As Ebola Ebbs In Africa, Focus Turns From Death To Life

By: NORIMITSU ONISHI JAN. 31, 2015

Life is edging back to normal after the deadliest Ebola outbreak in history. At the height of the epidemic, Liberians met horrific deaths inside the blue-painted walls of the Nathaniel V. Massaquoi Elementary School, as classrooms became Ebola holding centers and the education of a nation’s children, shuttered in their homes for safety, was abruptly suspended.

Now, parents are streaming into the schoolyard once again, not to visit their stricken loved ones, but with their restless children in tow, to register for the start of classes in a delayed and shortened academic year. Eager to learn and to play with her friends again, Florence Page, 11, bounded ahead, brimming with pent-up energy, as her mother, Mabel Togba, paused to look warily into the school building through its padlocked metal screen doors. “They still haven’t told us that Liberia is free of Ebola, so I’m still afraid,” said Ms. Togba, 42. “But it’s better than to leave my children at home doing nothing.”

New Ebola cases in Liberia, where streets were littered with the dead just a few months ago, now number in the single digits, according to the World Health Organization. In neighboring Sierra Leone and Guinea, the other two nations in the Ebola hot zone, new cases have fallen sharply in the last month, dropping to fewer than 100 in a week at the end of January — a level not seen in the region since June. With a virus as deadly as Ebola, officials warn that the epidemic will not be over until cases reach zero in all three countries. But after nearly 9,000 deaths from the disease, the W.H.O. announced last week that it was focusing on a goal that had seemed out of reach for much of last year: ending the Ebola epidemic, no longer simply slowing its spread.

Here in Monrovia, the capital, ambulances and body collection vehicles that once barreled through the streets are a rare sight. Soccer matches are now played throughout the city on weekend mornings. Buckets filled with chlorine water are gone from most entrances, or sit empty. People can be seen shaking hands once again, squeezing into taxis and touching during conversations, as the fear of the virus ebbs and Liberians slip back into their daily, tactile rhythm.

“We used to be afraid to touch our friends, but the fear is small, small now,” Patrick Chea, 19, said outside Mary Brownell Junior High School, where students horsed around as they cleaned up the schoolyard. Mr. Chea playfully placed his hand on the head of SonnieKollie, a 16-year-old girl — who promptly punched him on the shoulder. Experts are trying to understand how the disease, which has defied the ominous predictions of the world’s top infectious disease researchers, appears to be extinguishing itself with surprising swiftness. In September, the United States Centers for Disease Control and Prevention had projected that, by Jan. 20, the outbreak could reach 1.4 million cases in Liberia and Sierra Leone alone, but by that date only 21,797 were recorded in all three countries.

While many have emphasized the enormous assistance hauled into the region by the United States and international organizations, there is strong evidence, especially here in Monrovia, that the biggest change came from the precautions taken by residents themselves. “Fundamentally, this is about the extent to which societies change their behaviors, how they change them, and the speed at which they change them,” said Dr. David Nabarro, the United Nations special envoy on Ebola, who made frequent trips to the hot zone at the height of the epidemic. “I believe for various reasons people in Liberia changed quickly and dramatically. I believe Sierra Leoneans changed quickly in some areas and less quickly in some areas.”

When Ebola struck the densely crowded neighborhoods of Monrovia over the summer, the first time a capital city had faced Ebola’s full onslaught, the impact was devastating. Hundreds of new cases appeared around the country every week, hospitals collapsed or overflowed with patients, and sick people lay along the road, sometimes dying before help could reach them.

Disease Watchdogs

Reeling from the explosion of infections in August, volunteer Ebola watchdog groups sprang up in many neighborhoods, typically overseen by local elders and led by educated youths, drawing from a long history of community organizing to survive war, poverty and government neglect.

With little or no outside help in the early months, the groups educated their communities about Ebola, a disease new to this part of Africa, and collected money to set up hand-washing stations at key spots. They kept records of the sick and the dead. Many also placed households under quarantine and restricted visits by outsiders. As the sick were turned away at the gates of treatment centers because of a lack of beds, people inside homes began protecting themselves better, covering their arms in plastic shopping bags as they cared for ailing relatives. The gear became known as Liberian P.P.E.’s, or personal protective equipment, a reference to the more impermeable suits worn by health workers.

By mid-October, new cases in Liberia had dropped precipitously, to dozens from hundreds per week. A few clinics run by Liberians and international charities had opened, but the drop took place a solid month before any of the treatment centers built by the American military had even begun accepting patients. “Heroes emerged in every community,” said Dr. MosokaFallah, a Harvard-trained Liberian epidemiologist who often acted as a liaison between neighborhoods and the government. “The volunteer task forces may be the biggest reason behind the drop in October.”

The international response has been vital as well, Liberian officials and community leaders said, greatly expanding diagnostic and treatment options for people stricken by the virus. Even if many of those beds appeared late and sat empty, they said, the sight of the world rallying to their side reinforced the importance of the epidemic and provided a psychological boost to a beleaguered population.

“This was the first time in our nation’s history that we saw actual American boots on the ground,” said Liberia’s president, Ellen Johnson Sirleaf. “You can’t imagine the difference it made in the hopes of the people. It inspired them to do more.” In Sierra Leone, residents have also taken many matters into their own hands, criticizing their government and Britain, the country’s former colonial master, for a slow and disorganized response. Laid-off teachers tracked infections, some villages set up informal isolation centers, and residents in some neighborhoods set up blockades, taking the temperatures of those who entered.

