Health

Stunned silence after scathing analysis of Ebola response

VIENNA—After Oyewale Tomori finished his talk on Ebola here at the International Meeting on Emerging Diseases and Surveillance, there was stunned silence. Tomori, the president of the Nigerian Academy of Science, used his plenary to deliver a scathing critique of how African countries have handled the threat of Ebola and how corruption is hampering efforts to improve health. Aid money often simply disappears, Tomori charged, “and we are left underdeveloped, totally and completely unprepared to tackle emerging pathogens.”

Trained as a veterinarian, Tomori was the World Health Organization’s (WHO’s) regional virologist for the African region in 1995 during the Ebola outbreak in Kikwit in the Democratic Republic of the Congo (DRC). ScienceInsider sat down with him at the meeting in Vienna; questions and answers have been edited for brevity and clarity.

Q: You said in your talk that Ebola was “swimming in an ocean of national apathy, denial, and unpreparedness.” What did you mean?

A: We were totally unprepared. After the first cases occurred in West Africa, it took almost 3 months for WHO to know. When the first patient came to Sierra Leone and died, his son brought him back to Guinea and as far as Sierra Leone was concerned, it was Guinea’s problem. People abandoned their duty, they denied the problem, and when it became a big problem they became incapable of handling it.

This is not the first time Ebola has appeared in Africa. There have been more than 20 outbreaks since 1976. Not one of them has been declared a global problem. Of course, circumstances are different this time. But if we had been prepared, if we had learned from the past, we wouldn’t be where we are today.

Q: You seem angry.

A: Yes, I am, because I know Africa has the capacity and the capability to solve most of her problems, but Africa will not enable her human resources to perform effectively and efficiently. African leaders have little or no respect for their experts and would rather act on advice from external sources. In the end, they become the experts on Africa’s problems, not the Africans. This is why I am angry with Africa.

We have seen so many Ebola cases before, in the DRC, in Sudan, in Gabon. … Ebola is Africa’s problem. We should have put something in place. I remember in 1995, when we had the Kikwit epidemic, at the end we sat down at a table and discussed what we should do. There was a laboratory in Kinshasa built by the French; it was almost completed, but then abandoned. We had raised almost $2 million at the time. And we said: “Why not take a bit of that money and complete this lab and maintain it? Then at least when we have issues like this we can do quick testing.” But nothing happened. The carcass is still there. Each time I pass the place, I think: “What a waste.”

Q: But your own country seems to have been prepared. Nigeria managed to contain the virus after it was carried to Lagos by a traveler in July. There were only 19 infections, and WHO called the containment of the virus “a spectacular success story.

A: We were not prepared, we were lucky. Patrick Sawyer was already sick when he arrived, so he went straight to the hospital. And because our doctors were on strike, the public hospitals were not open, so he went to a private hospital. If Sawyer had gone into a public hospital, we would have had a bigger problem.

But within 2 to 3 days of Sawyer coming in, we knew it was Ebola from laboratory tests done in two of our university laboratories, and then action was taken. I praise Nigeria for that. We had this emergency center from the polio network and we brought people in and traced almost 1000 contacts. This was not passive tracing; people went to contacts’ homes on a daily basis.

Q: So why are African countries so badly prepared? Is it a question of money?

A: People say African countries are poor. But it’s not poverty. It’s misuse of what we have. As we are talking, with all the crises that are going on, the presidents of our countries are still traveling in the best of conditions. Some will come to New York in their private jets, although their national airlines collapsed years ago; in addition, they will bring along a long retinue of private, personal, and public assistants, all lodged in the best hotels. I am not saying the president should not be treated well, but these are issues we need to look at.

Take my country: We do not have a national airline, but the number of private jets we have is more than all the airlines in Africa have together.

It’s a matter of priorities. I do not believe there is an African country that cannot buy gloves for its staff. Personal protective equipment may be very costly, they may need assistance on that. But let us participate. As long as we are wringing hands waiting for the next glove to come, we will never be ready. There are certain things we can do now, with the resources we have.

Q: So African leaders should be held more accountable for what they spend money on?

