Archie Gbessay, 28, stands at an intersection in Monrovia’s West Point neighborhood next to a stall where mobile-phone recharge scratch cards are sold. Across the street is a school that, in August 2014, became the focus of Liberia’s Ebola crisis. It was being used as a holding centre for Ebola victims when enraged residents broke through its iron gate and released patients.
Now empty, it is being renovated to be used again as a school. The military quarantine imposed on West Point after the residents’ raid seems far away, as does the atmosphere of fear that enveloped Liberia. The country has made remarkable progress in the fight against Ebola. It is nearly a month since the last new case – thought to be a result of sexual intercourse with a survivor rather than transmission from an active case – and there are no Ebola patients in Liberia’s treatment units.
For many experts the efforts of community volunteers like Gbessay have played a critical role in halting Ebola’s spread. As deaths mounted in August and September, residents in some of Liberia’s hardest-hit neighborhoods organized groups that searched for Ebola cases, battling denial of the virus and sharing information with Liberian health officials.
Although many Liberians initially refused to acknowledge the existence of Ebola, these groups convinced their neighbours to adopt preventive measures and seek treatment if ill.
Gbessay and a few friends established their informal group in August when the epidemic began to overwhelm the Liberian government’s response. “We felt that if we did nothing, we would be judged for our actions,” he says.
Initially, they sought to combat Ebola denial through face-to-face discussions. Then the holding centre was attacked and West Point was cordoned off, provoking a violent confrontation between residents and soldiers, who shot and killed a 15-year-old boy. The government turned to Mosoka Fallah, a Harvard-trained infectious diseases specialist who had spent part of his early life in West Point, to mediate.
Tasked by the Liberian ministry of health with tracking down Ebola cases, Fallah recognized that engagement with communities was key to stopping the outbreak. Many people were angry at the long delays in removing infected bodies from neighboring homes, or refused to believe Ebola was real. It was often difficult to obtain information about people who were sick or had been in contact with Ebola victims.
Fallah heard reports of secret burials in West Point and feared there were unreported cases inside the neighborhood’s maze of tin-roofed shacks and alleys. He became aware of Gbessay’s group and realised its potential as a bridge into the community. Fallah offered to help train the volunteers, but says: “At the time there was no pay. It was just about saving your community.”
Under Fallah’s guidance, the group grew to more than 100 volunteers. He provided them with notepads and pens, asking them to record the names and condition of anyone exhibiting Ebola symptoms. “The first day they found a lot of cases,” Fallah says, adding that the group showed Liberia’s leaders that West Point’s residents were cooperating with the fight against Ebola. “It was so successful it convinced the president to de-quarantine West Point,” Fallah says.
By early September, the situation in Monrovia had become dire, with sick people lying in front of overcrowded treatment facilities. Health officials continued to have trouble getting communities to cooperate with government efforts. Dr Bernice Dahn, Liberia’s assistant minister of health, (she is now the current minister designate) asked Fallah to expand the West Point model to other neighborhoods.
Fallah organized community meetings across Monrovia. “We apologized to them first,” he says. “We told them that we’ve been doing a top-down approach and it’s wrong. We want to let you be the decision-makers and we’ll be the supporters.” Volunteers were dubbed active-case finders, and were soon knocking on doors and keeping an eye on those who’d had contact with the sick.
In late September, the World Health Organization (WHO) opened a 120-bed Ebola treatment unit (ETU), creating space for those found by Fallah’s volunteers. By the beginning of October, he says, “Everywhere we went we were seeing progress. There were challenges but those kids were working their butts off.”
In New Kru Town, the site of a community hospital where the deaths of nine clinicians had marked the worsening of Liberia’s Ebola crisis in June, Eric Patten, 30, had taken over as the lead active-case finder. “We were working 24 hours a day,” he says. Sometimes his teams would spend hours at a single house convincing a suspected case to report to a treatment centre. “Many of them would have just stayed home and died or gone to the drug store for antibiotics,” Patten says.
By mid-October, WHO data showed case rates falling rapidly across Monrovia. Officials from the US Center for Disease Control (CDC) reacted with disbelief, sending teams to check funeral homes and graveyards to see if deaths were being hidden.
When a cluster of cases was recorded in New Kru Town in late October, Fallah was dispatched to investigate. He found Patten waiting for him with the names and locations of the dead along with a list of all their contacts. “He was so meticulous and detailed – it gave me a lot of hope,” Fallah says.
At the same time there was a drastic reduction in the forested north-western district of Foya where Ebola first appeared in Liberia. Piet deVries, country director of Global Communities, says it was largely a result of independent measures taken by villages. In one example, known as “community fencing”, all new arrivals to the district’s towns were quarantined for three weeks. Many communities refused to allow visitors.
“Ultimately, the only way you stop the infection is when people practice safe behavior,” says DeVries. “If you have continued transmission, it doesn’t matter how many ETUs you have, people will still get sick.”
Millions of dollars have been spent on building ETUs since September but the majority of their beds have never been filled by an Ebola patient. By early January 2015, cases in Liberia had dropped to less than 10 a week, reaching zero at the end of February. Frank Mahoney, a CDC epidemiologist, says: “The engine of the outbreak was Monrovia. Getting that on a downward slope contributed to the slowdown.”
For Fallah, the slowdown has much to do with the efforts of volunteers like Gbessay. A study Fallah co-authored with researchers from Yale University found that better community engagement was the key factor.
He hopes the model of community participation in health outreach developed during the Ebola outbreak will continue after it is over. “People in West Point think it is normal for five or six people to die every day of diseases other than Ebola,” he says. “Why should we accept people dying in the prime of life? We have a model now that shows the power of the community to transform those health issues.”