Water and sanitation engineer Andy Clarke describes his experience of responding to the unprecedented challenge of the Ebola outbreak in Liberia. He explains why being able to adapt to people's needs proved a key part of the response, allowing efforts to be focused in the areas where they would be most effective.
A year on and the deadliest outbreak of Ebola Virus Disease (EVD) ever experienced has directly claimed the lives of over 10,000 people. Indirectly, this figure will have been multiplied many times over, as the resulting collapse of health services in those West African countries most affected, Liberia, Sierra Leone and Guinea, has resulted in many more, otherwise preventable deaths. The economic, livelihoods and social impacts of the outbreak are continuing to take an even
wider toll and will do so for some time to come.
This Ebola outbreak presented those communities and countries affected, and those who responded, with an unprecedented challenge: We hadn't been here before.
I arrived in Liberia in November 2014, to lead Oxfam's water and sanitation engineering team in Montserrado County, which includes Liberia's capital, Monrovia. The dominant focus of the global strategy to fight the outbreak, at this point, was on building Ebola specific treatment units and sufficient bed capacity to deal with the projected scenarios for the epidemic. When I left the UK, that is what I thought I was heading out to do. This Ebola outbreak presented those communities affected with an unprecedented challenge...
Shortly after I arrived we took the decision in country not to get involved in the construction of treatment facilities in Montserrado. There was already existing spare bed capacity in Monrovia and from our analysis the urgent gaps were in the identification of suspect cases, breaking down the barriers preventing people from seeking treatment and transport of suspect cases to testing and treatment facilities.
No one could say at that point whether or not more bed capacity might have been needed should the epidemic have spiked again, but other actors were clearly going ahead with construction of more treatment facilities. So, not having the specialist technical resources and training to operate inside existing treatment units, we had to figure out what our relevance was as a water, sanitation and hygiene promotion organisation, in what we were all perceiving as a medical emergency, and fast!
My public health promotion colleagues Qasim, Duoi and Nyan quickly launched an active case finding programme, a new approach to suspect case identification, in West Point, Clara Town and New Kru Town, some of the worst affected townships of Monrovia. It was an amazing piece of work! They mobilised a huge number of Community Health Volunteers from the local communities, who did a superb job going door-to-door re-engaging the traumatised and isolated
families and starting the process of breaking down the barriers of mistrust that meant the majority of families were keeping their sick loved ones at home, risking either death from treatable illness or the further spread of Ebola from the sick to carers.
Listening to an end of the day debrief from the active case finding team, it clicked. Over 95% of the sick being cared for at home were not suspect Ebola cases, but were being looked after at home because of a greater fear of what might happen if people took their loved ones to get treatment. Oxfam's public health promotion work was promoting health seeking behaviours to both the suspect Ebola and non-Ebola sick, and working to build trust in the medical treatment being provided. So what was the complementary piece to this? Where would people have
gone to seek treatment before Ebola and where were they likely to go back to? What was the capacity of those facilities to operate safely in the context of the outbreak?
The next day I went with Abraham Kianole, one of Oxfam's local engineers and unsung hero of Oxfam's Ebola response in Liberia, and we started doing assessments of community clinics and health facilities. It was a truly inspiring moment in my life to meet the health care workers who, with little equipment or specialist training, but an immense amount of courage, had kept on working throughout the outbreak and kept their facilities open for their communities, and those coming back to work at facilities that had closed due to the deaths of staff and patients, but
were now re-opening.
It was a truly inspiring moment in my life to meet the health care workers...These health facilities were seeing a handful of patients per day, compared to pre-outbreak numbers in a range from 70 to 100 per day. What was abundantly clear was that these facilities didn't have access to sufficient supplies of water or chlorine for disinfection, to implement effective infection prevention control measures, which are so critical to preventing the spread of the Ebola virus. Nor did they have safe and effective ways of dealing with
infectious waste, such as the huge amount of personal protective equipment (PPE) used in an infectious disease outbreak such as Ebola.
These were things we could fix. So we set about a programme of rebuilding the water and sanitation infrastructure of health facilities: digging wells, drilling boreholes, installing water tanks and pumps, constructing latrines and hand washing facilities, building incinerators and waste containment pits... so that they would be able to operate more safely in the current outbreak and also be more resilient for the future.
Using our own expertise and the government standards, we developed this work into a replicable package, so that over and above the 58 clinics targeted by the Oxfam programme, other actors will have a head start in taking on the challenge of rebuilding Liberia's health infrastructure. We developed a great partnership on the ground with MSF France, rebuilding the water and sanitation infrastructure in the health facilities where they were training medical staff on Ebola systems and practices.
For me, working on this response, in a totally new and very dynamic context, underlined the importance of really seeing what is in front of you, and having the flexibility and ingenuity to be able to respond to people's needs. Sounds simple, but it's surprisingly easy to lose sight of in today's world of contract driven humanitarian aid.
1. Drilling a borehole at MSF's IPD Paediatric Hospital, Monrovia. Credit: Andy Clarke/Oxfam
2. Well construction at Helton Clinic, Monrovia. Credit: Andy Clarke/Oxfam