A: GAVI [a public-private partnership that funds vaccines for low-income countries] just sanctioned Nigeria after a critical audit report. GAVI gave us money to do certain things, and we could not account for $2 million or $3 million of it. GAVI insisted that Nigeria must pay back that money, and the government agreed. But our government should not just agree to pay back the money, the government should find out who misused the money, get the money back from those persons and not from public coffers. And those people should be brought before the courts to answer for the deaths of the children who did not receive the vaccines that the GAVI money would have provided.

Q: So how should African countries contribute to fighting the Ebola outbreak?

A: To give you one example, there are 600 Nigerian health care workers who want to go to Liberia. But the process of getting them there has been going on for months. If the African team, the African Union, the Economic Community of West African States, and the West African Health Organisation all get their acts together, there are more than enough people in Africa—health care workers from Gabon, DRC, Uganda, Sudan—who have experience with this.

But we must find the funds to provide insurance for all national and international health workers who are currently working or have volunteered to work in the Ebola-affected areas of Africa. Bear in mind, in Africa we do not have a welfare system. I am the welfare system for my family, my brothers, my uncle. So when I go to an Ebola region, I am thinking of the 23 other people that depend on me. If there is no insurance, I will stay home.

Q: There has been a lot of criticism of the WHO regional office in Africa.

A: I am angry at them, too. They should take the lead of Ebola control efforts—not Geneva, not Washington, not New York. The [Centers for Disease Control and Prevention] can help, [Doctors Without Borders] can assist, but it is WHO’s African region that should coordinate and take the lead. It’s all meetings and reports. Nothing on the ground.

Q: As it happens, they are meeting in Benin this week; on the agenda is the election of a new regional director.

A: These elections are just horse-trading. If the person who wants to get elected requires the vote from Nigeria for example, because it is the ministers of health who do the voting, I might say: “OK, I will vote for you, but I need one directorship from my country.” If he accepts that, he has to accept whoever I bring, regardless of how competent the person is. That is what has messed up Africa. WHO’s regional office has never been able to solve Africa’s problems because of this system of electing its leaders.

You want to find the most competent person. Vote on that basis. Not because I visited you and I promised you this or that.

Q: Do you think this unprecedented outbreak will change things?

A: I wish I could say with confidence that in 10 years’ time we will not be where we are now with Ebola. But the countries have totally lost control of what is going on. If you go to Sierra Leone or Liberia today, there must be at least 10 international groups there. At the end of this epidemic, everybody will pack their bags and leave. The African countries will be left not really knowing what has happened to them. Like someone hit them smack in the face, totally disoriented. There will be millions of scandals about how money was misspent and so on. We will focus on those and move on. Ten years from now, people will have forgotten that there was Ebola and we will be back to where we started.

source: The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicine have made a collection of research and news articles on the viral disease freely available to researchers and the general public.

Leaked documents reveal behind-the-scenes Ebola vaccine issues

My commentary (synopsis):

Time and Money: GSK could have 24,000 doses ready by January 2015, but they don’t want to invest too much money ramping up production of a drug that isn’t 100% sure to work, be re-sellable, and provide their return on investment. Also – none of the global agencies have offered financing to cover R&D costs and early production if the vaccine fails.

Scaling Up Safely: GSK could make hundreds of thousands of doses if the health safety guidelines were relaxed, and they could use their mega-virus growing vats under bio-safety level 2 conditions instead of bio-safety level 4. That would increase the risk that their facility could be a source of ebola, as workers could get contaminated. So when the public asks why drug companies can’t make millions of doses right away, this is the reality.

From other sources: Current ebola-antibodies coctail from a competitor ZMapp faces similar production limits. There are only about a dozen doses available at the moment, which is why they haven’t sent any to West Africa.

From SCIENCE INSIDER

 By 23 October 2014 2:30 pm

The Ebola virus

Extensive background documents from a meeting that took place today at the World Health Organization (WHO) have provided new details about exactly what it will take to test, produce, and bankroll Ebola vaccines, which could be a potential game changer in the epidemic.

ScienceInsider obtained materials that vaccinemakers, governments, and WHO provided to the 100 or so participants at a meeting on “access and financing” of Ebola vaccines. The documents put hard numbers on what until now have been somewhat fuzzy academic discussions. And they make clear to the attendees—who include representatives from governments, industry, philanthropies, and nongovernmental organizations—that although testing and production are moving forward at record speed, knotty issues remain.

