Global response to Ebola in Liberia hampered by infighting

The global response to the Ebola virus in Liberia is being hampered by poor co-ordination and serious disagreements between Liberian officials and the donors and health agencies fighting the epidemic, according to minutes of top-level meetings and interviews with participants.

Even now, three months after donors began pouring resources into Liberia, many confirmed cases still go unreported, countries refuse to change plans to erect field hospitals in the wrong places, families cannot find out whether their relatives in treatment are alive or dead, health workers sent to take temperatures sometimes lack thermometers and bodies have been cremated because a larger cemetery was not yet open.

The detailed accounts of high-level meetings obtained by the New York Times, the most recent from Monday, lift the veil on the messy and contentious process of running the sprawling response to Liberia's epidemic, one that now involves more than 100 government agencies, charities and donors from around the world.

Despite these problems, with help from donors, Liberia, one of the three most afflicted west African countries and with the highest death toll, has seen new cases drop to about 20 a day from about 100 a day two months ago.

Experts attribute that to fearful Liberians touching one another less, more safe burials of bodies and distribution of protective gear to health care workers. However they also warn that cases are now holding steady and could explode again.

Participants at the meetings of the Incident Management System – which replaced the National Ebola Task Force – said the atmosphere

should not be characterised as chaotic or bogged down in bickering, instead calling them “collegial” and “effective”, although one who spoke on condition of anonymity described “showmanship and political posturing”.

Senior officials of the Centers for Disease Control and Prevention who attended – Dr Frank J Mahoney and Dr Kevin M De Cock – said in an email that there were “differences of opinion – accompanied by passionate discussions”.

At Monday’s meeting, De Cock cited serious logistics problems, including regular hospitals that could not separate out Ebola patients, counties with no ambulances and even temperature takers with no thermometers.

On November 12th, the representative of the UN secretary general complained that “hundreds” of vehicles had been made available but there was always a shortage. Asking where they were, he added: “The recipient also has to be accountable, just as the donor.”

The support documents also indicate that there is no national plan for Ebola survivors – either for reuniting them with their families or for using them to do nursing tasks because they are thought to be immune.

A report on the issue reads: “The current and planned work presented by the partners and government for survivors can be characterised as fragmented and lacking in scope, scale, comprehensiveness, evidence base and survivor-driven programming.”

US military helicopters ferrying doctors to remote areas were forbidden to fly back not only patients but even blood samples; recently, samples from a village had to be walked to a road four hours away.

At Monday’s meeting, according to the minutes, De Cock called this “unacceptable”, adding: “This has to change this week.”

Dr Hans Rosling, a Swedish epidemiologist and consultant to Liberia’s health ministry, said the helicopter order came “from somewhere in America.”

In an interview, he cited problems not listed in the minutes.

One Asian and two European donor countries were insisting on building new Ebola field hospitals in Monrovia, where hospitals have empty beds, rather than in remote counties where beds were desperately needed, he said – they insisted because they announced those plans two months ago; the national case count was not reported for two days recently because the government employee compiling it went unpaid and stopped working.

The minutes of the Incident Management System were made available along with PowerPoints and other documents by an expert who said the disorgani

sation of the Ebola effort should be made public.

The meetings are usually chaired by Tolbert Nyenswah, the deputy health minister, and include representatives from the Centers for Disease Control, the World Health Organisation, the World Bank, the UN Mission for Ebola Emergency Response, numerous UN agencies, the US Agency for International Development, the US Army, Doctors Without Borders and medical, aid or military representatives from many other countries. Nyenswah and other ministry officials could not be reached for comment; Rosling has worked with the ministry since October.

The minutes make it clear that accuracy of the national case count is shaky. On November 5th, Rosling said, “We are absolutely sure that we cannot be sure about the data.”

In an interview, he said that to improve reporting of cases, he gave a $13,000 Swedish government grant to “a chronically honest church lady” to buy mobile phone scratch cards for health officials in remote areas.

The CDC is bringing satellite phones to areas lacking mobiles service.

Despite problems, he added, the response was better than he had hoped. He compared it to Dunkirk, the hasty 1940 evacuation of British troops from France, which he described as “chaotic, but a success”.

In the minutes, Liberian officials regularly complain about the donors and the donors argue back. On November 12th, James Dorbor Jallah, the task force’s deputy manager, said: “People will sit in DC or Geneva and want to direct what is happening here.”

The health minister, Dr Walter T Gwenigale, backed him up, complaining that “the UN and other agencies got their money before the ink was even dry”, while, he said, a group run by a Liberian pastor to teach rural people about Ebola “has not gotten one cent”.

On Sunday, President Ellen Johnson Sirleaf replaced Gwenigale without explaining why, but said he would remain an adviser. Dr Emmanuel T Dolo, Sirleaf's youth adviser, complained that the donors were "showing a level of disrespect" by judging Liberian community groups by "harsh standards" and "western standards."

At the same meeting, Nyenswah, the deputy health minister, pointed to his government’s “team leaders” and warned: “Partners in the room have not been engaging them and involving them in strategy – but you have to.” A representative of the UN Children’s Fund replied that the local pastor needed to prove he could do the work. Two days later, Shiyong Wang, the World Bank representative, confirmed that UN agencies had received nearly all their money and that the Liberian government had received only 7 per cent of the $23 million allotted to it.

However, he said, the government had not produced required documentation – not even, for example, names of dead health workers whose families awaited compensation.

He criticised the government’s “overly complex and bureaucratic approval process”, including three signatures on each document.

Rosling said the three signatures were an anti-corruption measure. Beneficiary lists were hard to produce, he said, when Liberians had children whose births were often not officially recorded. And it was “arrogant,” he added, for donors to, for example, assign contracts to operate field hospitals without health ministry permission.

The November 12th meeting appeared to end on a bitter note, with Nyenswah telling every agency to document within 48 hours what people it had and what their jobs were. “If you don’t give us this list,” he concluded, “you are not allowed in this meeting.”

The meeting of November 14th opens with Nyenswah reminding scientists not to do research without permission from a government ethics review board. On November 17th, Dolo complains that "there are a lot of people in this room who never contribute anything to this meeting." – (New York Times service)