“The cavalry wasn’t coming,” said David Mandu Farley Keili-Coomber, the paramount chief from the Mandu chiefdom in Sierra Leone’s east. “We were the cavalry.” He said that the region’s chiefs enlisted the traditional leaders in the area and put together bylaws that barred residents from hiding their sick, interfering with health workers or carrying out traditional burials that increased the risk of spreading the disease by touching infected corpses. “We threatened that anybody who tried to do a traditional burial would be banished from the chiefdom,” he said.

Health officials are still trying to figure out why Liberia, once the raging center of the epidemic, experienced such a big drop in cases so quickly, especially compared with its neighbors. Unlike in Sierra Leone and Guinea, some noted, Ebola cases in Liberia were disproportionately concentrated in the urban setting of Monrovia. Initially, experts believed that would make the conventional method of combating the virus — tracing the contacts of infected people and isolating them — much harder, as large crowds of people moved about freely. Trying to figure out who had touched whom seemed a mind-boggling task. But the urban setting, it turns out, may also have presented a key advantage: a more educated population that was quicker to adapt. Beyond that, the virus was right in the center of power, making it impossible to ignore.

Resistance in Guinea

By contrast, in Guinea, where the epidemic has been concentrated in rural areas, change has often been slow and resistance fierce, fueled by a history of tensions with the central government. It took months before some villages in Guinea — where residents have killed local officials proselytizing about Ebola, blocked roads and refused help from outsiders — began letting health workers enter, their resistance waning only after so many among them had died.

Even in late January, more than a year after the epidemic started, three priests were assaulted and their car was set on fire in western Guinea by villagers who mistook them for Ebola awareness campaigners. More broadly, some experts pointed out that the surge in cases in Liberia also hit sooner, in August and September, forcing a strong response more quickly. In Sierra Leone, the surge came later, peaking in the fall, before plummeting this month. Dr. Tom Frieden, director of the United States Centers for Disease Control and Prevention, said the delayed drop in Sierra Leone’s cases simply reflected a delay in their climb.

“It’s a mistake to say Liberia did better than Sierra Leone,” he said. “The explosion in Sierra Leone happened eight weeks later. It’s not that they’ve taken longer to control it. It’s that they took longer to get there.” Sampson Nyan, the commissioner of the West Point neighborhood in Monrovia, said that the new Ebola cases since last October mostly stemmed from lingering denial about the disease, which he and others said persists in small pockets.

But even in West Point — the huge Monrovia slum that was placed under violent quarantine for 10 days by the government in August, leading to riots and the death of a 15-year-old boy — attitudes about the epidemic began shifting early. He said a change in behavior over the course of September bore fruit in the sharp drop in infections the following month. “You can create an E.T.U,” he said, referring to an Ebola treatment unit. “But if family members don’t want to carry a member to an E.T.U., there will still be a problem. When people started to change their attitudes, and call the Ministry of Health or an ambulance, the cases started going down.”

In Parker Paint, a neighborhood in eastern Monrovia, the local volunteer watchdog group helped limit Ebola cases to just one — even though the community was surrounded by four neighborhoods with high rates of infection. ObediahDaykeay, 22, who studied computer science at a technical college and served as the watchdog group’s secretary, read up on Ebola at an Internet cafe and printed documents for the community. The group invited Dr. Fallah, the Liberian epidemiologist, after listening to him talk on a local radio station. But aside from that visit, and a contribution by a local politician enabling them to buy buckets and T-shirts, the local watchdog group was on its own during the height of the epidemic, raising awareness and instructing residents on the proper use of bleach and water.

In September, as the epidemic widened, the group’s chairman, Jeremiah Fahnbulleh, 27, another technical college graduate, proposed two measures that many communities would adopt in one form or another: outsiders would not be allowed to spend the night in Parker Paint; and residents leaving Parker Paint for more than two consecutive nights would be placed under quarantine upon their return. Standing under a mango tree next to his family home, a transistor radio at his side, Mr. Fahnbulleh said he came up with the idea after listening to the radio during a sleepless night.“The thought came to me that Ebola came from one place to another, from house to house, from community to community,” he said. “Listening to the radio, I got to know how people got infected.”

‘The Sun Is Shining’

Today, as Liberia’s Ebola cases can be counted on one hand, the end of the epidemic appears in sight to many. “The sun is shining,” said Deborah R. Malac, the United States ambassador to Liberia. Recently, she was in Barkedu, Lofa County, one of the hardest-hit communities in rural Liberia. A town of 8,000 people, Barkedu had endured more than 1,000 Ebola deaths. Whole families were wiped out as Ebola tore through the town, where the mostly Muslim population observed local traditions like washing the bodies of the dead.

But Ebola has not been in Barkedu for more than 90 days, she said. And the protective bubble that Liberians had erected around themselves to avoid touching others and possibly become infected had dissolved. “The ladies were dancing, we were all much closer together,” she said. “It was much more normal, and I wasn’t really particularly concerned that someone might touch me.”

At the Mary Brownell Junior High School in Monrovia, many Liberian parents have re-enrolled their children despite their lingering fears of Ebola. Classes, originally scheduled to resume on Feb. 2, are now expected to start in mid-February. Joseph Garway, 46, came to register a son. He has three children, but he now also takes care of four more: the children of a cousin who, along with his wife, died of Ebola last August. “We are worried, but still we want our children to go back to school,” he said. “If we don’t do that, our children will be left behind, and the country will not be well.”

Felicia Koneh, who wakes up at 3 a.m. to bake shortbread and sells her goods on the streets or in schools, saw her daily sales of $16 fall to $6 during the height of the epidemic. In the last couple of months, though, they have risen slowly to $12, and Ms. Koneh hoped that the reopening of schools would lift her sales further. “Little by little,” she said, “things are returning to what they were like before Ebola.” (Courtesy of New York Times)

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