At the meeting, GlaxoSmithKline (GSK) of Rixensart, Belgium, which has the vaccine furthest in development, spelled out how it might scale up production in parallel with the safety and efficacy trials now under way so that the product could be ready for wider distribution by April if warranted. The company expects to have preliminary data in November from phase I studies that analyze safety and immune response in small numbers of people not at risk of contracting Ebola. If those data are positive, efficacy trials could start as early as January in Guinea, Sierra Leone, and Liberia, the three West African countries hard hit by the epidemic.

Earlier discussions suggested that efficacy trials should recruit health care workers and first-line responders like those who do burials or track contacts of known infected people. WHO estimates that there are about 12,000 health care workers in the three affected countries and another 17,500 “community” responders.

GSK is considering two efficacy trials. The largest would take place in Liberia and involve 12,000 people. This study, which could begin in mid-January, would randomize half of the participants to receive the vaccine and the other half a placebo. The study could also have a third arm, GSK said: A vaccine made by NewLink Genetics of Ames, Iowa, that has just entered phase I studies in the United States. The U.S. National Institutes of Health indicated that it was interested in leading this study.

A second trial would start simultaneously in Sierra Leone, Ripley Ballou, who is heading the GSK Ebola vaccine project, told ScienceInsider. “One of the trials may fail for logistics reasons,” he explained. “We only have one shot to get this right.” The trial in Sierra Leone would not use a placebo but instead would offer groups of health care workers the vaccine at different points in time. This “stepped-wedge” trial could involve up to 8000 people, and the U.S. Centers for Disease Control and Prevention has had preliminary discussions with affected countries about staging these studies. Although Guinea is also hard hit, it has the least infrastructure in place to do a trial, Ballou says. “It would be the most challenging place to do a phase III study.”

GSK estimates (see table below, and here) that it will have 24,000 doses of its vaccine ready by January for the efficacy trials. If it cranks up production to full capacity before the those trials are complete, the company could have 230,000 doses available in April, and then could steadily increase capacity to produce more than 1 million doses a month by December 2015.

GSK has made modest investments in scaling up production of its vaccine, and this table projects what it might be able to produce over the next year if it went all out and added several new production lines. The “at risk” noted by the asterisks refers to the company doing quality control without needing to wait for regulatory agencies to repeat the tests.

In one of the background documents, GSK noted that a “critical issue” is what’s known as fill capacity. GSK said there is a shortage of facilities that can fill vaccine vials under sterile conditions in a facility that meets what are known as biosafety level 2 conditions. It suggested the regulatory agencies relax their biosafety requirements. If GSK alone must do the filling, this will affect the company’s ability to produce other vaccines already on the market, including ones that protect against rotavirus, measles, mumps, and rubella, the document said.

The GSK document also outlines a number of proposals to make the first batches of vaccine quickly available, like running some of the quality control tests in parallel and changing the test used to prove sterility of the vaccine from one that takes 14 days to an assay that takes half the time.

Additional studies of the NewLink vaccine will start soon in Geneva, Switzerland, and Hamburg, Germany. A first lot of the vaccine arrived in Geneva on Wednesday, Marie-Paule Kieny, an assistant director-general at WHO, told ScienceInsider. The Canadian government has donated 800 vials of the vaccine to WHO, but is sending them in three separate shipments, Kieny explained. “It just felt too risky to put all eggs in one basket,” said Kieny, who has volunteered as a subject for testing the vaccine herself.

Janssen, a division of Johnson & Johnson, described its plans to speed development of yet another Ebola vaccine strategy that has yet to enter human studies. A delegation from Russia planned to discuss Ebola vaccines being made there, too.

A highly detailed, 28-page document by the Norwegian Institute of Public Health offered “crude cost estimates” for scaling up mass production of Ebola vaccines. By these calculations, 27 million doses of vaccine would cost up to $73 million, and the cost of the vaccination campaigns themselves will add another $78 million to the bill.

Several analyses laid out the complex regulatory and liability issues. The U.K. government argued that “there is a need to provide some form of relief of liability for the producers and distributors of the vaccines” and that WHO should coordinate discussions with regulators. The U.K. government also noted that “affected African countries will have the primary role of authorising or allowing use of investigational vaccines” and said “buy in” from those communities about the clinical trials must be obtained as soon as possible.

