The first case of Ebola Virus Disease (EVD) in Liberia was reported in March 2014, and in less than six months, the World Health Organization (WHO) announced the situation as “a public health emergency of international concern”. Although past outbreaks had similar fatality rates - of approximately 70% -, those outbreaks occurred in remote and sparsely populated locations where transmission was much lower . The 2014 outbreak was uncharacteristic as it was the first time the disease affected highly populated cities, such as Liberia’s capital, Monrovia . At the peak of EVD in Monrovia, where 90% of the country's population is located, there were approximately 200 cases per week. Ebola is transmitted through direct contact with other infected individuals; therefore, in urban settings, the virus may have a severe impact because of the close proximity in which inhabitants live and work . Monrovia is the largest city in Liberia and has a population density of over one million people, all located within an area of 194 km2 . This high population density allowed the virus to spread quickly; however, the devastating outcomes of the 2014 Ebola virus in Monrovia were further facilitated by the lack of pre-existing infrastructure, poor healthcare and sanitation systems, and rural to urban and cross border migration.
Infrastructure encompasses the social and economic organizational structures and facilities required for a country or city to function. The role of infrastructure and the spread of diseases have had a significant connection for hundreds of years. One early example of this connection is the mapping of cholera outbreak locations by John Snow in London during the 1800s. Using his maps of outbreak locations, he was able to see the role that infrastructure (specifically the water system) played in the spread of the disease. This new knowledge allowed for changes in the system to be made in order to better contain the disease. The importance of infrastructure is critical in urban settings by significantly affecting access to public and private facilities, and it represents the role of the government within these systems. Specifically, the majority of Liberia's population lives in Monrovia and the maintenance of infrastructure (or lack thereof) has been crucial in how the the 2014 Ebola epidemic unfolded. Prior to the outbreak, Monrovia was not sufficiently equipped with healthcare workers: only 51 doctors served Liberia’s entire population of 4.29 million people compared with South Africa’s 3,290 doctors for the same population in 2015. Another key factor in the catastrophic spread of EVD in Monrovia was migration. Before the virus spread to urban areas, Aylward et al. note that it had been confined to smaller populations, predominately in isolated forested areas. The spread to Monrovia was facilitated by highly interconnected populations: not only was there rural-urban migration to the heavily populated capital, there was also cross-border travel in West Africa, between Guinea, Liberia, and Sierra Leone. This combination became a lethal tool for EVD to disseminate amongst much denser populations such as Monrovia. The World Health Organization (WHO) concluded that denial and stigmatization surrounding Ebola in Liberian culture was a potent factor in the rapid diffusion of the disease; there was significant mistrust towards doctors and treatment facilities, thus many families “[hid] infected loved ones in their homes. Given the nature of the virus, these practices were ineffective for containment. Although there were many complex components, Monrovia-specific factors that worked together to exacerbate the 2014 outbreak, in our increasingly connected world it is important to understand health epidemics in urban centres in order to try to mitigate future pandemic diseases.
Infrastructure in Monrovia: Major Challenges to the Containment of EVD
The types of infrastructure in Liberia, and specifically Monrovia, were imminent challenges for the sustainment the crowded population prior to the Ebola epidemic. Out of the five West African countries severely affected by EVD, the number of cases were highest in Liberia, and they were “exacerbated by extraordinary socioeconomic disadvantage and health system inadequacies”. These included Monrovia’s prison system, nominal numbers of hospitals and treatment centers, outstanding loan payments to the International Monetary Fund (IMF), and extreme poverty in West Point slum.
One example of the plethora of issues facing the government of Monrovia during this time was their prison system. Just five months after the first cases of EVD were identified, the government began releasing inmates and announced they would temporarily cease to arrest and imprison citizens for minor offenses. While not explicitly stated, this decision demonstrates the government’s prioritization of funding towards the healthcare system and away from the penal system. Prior to the outbreak, Monrovia Central Prison was described as violating basic human rights: inmates did not have access to food, water, or healthcare. Furthermore, its designed capacity of 374 inmates had more than doubled, and “[i]n some cells there [wasn't] room for all inmates to lie down at the same time so they [slept] in shifts”. The overcrowding and absence of services indicate a prime breeding ground for EVD. Although the prison system in Monrovia was deficient given the number of inmates, this temporary policy illustrates a proactive response to the city’s growing need to redirect scarce resources towards the EVD epidemic and to dissipate areas of overcrowding.
Infrastructure also affected the “case isolation outside of Monrovia [...] [due to] the scarcity of ambulances for prompt referral to Ebola-specific treatment centers”. Further, assuming the number of emergency vehicles to transport infected individuals to treatment centers (where they could be properly isolated) was sufficient, many of the roads to rural areas were not accessible. This maintained the severity of cases in peri-urban areas, through hindering the ability to isolate known cases. Moreover, multiple sources emphasize the importance of “Reducing nosocomial transmission with the use of personal protective equipment (PPE) [...] to maintain medical infrastructure and to implement case isolation”. Even though it was reported that clinic assessments were conducted in order to update facilities in rural areas, reports of the same challenges persisted following additional containment training. Thus, Monrovia continued to be responsible for providing healthcare services beyond its city boundaries. This highlights the issues involved with merely addressing physical infrastructure as a containment strategy. Following targets set by the UN Mission for Ebola Emergency Response, more than 2,000 beds for treatment centers were available by December 14th. However, the geographical distribution of the extra beds did not coincide with the locations of active reports, nor their access to facilities with available space.
