One single case of Ebola can re-start an outbreak anytime, anywhere: Interview with ECHO expert in Liberia

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As the number of Ebola cases in Liberia is decreasing, neighbouring Sierra Leone and Guinea continue to struggle to contain the outbreak. ECHO’s expert in Liberia’s capital Monrovia, Dr. Imanol Berakoetxea, shares his reflections on how to rid the region of the scourge of Ebola.

How did you find the situation in Liberia when you arrived last September?

The epidemic was still at its peak. Cases had been doubling every 2 to 3 weeks. You would still find bodies abandoned in the streets or hidden in the bush. Denial had been replaced by fear and families hid the bodies of the deceased out of fear of being marginalized. Ebola had never before reached major towns. It caught everyone by surprise.

How has the situation evolved?

A fully dedicated Emergency Operations Centre was established a week after my arrival. This was really unique. It hosted a command centre where technicians from different countries and organisations shared the same working space. This offered the opportunity for real-time coordination between civil and military actors who normally struggle to act together. The setting allowed for direct interaction and reduced bureaucracy. Before this, most delaying factors came from the fact that not all the relevant government counterparts were located in the centre.

What are the challenges related to international staff?

Most international staff are deployed only for a very short period. After 3 weeks I found myself being one of the 'veterans'. Deployment of expatriate health responders to the frontlines has been slow. This is linked to the uncertainty for foreign responders to get proper medical treatment amid increasing reports of health personnel getting infected and dying from Ebola. To top it off, an irrational fear in many countries has led to short-sighted travel bans and unjustified quarantine measures.

Do we still need to bring in medical personnel?

Foreign medical teams are still needed, especially as health systems in the region are very weak. Although the pattern of the outbreak in Liberia has changed, we still need qualified people. Many Liberian colleagues have been infected and 177 are reported to have died. And the outbreak is not yet over. If not for Liberia, we need teams to assist the other countries in the region. This outbreak has no borders and one single case in one country can rapidly spread across the region.

We should take stock of the lessons learnt and continue to create the right conditions for deploying medical teams, such as ensuring medical evacuation and insurance. We need to contain an outbreak like this where it happens, when it happens. Delays in the response have a high cost in terms of human lives, but also in financial terms and with regard to the stability of the countries and the region.

What type of personnel is most needed?

We need personnel to staff the Ebola treatment centres: doctors and nurses, people who know about psycho-social support. Possibly more laboratory support, although the issue right now is more related to the transport of samples than lab capacity in itself. And we need people with expertise in the strengthening of health systems to help restore safe healthcare services. At the beginning of December last year, only 46% of the health services were said to be functioning. And we need possibly also epidemiologists, if they can stay long enough to improve the use of data in 'real time'.

Do we also need to adapt our response?

Yes, we should be flexible and dynamic so as to adapt to the real evolution of the outbreak. It is pointless to keep following plans that are no longer relevant. In this phase we need to decentralise the response system to the level of the country’s counties where 'hotspots' emerge in often hard-to-reach areas. When there’s an alert, we need to go there fast, assess the situation, rapidly get the samples to the laboratory to ascertain if it is an outbreak of Ebola or something else, and then mount a response that will contain the outbreak on the spot.

Right now there is no need to build more Ebola treatment units in Monrovia. Instead we should build small units in the counties, not with 100 beds but with 10. Earlier plans were made against the forecast of up to 1.4 million people infected by Ebola by the end of the year 2014. We don't have that same pressure now. The medical teams need to be where the treatment centres are, that is close to where the cases are.

How does the future look like?

Although at this stage it doesn’t look as terrible as predicted by some studies, we should not be overoptimistic or complacent. We still need to put many things in place and keep focus. It may take a long time to control the outbreak. If we fail, Ebola could become even endemic in the region. And if the virus persists in one country, it remains a threat to the entire region. A study in Sierra Leone looking at DNA linked 78 active cases of Ebola to one single funeral. One case is already an epidemic, and can re-start an outbreak anytime, anywhere.

The Ebola crisis has been a global 'wake-up call'. We must use the current phase to build our global strengths and prepare for the next outbreak, be it Ebola or any other disease potentially even more complicated to control.