As far as financing, the U.K. government contends that a “multi-donor club” should pay for the vaccine development in “the medium term.” But for now, the United Kingdom says it will “unilaterally” cover the costs for purchasing vaccines in Sierra Leone, and it asks the governments of the United States and France to make the same commitment for Liberia and Guinea, respectively.

In a planning document, WHO pointed out multiple logistical issues, including “the ability to safely and securely transport the intervention to the delivery site, the existence of safe and secure storage facilities with appropriate cold chain capacity, the availability of sterile equipment to administer injections.” But to Ballou the greatest question hanging over the vaccine trials is the stability of the countries. “The thing that is going to have the biggest impact is what is happening to the trajectory of the epidemic curve,” he says. “If you progress the current trends 2 months into the future are we still in an environment where you can even consider doing a trial?”

*The Ebola Files: Given the current Ebola outbreak, unprecedented in terms of number of people killed and rapid geographic spread, Science and Science Translational Medicinehave made a collection of research and news articles on the viral disease freely available to researchers and the general public.

Fighting the Spread of Ebola in a Weak and Poor Governance Structure: A Liberian Peacebuilder’s Perspective

TEST

As the Ebola virus spreads throughout Liberia, the effects of bad governance, weak health infrastructure, mismanagement, and greed are manifest as death rates continue to surge. On September 23, the Center for Disease Control estimated that cases of Ebola in West Africa will double every 20 days — and in an absolute worst-case scenario without any intervention, the disease could infect 1.4 million by January. The government has lost control of the situation and is now dependent on the goodwill of the international community for both manpower and basic supplies.  For example, hospitals and government-run Ebola centers are plainly unable to handle the caseload — many suspected victims have been asked to return home due to lack of beds and unavailability of staff to care for them. At the same time, local organizations are engaging in awareness activities hoping to reach out to populations in Monrovia and beyond, but with little or no support from the government.

The Ebola virus epidemic started in Gueckedou, a city in Guinea near Voinjama in Liberia’s Lofa County. The index case of Liberia is suspected to have been a health worker who became infected while treating two suspected cases of Ebola in Liberia’s Foya Hospital near the country’s border with Guinea. This nurse was further alleged to have travelled to relatives in Margibi County, about an hour drive away from Monrovia and subsequently sought treatment at the Liberia’s Firestone Hospital in March 2014. The Liberian government declared the Ebola epidemic in middle of March when two out of four samples sent to Guinea for testing came back positive. The numerous further contacts  apparently among those that had interactions with the first victims and additional cases from Guinea to Liberia resulted in the first wave of the epidemic, which was mostly confined to Lofa County running from March to June. After a period of lull, there came a second outbreak in July which spread at a faster rate and engulfed the capital city of Monrovia.

Fighting the Spread of Ebola Nat B. Walker Building Peace Forum

The government reacted slowly. It appeared to expect the international community to do for Liberia what it should have done for its people during the early stage of the crisis. For instance, when international organizations mobilized to control the situation at the borders, senior government officials made pronouncements dismissing the claims that the outbreak was Ebola. When Médecins Sans Frontières (MSF) and Samaritan’s Purse fought to contain the virus, the government was unable even to support the establishment of a testing center. It took days to get test results from the only testing facility in the country and even as the virus spread, confirming results was a challenge as it remained the only testing facility for months. With the help of the international community, there are now three active testing centers.

Much later, in July of 2014 in an attempt to contain the situation, Liberia’s President Madam Ellen Johnson Sirleaf announced the formation of a national Task Force on Ebola, to be headed personally by her. But the Task Force idea appeared like another political decoration: it had no clear mandate, a very weak coordination structure.  It was a rapid response team with little or no logistical support and no involvement of local people.  The ineffectiveness of the government institutions on the task force and the overall poor and inadequate response to the crisis ultimately led to violence.

The virus spread and continued to claim lives daily, yet for almost three months, only two ambulances served the 1.5 million citizens of Montserrado County (the area around Monrovia). A popular Liberian politician aimed to help by providing a third ambulance, but it was instructed only to pick up sick people. The dead were left to rot, accumulating at alarming rates and contributing to infection.  Vehicles were quickly donated to government agencies by international organizations when government officials declined to contribute their luxurious, government vehicles to the urgent need. Community dwellers were forced to expose themselves to the virus by removing the bodies from their homes to the roadside because the response team had no logistics to respond to the many calls for help. For them, placing the bodies in the streets made their homes safer while urging the government to clear the streets, but many contracted the virus from the contact.

