As the Ebola outbreak in West Africa enters its fourth month, the World Health Organization (WHO) called for "drastic action" to stop the spread of the tropical virus on Thursday, while Liberia's health ministry said it needs more international support to handle the reemergence of the hemorrhagic fever the country is experiencing.
"WHO is gravely concerned [by] the ongoing cross-border transmission into neighboring countries as well as the potential for further international spread," Dr. Louis Sambo, the UN agency's regional director in Africa, said in a statement.
According to the WHO, the situation is now being considered the largest ever Ebola outbreak since the virus was discovered in central Africa in 1976, "in terms of the number of cases and deaths as well as geographical spread."
The organization said that every day over the last three weeks there has been a "significant increase" in Ebola cases reported.
An estimated 399 people have died since the Ebola virus first took hold in Guinea in March and quickly spread to Sierra Leone and Liberia. There have been at least 635 probable, suspected, or confirmed cases of the disease reported in the region to date.
"This is no longer a country specific outbreak but a sub-regional crisis that requires firm action by governments and partners," Sambo said.
While Guinea has been ground zero for the crisis, reporting 400 total cases of Ebola, concerns are growing over the recent spike of infections in Liberia, especially with the spread to the capital city Monrovia.
"Previous outbreaks were generally fairly rural and isolated in comparison. The move of Ebola into cities is a double-edged sword," University of Reading virologist Ben Neuman told VICE News. "Cities have better hospitals, so Ebola patients can get better care and have a better chance of survival."
But while urban centers, like Monrovia, may have better medical care, Neuman said "cities are a hotbed of human interaction, and may help the virus to spread more rapidly."
Since the virus first appeared in March, Liberia has tallied 63 infections, including 41 deaths, with 32 of those deaths occurring in less than a month — all between May 29 and June 24, according to WHO.
"The situation is not stable, it's volatile," Tolbert Nyenswah, Liberia's Assistant Minister of Health, told VICE News. "International support is very much needed."
Nyenswah also specified the growing need for international doctors and assistance in training local medical staff. He acknowledged that many international groups and agencies — like Doctors Without Borders (MSF), WHO, USAID, and the Center for Disease Control and Prevention — are all present in the country and have been helpful, but he said the Ministry is still in need of additional support. There are some outbreak epicenters within Liberia where only local medical officials are on hand.
Due to frequent border crossing between the three affected countries, Ebola unsurprisingly crossed into Liberia rather quickly during the initial weeks of the outbreak. However, for most of April and May the country did not see any new cases.
"In March it was a panic," Alaska Moore Johnson, editor and health reporter for Liberia's Daily Observer, told VICE News. "During the first outbreak, people were washing their hands more and stopped shaking hands."
But Johnson, who has been to several of the outbreak zones in Liberia, explained that when reports of new cases dropped off, people relaxed and went back to their daily lives.
"People are dying from Ebola, but people are still living in denial," he said.
According to Nyenswah, the main challenges Liberia faces in controlling the outbreak include social mobility, contact tracing, and providing medical staff with proper training and personal protection equipment.
There are social behaviors and cultural traditions at play as well. For example, one of the major areas of concerns in Liberia — and throughout the outbreak zone — has been traditional mourning practices.
One of the ways in which Ebola is transmitted is by coming into contact with an infected corpse. Funeral rites and rituals in the country often require touching the body, carrying the corpse through town from one locality to the next, and public burial ceremonies.
Many in the country also seek out traditional medical care at healing centers, even for Ebola symptoms. According to Nyenswah, on Wednesday alone, health officials had picked up three bodies from these types of alternative treatment clinics, although it wasn't yet confirmed whether they had been infected with Ebola.
In a June 24 press release, Chief Medical Officer and Deputy Minister at the health ministry Bernice Dahn warned that deaths at homes or clinics not certified by a licensed doctor should "be confirmed by the County Health Teams or the Ministry of Health and Social Welfare which will issue a death certificate and clearance before burial can take place."
"We have to do a lot to change the behavior of our people," Nyenswah said, citing radio announcement and public education campaigns being used to increase public awareness about the severity of the situation.
But government involvement may be part of the reason the population is not completely going along with Ebola risk reduction efforts in the first place. According to Johnson, after the lull in reports of new cases in April and May, when the government announced new infections and deaths in mid-June, people believed the government was lying to gain international aid.
"After a two month break, now they're saying with the most recent outbreak, that the government just wants to get some money," he said.
This lack of trust in authorities has been an enduring problem in the region throughout the outbreak. Previously, MSF Physician Armand Sprecher said international officials were having a hard time gaining the trust of people in Guinea. In fact, many believe medical workers are there to spread Ebola, not cure it.
"The way things are going, the virus might spread rapidly in the country because people are not taking precautions, even with the outbreak right now in the capital city," Johnson said.
And even in an Ebola outbreak, politics are not off-limits, especially on the side of the local health care workers.
Doctors, nurses, and hospital staff in Liberia went on strike in August over low wages, delayed or lack of payment, and poor benefits. According to Johnson, these conditions do not provide enough incentive to risk treating Ebola. Johnson expressed concerns that the medical workers may go on strike again, especially as the outbreak continues.
When a nurse died of Ebola at Liberia's Redemption Hospital in mid-June, the hospital workers fled. When Liberian President Ellen Johnson Sirleaf made a visit after the incident, she asked that Liberians stop politicizing the issue.
While the Ministry of Health has said they are working closely with local medical officials, they did acknowledge some problems in a June 24 press release.
"Health facilities are also requested NOT to refuse any patient who presents Ebola-like symptoms," the statement read.
According to the Ministry, there were also reports that health workers were not "adhering to infection control measures in handling patients." To combat this issue, the ministry asked health facilities to train their staff on Ebola management.
Nyenswah said there has been a lot of support from all levels of government, as well as good in-country coordination. While he stresses the need for more international help, personnel, and supplies, Nyenswah said the countries in the region were working well together. In fact on June 25, officials met in the Guinean capital of Conakry to discuss efforts.
On top of regional integration, Liberia may soon get the additional help it needs. In the Thursday announcement, the WHO announced it would hold an 11-country meeting starting in Accra, Ghana next week.
WHO will aim to bring together health ministers from the three affected nations, as well as the Gambia, Ivory Coast, Mali, Senegal, and Guinea Bissau, among others. Agencies like Doctors Without Borders and the Red Cross have also been invited.
"Everyone needs to work together to prevent further spreading, only with collective efforts from the top international stakeholders, to the government, to the citizens, that's when Ebola will stop," Johnson said. "If we still live in denial it will be bad for Liberia and the region."
Follow Kayla Ruble on Twitter: @RubleKB
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