Dispatch

Death and Denial in the Hot Zone

Why do so many people in West Africa think the Ebola outbreak sweeping through the region is a hoax?

ZANGO TOWN, Liberia — In this small farming village, sinewy elderly men and women sit outside their thatched mud houses, with children scattered around. It is quiet and desolate. But one day in mid-July, in the town's largest house, two women wail as they deliver news of death from a neighboring village: a young man, killed by Ebola.

The lethal virus has already arrived here too. According to Liberia's assistant minister of health, Tolbert Nyenswah, 19 people from Zango Town have died. A few tested positive for Ebola and were treated in "case management centers" run by Samaritan's Purse, an international Christian NGO. Yet many in Zango Town are skeptical of what they have been told. Some do not even believe Ebola has struck their community. They imagine the deaths were caused by something else or that health workers are killing patients.

A few weeks back, citizens of the town attacked a community health team that came to spray the area with chlorine, a cheap and effective way of killing Ebola, and tried to set its car on fire. Now a lone pink plastic bucket containing chlorinated water sits in the middle of the town, intended for people to use to wash their hands. No one touches it.

Henry Jallah, a 23-year-old farmer, recently lost five family members to illness, including his mother, an uncle, an aunt, and two of her children. He expresses his loss matter-of-factly and says that God is telling him to get on with his life. "There be no hope," he says. "So many people are dying."

Jallah says he has accepted the advice of Liberia's Health Ministry to stay away from dead and sick people in the town, yet he is hesitant to believe it is really Ebola that claimed his family. He offers other explanations: poisoned drinking water as vengeance for a conflict over land, or some kind of curse. His family never took his aunt to a case management center, he says, because "some people say when you go over there, they can inject you -- when you having the sickness, they inject you and kill you."

Liberia, along with its neighbors, Guinea and Sierra Leone, were once racked by war. Today, they are all facing a new and deadly crisis: Ebola, a virus that attacks organs and leads to fever, diarrhea, bleeding, and in most cases death, has swept across the countries and threatens to extend its reach. The virus, which cannot be cured but can be treated, can kill up to 90 percent of those who catch it. The overall death rate in the three West African countries is currently around 60 percent. Roughly 1,200 cases have been identified, the most ever in an outbreak, and some 670 people have already died.

On Friday, July 25, a case was confirmed in Nigeria, Africa's most populous nation: A Liberian man collapsed at the Lagos airport and later died. Liberia, in which seven of 15 counties have identified cases of the virus, has announced that it is restricting public gatherings, shutting many border crossings, and opening testing centers at others. (One reason public-health experts think this outbreak has hit three countries and their urban centers simultaneously -- a first in history -- is due to porous borders. Often members of the same family living on different sides of a border cross to see one another, while other people border-hop to engage in commerce.)

Médecins Sans Frontières (MSF) Director of Operations Bart Janssens has called for a massive deployment of resources by regional governments and aid agencies to combat the outbreak. But it is unclear where these resources will actually come from. Liberia, which has identified 290 cases and suffered almost 137 deaths, has set up a new task force to address the situation, and a national operational plan will be released in the coming days. It will require $10 million to $15 million to be implemented, however, and the government has yet to muster the funding, according to Nyenswah.

Yet the biggest hurdle in stopping the spread of Ebola seems to be overcoming denial and fear in communities that are deeply suspicious of the government, the health-care system, and international institutions. This includes remote areas, which are relatively untouched by the government or have only experienced it in the form of force and coercion. But Monrovia, the capital, is not immune: In bustling Duala Market, 92 percent of people said they did not believe Ebola existed, according to a recent survey of 1,000 people conducted by Samaritan's Purse. In fact, many in the capital initially viewed the virus as a hoax created by the government to generate and "eat money" from aid donors.

Often, too, people here view life events, including tragedies, through the prisms of religion and superstition. There is a Liberian saying that goes, "Nothing for nothing" -- meaning, everything happens for a reason. Even Ebola.

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Over the weekend, in a community called Popalahun, in Liberia's Kolahun district, residents staged a roadblock and attacked health workers traveling in a jeep. They smashed the jeep's windshield and gashed its tires with a machete. Four Liberian health workers who were part of a team, employed by Samaritan's Purse and tasked with collecting the body of a person who had died of Ebola, scrambled to safety in the bush. One who was beaten with a hammer managed to escape. Kendell Kauffeldt, the country director for Samaritan's Purse, says his organization will be forced to cease outreach -- that is, collecting patients and bodies from towns and villages. "We just cannot afford to put ourselves at that risk at this point," he says.