As the government continued to demonstrate inefficiency in containing the situation and failed even to communicate in a coordinated fashion, distressed and marginalized citizens took to the streets.  These attempts to spur government attention led to outbursts of violence. In late July, I witnessed residents of the St. Paul Bridge Community in Montserrado County block a major highway connecting the western region with the capital, demanding that the government remove five dead bodies from their community. Only then did the government-coordinated Ebola response team respond. More recently, on the capital by-pass road, less than two miles from the Executive Mansion, a similar situation occurred. In the meantime, angry citizens called in to radio shows (the most popular form of mass communication in the country) to narrate how they were forced to sleep in streets while waiting for the government to remove dead bodies from their homes. The authority and legitimacy of the government are constantly being questioned by the citizens because of how inadequately they have addressed the virus.

The government instituted a curfew from 9:00 PM to 6:00 AM, intended to prevent people from coming out at night to throw bodies in the streets or to secretly bury their dead. Later adjusted to 11:00 PM to 6:00 AM, the curfew still remains active, but for many, the official justification is not logical. If intended to prevent people from taking actions to remove dead bodies from their homes, why not focus on strengthening the capacity of the agencies responsible for gathering the sick and deceased?  Instead, armed robbers have taken advantage of the curfew by attacking homes at night, since the government-imposed curfew now prevents community dwellers from organizing community watch teams and security agencies lack the capacity to patrol communities at night.

A health worker at Island Clinic in  Monrovia, Liberia checks on a patient. (Photo Credit: Morgana Wingard, USAID via Flickr)

At the moment, there is better coordination with the arrival of international experts and the much-delayed appointment of a national coordinator to the government task force. Much of what the task force is now doing, it should have begun months ago and undoubtedly would have saved many lives. But serious challenges remain. The biggest of these is how to address the virus outside of Monrovia. Beyond the capital, there is no clear support to empower health workers and social mobilization committees to carry out community-driven response activities.  Allegations of bribery are also on the rise, indicating continued state inefficiency.  A member of a recent civil society team confirmed that he paid 400 Liberian dollars (less than five United States dollars) to security personnel at the checkpoint between Grand Bassa and Rivercess in order for his colleagues to pass through since one was traveling without identification. It is even alleged that members of the government response team are requesting bribes to pick up dead bodies from communities.

In the government’s fight against Ebola, there is also suspicion of financial mismanagement. Nurses and doctors, whose lives are most at risk, are still not receiving adequate compensation and have no life insurance or medical insurance. There have also been fears of abuse and waste when handling Ebola funds. The Head of the Anti-Corruption Commission recently warned that his agency is monitoring the flow of cash and that corrupt officials will be prosecuted. Unfortunately, a lot of skepticism remains about the political will of the commission — since its formation over eight years ago, it has not closed a single case of corruption in the interest of the Liberian citizens. It remains a toothless bulldog to the excitement of the establishment.

Unless the fight against the spread of Ebola is fully decentralized to the county, district, and community levels, and adequate support is provided to caregivers including health practitioners, we should expect many more people to die. This is a sad reality. The government and its partners should take keen note of this and consider identifying, strengthening, and supporting community-led structures, especially in counties not yet overpowered by the virus.

President Barack Obama’s pronouncement of 3,000 US troops to help contain the situation is highly welcomed, but I recommend  that, as a matter of policy, U.S. troops and other international actors be directed to exercise caution. Liberians are already disenchanted with the government’s poor handling of the crisis.  If care is not exercised, the anger of the citizens could easily be transferred from the government to international actors. Involving local civil society actors, especially grassroots organization is an essential factor to any international intervention. This will help address the negative perceptions and mistrust the public has in the government’s handling of the crisis. This critical step must be implemented at the very beginning of the process if the desire result is to be achieved swiftly.

Nat B. Walker is a development and peacebuilding consultant working in Liberia. Hired on a long-term basis by Humanity United and TrustAfrica, he is currently supporting the development and expansion of a community-based conflict early warning and response system in Liberia. Nat is also a Liberia correspondent for Insight on Conflict, a UK-based project of Peace Direct and has previously worked for international organizations including the Catholic Relief Services, Mercy Corps and Conservation International. He is also an adjunct faculty member at the Kofi Anaan Institute of Conflict Transformation at the University of Liberia.

