Ebola veterans warn that vigilance is still needed as case numbers drop

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Marco Werman: It’s been one year since the World Health Organization officially declared that there was an Ebola outbreak in West Africa. Since then, more than 10,000 people have died from the disease. Recently, some good news from Guinea, Sierra Leone, and Liberia: the number of new cases is way down, and in some places schools have reopened. But health experts warn that the crisis as a whole is not over yet. British doctor Oliver Johnson just got back from Sierra Leone three days ago. He leads the Kings Sierra Leone Partnership in Freetown.


Oliver Johnson: In Sierra Leone, things have definitely improved from what they were towards the end of last year. So, from about August to December, there were just queues of patients outside the hospitals and the treatment centers trying to get beds. But in December, a huge number of beds, ambulances, and other essential services came online. So, but January the number of cases started to decrease significantly. So, things are getting better but we’re not out of the woods yet. We still have disease transmission, we still have four or five cases a day sometimes being diagnosed in Freetown, so we’re very mindful that we’ve got to keep the pressure up to get down to zero and catch up with Liberia, who are a bit further ahead.


Werman: But from your experience, you saw those trends at the hospital where you were working in Freetown?


Johnson: Yeah. We used to have queues outside the hospital, we used to have every bed full, we were diagnosing seven or eight new patients a day. now it’s two or three patients a week. So, things are definitely better. But I’d have hoped by now already that we’d be seeing zero cases and there are still some. If you look at neighboring Guinea, you’re starting to see signs that there might be an increase in cases. So, we’re very mindful that this trend isn’t inevitable, that the cases could start to increase again. Until it gets to zero, things aren’t over.


Werman: You were in Freetown coincidentally when the Ebola outbreak started. You started your relationship with Sierra Leone in 2009, working on health systems. When you pull back, when you look at the last ten years in Sierra Leone, what have you seen as the overall story of health infrastructure in that country?


Johnson: What’s particularly sad and challenging about this outbreak is that Sierra Leone was really starting to come out of a previous devastation, and that was the civil war. Sierra Leone became known for blood diamonds, for child soldiers, and for horrendous mutilation and war crimes and other things. It’s not the country I know. The country I know when I first went out there in 2009 was a completely peaceful place, and yet it still had this brand. Now, of course, it’s been set all the way back again with a new stigma around Ebola. This outbreak has had a devastating effect on the health workforce. Once again, so many health workers have died because of Ebola. At the hospital where I work, some extraordinary individuals as well as key roles have been lost--a head of the department of surgery, the head of the emergency department, some of the key nurses have died and they’re irreplaceable. It really is a reminder that as much as this is about getting to zero for Ebola, that only opens up what comes next, which is an extraordinary task for Sierra Leone, hopefully with the strong support of the international community, to rebuild, to build back better.


Werman: What about concerns about the next outbreak of a virus like this? Last summer, we were so fluent in how these things work--they emerge, they kill some or many people, and then they retreat. But we know that they can come out again, maybe Ebola. Is there concern, like in Sierra Leone, that it’s going to hit Sierra Leone again as opposed to central Africa or some other part of the world?


Johnson: There’s absolutely a concern and it’s critical that we learn the lesson of this. As much as we should be proud of the national and international efforts, all the work that’s been done, we should also recognize that this outbreak was avoidable, and that the next outbreak is still avoidable but we’ve got to learn the lessons, we’ve got to put changes in place. Part of that is around strengthening health systems. So, we cannot just leave a country with a devastated health system and think that it won’t have consequences. We have to get in there early. Let’s invest now so that these sorts of outbreaks can’t happen. But there’s another side to that, and that’s how slow the international community was to appreciate the scale of the risk, of the threat, and to mobilize international resources to respond. I think that’s true of a lot of the international community. I mean, it’s extraordinary that Kings, a British university, has been on the frontline of a humanitarian medical emergency like this in Freetown. We have seen over a thousand Ebola cases in Freetown. But it’s extraordinary that a British university should have been left to do that, and it just shows how little the international response was in the beginning. In particular, I think there are some hard questions being asked of the World Health Organization to say politically why wasn’t this picked up on and taken seriously, and why were resources not committed to Ebola early on? But also, why has WHO not had more capacity, not had more technical expertise? So be it another outbreak in Sierra Leone of Ebola or Ebola outbreaks elsewhere, or a different disease, be it the MERS virus that’s emerging in the Middle East at the moment or something else entirely, I think that there is a great threat than we realize that we’ve got to acknowledge.