Similar attacks have occurred in Guinea and Sierra Leone. In Freetown, the capital of Sierra Leone, thousands marched at an Ebola treatment center this weekend following allegations by a former nurse that the deadly virus was invented to conceal "cannibalistic rituals" at the facility, a regional police chief told Reuters. (A local doctor also told the news agency that some health workers weren't showing up for work because of "misconceptions by some members of the community.") MSF also had to evacuate a clinic in rural Guinea after attacks in April.

Back in Liberia, families in Monrovia have fought hospital staff to retrieve bodies of family members who have died. (Touching the deceased is extremely dangerous, given the virus's contagiousness.) In one incident, people threw stones at Redemption Hospital in New Kru Town, a densely populated slum community, after the body of a woman who bled to death after giving birth was tested for Ebola. Also in New Kru Town, residents protested and stopped the construction of an isolation ward, meant to limit the chances of exposure to Ebola among health populations.

Samaritan's Purse has halted the expansion of its case management center in Monrovia due to protests from the local community who fear illness. That facility, the main one in Liberia, currently has 20 beds that are fully occupied with confirmed and suspected cases. The NGO is looking to add another 60 beds, but it needs the government to negotiate with the community before it can do so.

"Right now we have no more space," Kauffeldt says. "When the next Ebola patient comes, there is nowhere to put them, and the worst thing that can happen is that patient goes back into the community."

"If we are still getting 90 percent deniability [of Ebola's existence] in the hot zone of Monrovia, communication is not working," he adds.

Although there has not been violence, Kauffeldt says he is concerned about security. The gates surrounding the case management center are manned by unarmed police officers. The Liberian National Police force is currently developing a strategy to deal with violent incidents at hospitals, as well as when bodies of Ebola victims are being transported for burials, which must be done by specialists using body bags and chemical sprays -- in violation of long-standing customs in which family members are responsible for washing and preparing corpses for burial.

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Compounding these problems, even when people believe Ebola exists, many are wary of hospitals because they believe the institutions provide poor care -- a concern that existed well before the current crisis. To be sure, Liberia's health-care system has improved since civil war ripped the nation apart; there has been a reduction, for example, in the under-5 child mortality rate. Yet Monrovia's largest hospital, John Fitzgerald Kennedy Memorial Medical Center, or JFK, is nicknamed "Just For Killing" among locals because people go there with treatable diseases such as malaria and still die. There have been reports that, recently, health workers at JFK refused to treat patients suspected of having Ebola, even abandoning the facility's emergency room. (The hospital's Ebola ward has since been closed. JFK was "dangerous," according to Kauffeldt, as proper procedures for dealing with the disease were not followed.)

Ebola infections among doctors and health workers, in Liberia and elsewhere, have also raised fears about coming into contact with the health-care system. A leading Liberian doctor, Samuel Brisbane, who was working as a consultant with the internal medicine unit at JFK, died and was buried over the weekend. Another Liberian doctor has been infected and is currently undergoing treatment. Two Americans working to end the outbreak, including one doctor, have also tested positive.

Liberian health workers have complained about a lack of protection and equipment, saying it is limiting their ability to do their jobs and stay healthy. But Nestor Ndayimirije of the World Health Organization (WHO) says that part of the problem is inappropriate use of equipment. He says health workers, for instance, ran through a supply of 8,000 protective suits, worn when dealing with infected or potentially infected individuals, from donors too quickly because they were using them unnecessarily.

"Some don't have the personal protective equipment, but this cannot explain the number of infections among health workers," says Ndayimirije, who witnessed and worked on major Ebola outbreaks in eastern and southern Africa in the late 1990s and early 2000s. There are currently 37 suspected cases among health workers in Liberia, and there have been 16 deaths.

The Ministry of Health says it is making an effort to speak to and further train hundreds of health personnel, including workers in counties that have not yet even registered cases of the virus. But this will be difficult, given that the country's operational plan against the outbreak has yet to be finalized and financed.

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Despite violence, skepticism, and other obstacles, in Foya District, where Zango Town is located, the government and Samaritan's Purse have had some success in working to raise awareness and provide treatment. On July 17, Liberia's minister of health, Walter Gwenigale, and the nation's chief medical officer, Bernice Dahn, held an emergency meeting in Zango Town to warn residents about the virus. Some people gathered to listen, if hesitantly.