All of these cases can be linked to Liberia’s outstanding loans to the IMF (International Monetary Fund), accumulated debt starting from 1963. Furthermore, ‘conditionalities’ strained where and how the country could invest money into their fundamental sectors, specifically their health services and public health infrastructure. With the priority placed on debt relief, Liberia reduced the number of doctors to only 60, and healthcare workers’ incomes were capped at extremely low levels. Moreover, following the depletion of investment in health services, many public facilities were no longer maintained resulting in some of these facilities lacking access to water and/or electricity. The global connection between Monrovia’s infrastructural inadequacies and unresolved loans from the IMF epitomizes the complexity of this urban problem.
The spread of Ebola was especially prevalent in West Point, Monrovia’s largest slum, where 75,000 people live in half a square kilometer without access to clean water, sanitation, or a sewage system. Access to physicians and proper diagnosis is severely limited as the entire community is treated by only one doctor. The spread of Ebola in West Point was exacerbated through the practice of dumping infected bodies of the deceased into the adjacent river: the same river which services the community due to the lack of hydrologic infrastructure. These conditions accelerated the spread of Ebola in the community, and the initial implementation of containment strategies failed for two primary reasons. First, due to the inability to implement the WHO’s suggested Ebola management strategy, and second, due to the lack of trust between the community and the Liberian government. The WHO’s protocol for Ebola management was to promote frequent hand-washing; however, for the 68% of Liberia’s urban population that live in slums like West Point, this was impossible. Lack of trust for the government resulted in the ransacking of contaminated materials from isolation chambers, mass quarantine of the entire slum by the Liberian army, and armed conflict between the army and community members which resulted in a the shooting and death of a young boy.
Ebola management in West Point slum was successful once community-based initiatives were put in place. The UN Development Programme funded community-based initiatives that employed 152 local community members for door-to-door community surveillance, aimed at early isolation of infected persons. In areas where these community-based initiatives were employed, the mean time from symptom onset to isolation decreased from 6.5 days to 4.7 days. In the first 24 hours the program was implemented in West Point, 42 people with Ebola-like symptoms were transported to treatment facilities, indicating its efficiency and effectiveness.
The intervention of international organizations in implementing regulatory burial practices for EVD victims were both effective and removed from their social context. Many Monrovians who attended the funerals of Ebola victims soon became infected with EVD themselves; thus, “safe and dignified” burials became an important aspect of preventing new infections. The Ebola virus can survive in and on the body of a dead person for days, and poses a very high risk of infection to other people. Multiple non-governmental organizations (NGOs) including Doctors Without Borders, the Centres for Disease Control (CDC) and the WHO agreed that local practices (including washing, touching, and kissing the dead) should be abandoned in favor of practices advised by biomedical experts, due to the potential worldwide risk of the epidemic. However, many people resisted these changes because of the contradiction between foreign medical advice and their own experience. For example, not everyone who touched the body of someone who died of EVD would become infected, and government-imposed quarantines, mandatory cremation, and fines or threats of jail time for ‘secret burials’ were aggressively imposed upon citizens. Following local focus groups in Monrovia, it was found that most people could indeed tolerate cremation or mass burials: it was the lack of information about their loved ones’ bodies after they died in hospitals or were removed by burial teams that caused such resistance towards these practices. The cultural importance of known burial sites or ashes to spread were vital to the acceptance of international intervention in Monrovia. Biomedically safe and culturally acceptable burial practices were eventually agreed upon. They involved washing bodies with chlorinated solution, placing bodies in two body bags, and rapidly burying the dead. The family and friends of the deceased were included in the burial process as much as safely possible. International organizations, then, must be sensitive to the local culture of urban contexts.
EVD and other communicable diseases need to be considered within the local context of cities, as this context directly affects the magnitude and severity of the disease. The case study of EVD in Monrovia highlights the cultural values and systems that influence the spread of disease. In addition to the biological nature of the virus, Monrovia's outstanding debt to the IMF, population density and poverty in slums, inaccess to services such as clean water and healthcare (including trained professionals and medical equipment), and foreign assistance facilitated in the spread of EVD. The inability of Monrovians to follow NGOs' containment advice, due to lack of sanitation infrastructure and distrust in foreign healthcare workers, is an example of the ineffectiveness of translating global north policies to cities in the global south . Community based responses organized and managed by local community members were vital to the control and end of the epidemic, as they directly addressed the needs of the community and applied successful containment strategies within the infrastructure available to Monrovians . It would be useful for NGOs from the global north to implement strategies involving local community members, as well as to evaluate the urban context prior to enforcing policies from the global north. Despite this recommendation, we also recognize that managing and reassessing outstanding debt is also vital to the preparation for and prevention of future outbreaks. Through debt relief, healthcare infrastructure can be improved. This may result in more effective recognition of symptoms, diagnosis, and treatment by trained professions, who are proficient in proper containment protocol. Future strategies also need to account for the gendered nature of communicable disease contraction, as women were expected to take care of the sick in Monrovia, thus exposing them to Ebola at higher rates than their male counterparts . We suggest it would be beneficial to examine the gender roles and cultural roles within urban settings which affect epidemics. This may bring global north theorists a more thorough understanding of how diseases spread in different cities, and allow a platform for mitigation strategies that are effective and fast-acting. Future management strategies for Ebola and other communicable diseases should therefore target this subset of the population: furthermore, education on proper identification and care-giving strategies for EVD, tailored to specific communities and cultures, may ensure early detection and thus higher chances of survival in densely populated urban settings.
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