Werman: Oliver Johnson is a British MD who leads the Kings Sierra Leone Partnership in Freetown. He just got back from Sierra Leone three days ago. Dr. Johnson, thank you very much for your time.


Johnson: Thank you.


Werman: My colleague, Tulip Mazumdar, is the BBC’s global health correspondent. She’s traveled to West Africa several times over the past year to cover the Ebola crisis there. Tell us what you saw.


Tulip Mazumdar: It’s interesting, I remember going back in July, so the outbreak in Guinea was in full swing, what we saw, and I remember it very clearly, is that we went into one village that had been very resistant to get help from health workers. These health workers, some of them had been attacked last time they came, but they had negotiated with community leaders and they’d come back into that community. I remember going in there and people were understandably utterly terrified. They didn’t understand this thing, they’d had several members of their community die in this very harrowing way, and they didn’t know what was happening. You really got the sense of the mistrust--them being incredibly suspicious of the health teams that we were traveling with. But as time went on, by the time I went to Freetown a couple of months later, the Sierra Leone capital, there were buckets of chlorine outside every public building, we had our temperatures checked five, six, seven times a day, there were  Ebola posters everywhere telling people to avoid body contact because that’s how it’s spread. So, you really saw, from close to the start of this, fear and suspicion and confusion, and really as the outbreak went on, there was a better understanding of the virus.


Werman: But then there was also a sense of safety, perhaps a false sense of safety, and that dynamic then feeds a backslide as well, right?


Mazumdar: I think as time has gone on--sadly, this has raged on and, as we know, has killed so many--it’s only now from the start of this year that we’ve seen cases coming down and some degree of normality coming to these countries. Liberia, as we’ve heard, was in a much better place, there hadn’t been any cases for the last three weeks or so, but sadly over the weekend we did hear about Liberia’s first new case in about three weeks and that was a real blow. But that does go to show that the world, specifically these three countries, cannot switch off to this; even though cases are coming down, this is very far from over. As it continues in Sierra Leone and Guinea, the rest of the countries of West Africa and, indeed, the world remain at risk.


Werman: Have you kept in touch with any of the people you met earlier in your coverage who survived the infection?


Mazumdar: We went to an orphanage back in January and sadly the man that ran that orphanage that we had interviewed, Augustine Baker, you may have heard in the news that he tragically caught Ebola himself. His job was to go out into communities, find young children orphaned by Ebola and bring them into the orphanage if they didn’t have anybody else to take care of them. He himself contracted Ebola. We’ve since heard that his wife also caught the virus and has died. They’ve left three children, now orphaned by Ebola. Again, it just goes to show how far from over this is. I very much hope to be able to get back to Sierra Leone and visit that orphanage. The orphanage itself was put into quarantine for three weeks to make sure nobody else got sick there. Thankfully, they’ve come through that period and everyone else there is okay.


Werman: Just lots of stories mixed with resilience.


Mazumdar: It’s the hundreds of health workers, and we met many of them, the West Africans who have come on board and fought this virus from the very, very beginning, putting their lives at risk. I met one nurse, she lost 17 members of her family, she’d caught Ebola herself and had survived, and she was, within days of surviving and pulling through, back in the hospital and looking after Ebola patients. There were so many tales of great bravery and resilience in the face of what was and what is such a tragic situation.


Werman: Yeah, those people’s stories are so inspiring. We keep hearing, as we just did from Dr. Johnson, that Ebola is not over until there are zero patients attached to this outbreak. What does that mean for you? Are you on the beat until there are no more patients?


Mazumdar: Once Ebola is done, what happens next? The health system was completely decimated by this outbreak. These three countries have lost hundreds of health workers, which they simply couldn’t afford to do. So looking ahead, we need to keep reporting on what happened to immunization programs, what happened to people who were having HIV treatments or cancer treatments--all of these things have been interrupted and things could get much worse for people who have literally no health infrastructure in the coming months. I think it’s very important that we keep tabs on that, and I’ll certainly be doing that.1


Werman: Tulip Mazumdar, the BBC’s global health correspondent. Thank you very much for your reporting.


Mazumdar: Thank you.