of people hit by the virus, but also the hard road ahead as families deal with social stigma and the loss of income.

Previously an English teacher in a local school, Yardolo is unsure whether she will return to work there.

When the presidential motorcade at last edged up the mud track towards Yardolo's house, a large welcoming party flanked by state security officers was standing on the porch.

In lieu of a red carpet, some steps covered in scarlet velveteen were lowered from a black four-wheel-drive limousine and out stepped Johnson Sirleaf in beige slacks and a baseball cap with a Liberian flag on the front.

After meeting the Yardolo family and a phalanx of curious neighbours, Johnson Sirleaf asked Yardolo what help she had received from the social protection ministry. None at all, came the sobering reply.

That seemed to be a prompt for The Africa Report team to ask President Johnson Sirleaf about the way forward.

Switching effortlessly from populist politician into technocratic mode, she said that the Ebola crisis had to be seen as a regional one: "We need support for all three countries to get to zero Ebola and to upgrade their healthcare systems."

That is in fact Johnson Sirleaf's new role. At a European Union conference in mid-March, she was appointed official representative of the three countries hit by Ebola.

As a Nobel Peace Prize winner, an ex-administrator of the UN Development Programme (UNDP) and former executive of Citibank, 76-year-old Johnson Sirleaf is a seasoned campaigner on the international circuit.

And, to her frustration, she is often more revered overseas than she is at home. Nonetheless, she is optimistic, saying: "Once we beat Ebola, we are going to bounce back."

Once we beat Ebola, we are going to bounce back

Tough as it was for her government to revive the country's economy after 14 years of war preceded by 18 years of financial meltdown and plunder, the Ebola outbreak represented a greater challenge for Johnson Sirleaf– and an insidious threat.

As cases multiplied last July and August, some of her political foes and retired warlords came out of the wood-work to see if they could exploit the crisis.

The turning point was when the government put West Point, one of Monrovia's toughest areas and a zone particularly hit by Ebola, under enforced quarantine.

Troops and police blocked off all the entry points, and trade in the area almost ground to a halt.

Days later, a riot broke out as some local officials tried to sneak out. Soldiers shot two young men in the melee, one of whom died.
community strategy

That forced a rapid rethink by government. West Point had shown that a security strategy would fail.

The government then sought out local leaders with whom they could work to win over communities with a widespread and intelligent in- formation campaign.

At the same time, Johnson Sirleaf appointed assistant health minister Tolbert Nyenswah as head of the national incident management system.

"Coordination was a nightmare from the beginning over the Ebola crisis," Nyenswah tells The Africa Report. "At the height of the disease, people were running away from Monrovia, seeking care from traditional healers in the villages. Unsafe burials were taking place."

Infected corpses and the traditional practice of washing and dressing bodies before burial was beginning to spread the virus exponentially.

Nyenswah's team, in collaboration with the US Centers for Disease Control and Prevention, set up operations in a building at 18th Street in Monrovia that would house all the necessary specialists.

Case managers, lab technicians and epidemiologists shared offices with psychologists, community activists and medical planners.

From this command centre, public information campaigns using radio, billboards and local news- papers were launched to warn people of the horrors of the virus.

A top priority was to spread treatment centres – usually tent camps where patients could be isolated – across the country to reduce the transmission of the virus via public transport.

In the basement of the 18th Street headquarters was a call centre operating around the clock, getting information about new cases and offering advice to worried citizens.

At the heart of this new strategy was the role of activist citizens. Of Liberia's 10,000 health workers, less than half are on the public payroll.

The remainder are volunteers or receive only a small stipend for their work. "When the community got to know that this was serious they took charge.

"There were areas in the communities where task forces were formed – community support groups, check points, community quarantines. By the time we got there as health authorities, the community had quarantined sick people and provided food for them," recalls Nyenswah.

Kamil Kamaluddeen, the UNDP country director for Liberia, says that this strong community spirit and the government's endorsement of devolution and decentralisation will be critical in the post-Ebola recovery period.

"We met communities in Grand Cru, in Georgia [...] they almost created their own municipalities. They chose their own leaders, established their own structures, recruited their own community workers, found new ways of keeping chlorinated water. They keep records of who goes in and who comes out for the contact tracing," says Kamaluddeen.

Not all the assessments were so positive. Victor Flomo of the Grand Bassa Civil Society Council discovered that items such as buckets for washing and foodstuffs intended for the countryside were being hoarded in the county capitals.

"Ebola actually exposed to what extent people are inhumane when it comes to issues of corruption [...] corruption against the survival of people," Flomorecounts.

Trust factor

Finance minister Amara Konneh insists the government is not making excuses for mistakes over the handling of Ebola but says the 'trust factor' is key: "After years of war, the governed no longer trust the governors. That's more acute with a crisis such as Ebola."

Konneh, who lost family members during the civil war and fled to a refugee camp, says the legacy of Liberia's lost years of instability and warlordism still undermines development efforts.

He adds that Ebola has put Liberia's ascent from a country with an annual budget of $80m in 2006 to one of $600m in 2014 on hold. Revenue losses this year could run as high as $100m, and the out break will require at least $80m of fresh state spending, Konneh calculates.

This year, fundraising and recovery will dominate his time and the national agenda.

Konneh is working on a regional recovery plan with his counterparts in Guinea and Sierra Leone that is to be launched at the spring meetings of the World Bank and International Monetary Fund in mid-April.

That will be followed by a fundraising meeting convened by UN secretary general Ban Ki-moon in New York in May.

And in June, the African Union is due to assess the progress of the Ebola-hit countries, perhaps casting a critical eye on its own performance and bringing in again that group of African companies that contributed substantive private funds for emergency healthcare last year.

Even if all three countries have hit zero Ebola by the time this conference calendar starts, Konneh argues against any complacency: "We have to restart growth, diversify our economies and decentralise healthcare and build thousands of small health centres," he says as he heads back to his office early on a Friday evening.

Remembering for a moment the disastrous scenes in the capital, Konneh adds: "It won't be business as usual, we can't afford that again." ●



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