Yet there are miles to go: Luana Korvah, a mental health clinician working for the government, estimates that the vast majority of people in Zango Town and the surrounding area do not believe the disease exists. And in Foya's Ebola case management center, where white tents are sectioned off with bright-orange netting, shellshocked survivors of the virus admit they are worried about going back to their communities, uncertain as to how they will be met.

Harrison Sakela is one of them. Sakela was the nation's first-known survivor of Ebola, which he contracted when his mother got sick after attending a family burial in Sierra Leone. His mother, father, and sister have all died, along with his 19-year-old niece and her daughter, who passed away in the treatment center while he was there.

"People believe that if you come here, they will give you an injection and put you in the body bag," Sakela says, echoing the words of Henry Jallah in Zango Town. "That what makes the fearness, and people are dying in the bush."

Saah Tamba is also worried. A young rice farmer who contracted Ebola after caring for his uncle in Sierra Leone, Tamba will be going back to his community after two months in the center. His body is frail, his brow furrowed, and his face strained. In his native Kissi language, he says he is uncertain whether his community, just 10 kilometers from the center, will accept him.

Randy Schoepp, who works for the U.S. Army Medical Research Institute of Infectious Diseases and is helping monitor a testing center outside Monrovia, says the "first line of defense" in the outbreak is communication. "There are reports of people hiding sick relatives and friends, and they die and then the people that are hiding them get infected and they die, and it just goes on and on," he explains. It's a cycle that must be stopped.

Ndayimirije of the WHO says building trust in communities, including with elders and traditional leaders, is the key in the fight against Ebola. Without trust, fear and suspicion cannot be cut from their deep roots -- and the work of helping a region overcome a devastating illness could drag on indefinitely. Making populations understand the disease in scientific terms is urgent, Ndayimirije says: "We must go door to door."

Photo by CELLOU BINANI/AFP/Getty Images

Dispatch

Putin's Next Move

The Russian president isn't checkmated quite yet. But the downing of MH17 has left him with few good options.

MOSCOW — When the Kremlin announced that Vladimir Putin would hold a special session of his Security Council on July 22 to discuss the "safeguarding of sovereignty and territorial integrity," observers around the world wondered what ace the cagey Russian president might have up his sleeve this time.

Since Malaysia Airlines Flight 17 was fell from the skies over eastern Ukraine on July 17, Putin has faced increasingly angry calls to end his support for the rebels who are suspected of shooting down the plane. Would he take this opportunity to close the border with Ukraine and cut off the uprising from Russian volunteers and weapons? Or would he react defiantly, perhaps by starting a military operation in response to Ukrainian troops allegedly shelling Russian territory in recent weeks?

Putin has done neither. For the moment, at least, the Russian president appears to be stalling, moving neither toward reconciliation nor toward a complete break with the West. He promised to put pressure on the rebels to ensure that the investigation of the crash site moves ahead, a significant development considering that throughout the five-month-long Ukraine crisis he has not agreed to compel the rebels to do anything at Western leaders' request. But at the same time, Putin also defaulted to the role in which he has been the most comfortable since the crisis in Ukraine began, lashing out at the West for its sanctions and pinning the blame on the government in Kiev.

The Malaysia Airlines disaster seems to have put Putin in a zugzwang, the German chess term beloved by Russian political scientists that signifies a situation in which any move will weaken a player's position. On the one hand, new sanctions could take a serious toll on Russia's economy. Former Finance Minister Alexei Kudrin, a top advisor to Putin, recently warned that further sanctions could lead to cuts in ordinary Russians' salaries by up to 20 percent. Additional sanctions from the European Union are likely this week because Putin has failed to offer last-minute concessions and has reportedly decided to continue arming the rebels in eastern Ukraine. But on the other hand, Putin cannot abandon the conflict in eastern Ukraine after investing so much political capital, both domestic and international, into the conflict with Kiev. He is unlikely to allow the rebels to be defeated.

"Putin was, throughout the previous months, able to execute clever foreign-policy maneuvers so as not to compromise on his policy on Ukraine but yet avoid deeper and broader sanctions, by playing on differences between the United States and Europe and even between different European countries," says independent political analyst Masha Lipman. "But it seems his space for maneuver has shrunk after the Malaysia Airlines tragedy."

For now, the president may just be biding his time. Fyodor Lukyanov, chairman of the Council on Foreign and Defense Policy, an independent think tank, says Putin will wait to see whether the investigation turns up direct evidence of who is to blame for the plane's downing. Only then will he have to formulate a reaction.

