Exorcising the ghostly fever

THE first time Jonah Kieh heard about Ebola was last spring, when a friend warned him of a “wickedness” spread by ghosts, turning victims feverish and then killing them. Mr Kieh was visiting his extended family near Takpoima, in the forest of Lofa-Mano national park in Liberia, to sell hair brushes and other cosmetic products from Monrovia, the capital. He paid little heed to the wickedness, but after several weeks he became frightened as people kept dying around him. “I ran back to Monrovia,” he says. Back in West Point, the city’s main slum, Mr Kieh fell ill with either Ebola or malaria (the initial symptoms are very similar). He stayed indoors for weeks and eventually recovered.

Mr Kieh’s story says much about the spread of Ebola. The illness first broke out some time in December 2013 in the remote town of Meliandou, in the forest of Guinea. Through ignorance, lack of prompt diagnosis and the movement of people, it spread and took hold in the teeming cities of the region—especially Monrovia and Freetown, capital of Sierra Leone.

It took months for villagers to view the virus as a medical rather than spiritual problem, superstition being a central part of life in the forest. Occult leaders encouraged the expulsion from the community of the sick, further accelerating the epidemic. Even when villagers accepted the need for medical help they initially relied on traditional healers who treated them with tree bark. Dead bodies, which are highly infectious, continued to be washed by hand before burial, according to local rituals. Rather than isolate the sick, families drew closer to care for them. “Relatives came to bring food and be together,” says Mr Kieh. Especially in the cities, cramped conditions provided favourable conditions for a disease that is passed on by contact with body fluids. Neighbours share toilets, taps, bedrooms and, at times, mattresses.

The situation was made worse by mistrust of government. Many avoided health workers and hid the sick so that they would not be taken away to hospitals, where the patients all seemed to come out dead. Indeed, some blamed the government for the sickness. “Anything so deadly must come from the powerful, we thought,” says Momo Conneh, a teacher in Takpoima. Years of conflict, and power-grabbing elites, have bred profound mistrust of officialdom. In Liberia the descendants of American slaves are dominant. In Guinea officials a generation ago tried to secularise rural communities and destroyed symbols of traditional worship, such as masks.

Eventually, though, communities have listened to advice and adapted: “learning by dying,” as one foreign-aid worker put it. After watching neighbours perish, hand-washing with diluted bleach is now common in the region, as are signs saying ABC: Avoid Body Contact. Instead of shaking hands many greet each other by touching covered forearms or legs. In churches many congregants sit a few inches apart to avoid contact. Public buildings have temperature checks at the entrance. Ebola survivors are being enlisted to travel to affected towns and educate people by retelling the story of their healing. Others volunteer in hospitals, taking advantage of their hard-won immunity. “Someone like me has a duty to help,” says a 26-year-old survivor in Tubmanburg in Liberia. Clinical trials with transfusions of survivors’ blood are starting (see article).

Hospital treatment and swift burials have become commonplace. Grave-diggers say they were taunted a few months ago but now receive occasional expressions of thanks. Secret funerals by candlelight in breach of strict government rules have become rarer. One nurse in Conakry, the capital of Guinea, shows off a pocket calculator given to her by the grateful family of a patient.

Fear is slowly waning. Some already speak about Ebola in the past tense. In Monrovia combative football matches are played on the edge of West Point and markets are thriving. A nightclub called Moon Bar playing American hip-hop reopened after painting anti-Ebola slogans on the wall. Patrons say they are warier of strangers; aftershave masks the smell of chlorine.

In September American officials estimated that, in a worst-case scenario, 1.4m people might become infected by January. Such figures now seem alarmist, given that the total number of infections stands at fewer than 20,000 (with about 6,300 deaths). The number of new cases is falling sharply in Liberia, though it remains high in Sierra Leone (see chart). Hospital beds remain in short supply in Sierra Leone and new graves are being continually dug. Though the outbreak started in Guinea, its epidemic was not as acute.

What accounts for such differences? Three possible explanations have been advanced. First, health infrastructure is better in Guinea. According to Afrobarometer, a research company, the share of people with access to clean water in Liberia and Sierra Leone is 11% and 25% respectively, while in Guinea the figure is 83%. Similar discrepancies apply to the health sector.

Second, the three countries have received different levels of international help. Guinea, a former French colony, received what little it needed promptly from France and was able to confine the disease mostly to rural areas. Liberia, founded by former American slaves, has been the recipient of a vast American aid effort. Sierra Leone, a former British colony, received help from the United Kingdom on a smaller though now increasing scale.

A third factor is that Sierra Leone has struggled with public-sector strikes. Hundreds of health workers in Bo County protested in November against the government’s failure to provide a promised additional $100 a week in hazard pay. In Freetown hundreds of unpaid contact tracers besieged the health ministry. In Kenema unpaid burial workers dumped dead bodies, among them babies, on the street outside a hospital.

Overall Sierra Leone may be cursed by the fact that it is neither as developed as Guinea, nor as wretched as Liberia, which still has a UN peacekeeping mission that could offer help before the American effort took off. Geographically, too, Sierra Leone is the middle country, with Ebola-struck nations on all sides.

Nonetheless, the UN reckons that in most of the region it is now meeting its goal of getting 70% of the infected into clinics and 70% of the dead properly buried—the level needed to tame the epidemic. One consultant says the fight has turned from an industrial war into a guerrilla fight. Some doctors and aid workers fear this is just a lull: the recent end of the rainy season may lead to an increase in travel and, with it, rising rates of infection. In any case, World Health Organisation officials warn that complacency is a “major obstacle”.

The biggest challenge now confronting Ebola-struck states, particularly Guinea and Liberia, is to control new cases in remote areas, lest they start a new cycle of infection. There is a shortage of personnel; remote communities struggle to live with the rigour of avoiding body contact. Can a sick child, perhaps one that has lost its parents, be entirely quarantined?

The worst-affected west African countries took time to respond effectively to the crisis. But their governments now appear to be fully focused on the problem. In Sierra Leone and Liberia, health ministers have been replaced with more capable officials. The collapse of already-weak institutions, a prospect that many worried about just a few months ago, has been averted. Liberia is already planning to have a national remembrance day for Ebola victims once the epidemic is over.

There is much that could still be done better. The response continues to be hampered by poor co-ordination and the weakness of states; morticians can be bribed to release infected bodies to relatives who want a traditional burial; clinics are short of donated gloves, which end up on the black market; donors complain of vehicles unaccountably disappearing. By contrast, local officials complain of foreigners who prefer to give funds to external organisations rather than to state bodies. Yet the judgment of one consultant, who drew a parallel with the British army’s retreat from Dunkirk in 1940, sounds about right—the struggle is “chaotic, but a success”.