Progress being made, adapted response still required

In terms of the number of cases, Liberia has been the worst hit by this outbreak, and Monrovia and the
capital region the most gravely affected area of the country. Case numbers have begun to drop in
Monrovia, and the four case management centres (CMCs) in the capital currently have spare bed
capacity. However, elsewhere in the country, such as in Bong, Margibi, Gbarpolu, Grand Cape Mount
and River Cess counties, new cases are appearing. The outbreak is far from over, as a single case can
start a localised epidemic.

Case management facilities with large bed capacities are now being built by foreign governments and
NGOs. Beds for Ebola patients are currently concentrated in the capital, and 16 more CMCs are to be
built across the country. However, the staffing of these planned case management facilities will fall
largely to “implementing partners”, such as local healthcare workers and NGOs. A number of actors
are providing training to these implementing partners; but it will take some weeks before these
individuals are trained up and ready to safely care for patients.

Striving to deliver on what was promised two months ago, many international actors seem unable to
adapt to the rapidly-changing situation in Liberia.
The result of this is that resources are being
allocated to activities that are no longer appropriate to the situation. For example, the Chinese
government has just built another 100-bed CMC in Monrovia – where there were already 580
operational bedsin four existing CMCs – while there are only 178 operational beds in CMCs in the
rest of the country. Two more CMCs are planned to open in the same neighbourhood.

Though seemingly sufficient in Monrovia for the moment, isolation and supportive medical care for
patients are still urgently needed in rural parts of the country. In some cases, such as in River Cess
county, patients must travel for up to 12 hours by road in order to reach a functioning laboratory and a
CMC. Getting care to patients in rural, hard-to-reach areas poses major challenges in terms of logistics
and transport.

In many places, personnel at regular healthcare facilities have not received training on infection
control and how to manage Ebola patients,
should one walk through the door; nor have they received
medical equipment required to protect themselves. Healthcare facilities are fast becoming sites of
Ebola transmission and many have closed as a result: in Monrovia, for example, most healthcare
facilities have shut their doors. To allow them to safely reopen, triage points must be set up in these
structures, and activities to restore trust in healthcare facilities must be carried out.

There are still active chains of transmission in almost every part of the country, demonstrating the
need for further awareness-raising and community engagement. MSF teams are still finding that
misconceptions about Ebola are widespread and stigma is intense, leading some to avoid seeking
treatment or report cases. On a recent exploratory mission to Bong county, for example, MSF found
that people who had been in contact with the sick were fleeing into the bush so as not to be traced as a
contact or taken to a case management facility, fearful of what may happen.

Other activities that require urgent support – especially in remote, rural parts of the country – are
laboratory services(with transport if necessary for quick turnaround),safe burials, alert and
surveillance systems, ambulance services and contact tracing. Though Ministry of Health (MOH)
teams have been dispatched to all countiesto carry out these activities, they sometimes lack the basic
equipment necessary to do it and are not paid for their work. On an exploratory mission to Margibi
county two weeks ago, MSF found that contact tracing and active case finding teams lacked essentials
like vehicles and SIM cards for their mobile phones. Support from foreign actorsis starting to appear
in some affected rural counties; but there are others where this is not the case.

MSF has seen that a comprehensive response to Ebola that includes all of the necessary elements can
help to reduce transmission. In Foya, Lofa county, where the full complement of Ebola response
activities has been carried out and the local community has been very engaged, there has not been a
single confirmed case for more than four weeks. In this fluid and rapidly-changing outbreak, all actors
involved in the response to it must take a flexible approach and allocate resources to activities when
and where they are most needed.