But stalling will only work for so long. U.S. officials have repeatedly called on Putin to stop supporting the rebels in eastern Ukraine. But if the rebels suffered a military defeat at the hands of Kiev, which would likely occur if they were cut off from Russian supplies, Putin would face serious challenges at home.

Shrill Russian media coverage of the Ukraine crisis, as well as Putin's own promises to protect Russian-language speakers across the former Soviet Union, have placed the public solidly behind the rebels. A June poll found that 40 percent of Russians supported direct military intervention in eastern Ukraine, and 64 percent thought Moscow should support the rebels with weapons and military advisors.

Backing down from the Ukraine standoff by closing the border, summoning back Russian leaders and volunteers, and leaving the rebels to their fate in the hands of the "fascists" in Kiev would surely cut into Putin's approval rating, which according to Gallup has just tied the 83 percent he achieved after Russia's military intervention in Georgia in 2008. This widespread support cements the "pillar of Russian stability" -- Putin's position as the arbiter of Kremlin disputes -- and any decrease in popularity or disappointment of expectations could open fractures within the political elite, Lipman says.

Further pressure on Putin comes from the far-right pundits who have been promoting a "Russian Spring" in which Russian-speaking territories scattered across the former Soviet Union will be reconquered. Ideologues such as Alexander Dugin, a philosophy professor who has called on Russia to seize Ukraine and challenge American hegemony in Europe, regularly appear on prime-time television and serve as advisors to members of parliament.

"We shouldn't depend on Putin's vacillation," Dugin wrote on his Facebook page the day after Putin's Security Council speech. "He vacillates, but the Russian people do not. He drags out the decision, but the Russian people have already made it. Novorossiya will exist. The Russian World will exist." (Novorossiya is a term pan-Slavic nationalists use for the swath of southern and eastern Ukraine they consider to be Russian by history and culture.)

But while Putin puts forward a strong face for domestic consumption, the reality on the ground has been different. The Kremlin did not deploy ground troops to eastern Ukraine as the rebels requested, and the pro-Russian militias remain poorly armed compared with the unmarked Russian units that took over Crimea in March. This is not an accident, says Gleb Pavlovsky, a former Kremlin insider turned liberal pundit: Putin has even been conducting a policy of "careful de-escalation" in eastern Ukraine for the past two to three weeks, removing Russian fighters -- and therefore Kremlin culpability -- from the rebellion. But to compensate, he had to step up weapons shipments to the rebels, which led to the Malaysian Airlines disaster.

"He was the first to distance himself from the rebels, and the fact he said he is ready to put pressure on them is really a gesture," Pavlovsky says. "We don't know whether it will be fulfilled, but he's showing he wants a diplomatic solution to the conflict." Now Ukraine and the West must make concessions of their own to show they want to negotiate and allow Putin to compromise without losing face, Pavlovsky argues.

But those close to the Kremlin, such as Sergei Markov, the deputy head of Plekhanov Russian University of Economics, don't see Putin as compromising right now or in the future. Putin will continue his current strategy of helping the rebels, and not only out of fear for his approval rating, Markov says.

"Putin is not afraid to make harsh decisions," Markov said. "More important for him than his rating is that he really thinks that the U.S. goal [in the Ukraine crisis] is to make Ukraine anti-Russian and start a war between Ukraine and Russia, engineer a coup, and bring to power its puppets, who will destroy Russia."

That may sound outlandish, but Putin spent much of his July 22 speech warning against fifth columnists and coup attempts. Countries opposing the West face externally incited "color revolutions" to overthrow their governments, Putin said in his 13-minute speech to his Security Council. He added that intelligence services, information technologies, and nongovernmental organizations will be used to "stir up the sociopolitical situation" and "hit weak spots" in Russia. He pledged to strengthen the country's defenses, especially in recently annexed Crimea, and to retaliate against new NATO exercises near Russia's borders and U.S. efforts at missile defense.

Despite the defiant tone, Putin is clearly at a crossroads. He will have to reckon with the promises to protect Russian-language speakers that he made to justify Crimea's annexation and the nationalist fervor they evoked, says Lukyanov. "He needs to make a choice between the idea of a national Russian Spring, protecting our countrymen, reuniting the Russian world that's been fragmented, and Russia's geopolitical strategic interests," he says. No matter which way he moves, Putin can only lose.

Photo by ALEXEI NIKOLSKY/AFP/Getty Images