Nigerian doctor flaunts quarantine, infects 60

The hopes that Nigeria’s Ebola outbreak could be quickly stamped out have evaporated. The World Health Organization (WHO) this afternoonissued its first detailed report of the spread of the virus in Port Harcourt, Nigeria’s oil hub. Last week, authorities announced that a doctor there had died of the disease, after secretly treating a diplomat who had been infected in Lagos by a traveler from Liberia.

The doctor had close contact with family, friends, and health care workers during his illness, but he did not disclose his previous exposure to the virus. His infection wasn’t confirmed until 5 days after his death. Experts are now following hundreds of the doctor’s contacts, 60 of which had “high-risk or very high-risk exposure,” WHO says.

The diplomat had been instructed to stay in Lagos in quarantine. Instead he flew to Port Harcourt, where he was treated—in a hotel room—by the doctor from 1 to 3 August. The diplomat survived and returned to Lagos, presenting himself again to health authorities, who confirmed he was no longer was infected. He did not tell them that he had sought treatment in Port Harcourt.

The doctor who treated him became ill on 11 August. He continued treating patients at his private clinic for 2 days, operating on at least two of them. Between 13 and 16 August, he was ill enough that he stayed home, but, according to the WHO report, he received multiple visitors who came to celebrate the birth of a baby. On 16 August, he was hospitalized. He did not tell doctors there that he had been exposed to Ebola.

The WHO report is grim: “During his 6 day period of hospitalization, he was attended by the majority of the hospital’s health care staff,” it says, and members of his church community visited and performed a healing ritual that apparently involved laying on of hands. “On 21 August, he was taken to an ultrasound clinic, where 2 physicians performed an abdominal scan. He died the next day.”

It was not until 27 August that tests confirmed he was infected with Ebola.

His wife (who is also a doctor) and another patient at the hospital where he sought treatment are also infected. Twenty-one trained teams are monitoring more than 200 contacts, and a 26-bed isolation facility is set up. WHO says two decontamination teams and a burial team “are equipped and operational.”

The diplomat, associated with the Economic Community of West African States, may face manslaughter charges, according to Nigerian press reports.

*The Ebola Files: Science and Science Translational Medicine have made a collection of research and news articles on the viral disease freely available to researchers and the general public.

Beyond the health crisis, Ebola hits Liberia’s economy hard

Originally posted Aug 15 2014 – by Patrick Hettinger – African Development Bank – reposted

With over 400 deaths in Liberia and more than 1,000 across West Africa, the Ebola epidemic has been the deadliest in history and has spread fear and panic across the region. But beyond the terrifying health crisis, the Ebola outbreak threatens to reverse much of the economic and social progress Liberia has made over its decade of peace. While GDP growth had averaged over 8% since 2011, it was already forecast to slow down to 5.9% in 2014 due to slower growth in iron ore production, weak timber and rubber exports growth, and the gradual drawdown of the United Nations force (UNMIL). However, restrictions on transportation and commerce, the withdrawal of international workers, a slowdown of investment, and a panicked population will further reduce growth this year. Containing the crisis rapidly will be critical to preserve the progress made, and to reduce risks to the short- and medium-term outlook.

Government measures to control the spread of the virus, including the quarantine of communities, restrictions on travel between counties, sealing land borders, and the closure of major markets, have severely restricted trade within Liberia and with its neighbours. Free movement has also been restricted with all but two airlines suspending flights with Liberia. Additionally, public fear of the disease has led many consumers, traders and businesses to stay home or otherwise limit their activity and potential exposure. Families and communities with Ebola cases are stigmatized, and neighbours, drivers and traders avoid them. This is reducing the supply of food, other goods and services throughout the country. Reports that ships from Liberia are being blocked in Côte d’Ivoire would exacerbate this, especially for fuel supplies, which would have a severe impact on transportation and power availability.

Liberia imports more than 60% of the rice it consumes, but some areas are self-sufficient in rice production. One of the epicenters of the outbreak – Lofa county – produces around 20% of Liberia’s rice and largely meets its own rice demand while producing numerous other crops and trading with cross-border markets and Monrovia. However, some fields are being deserted, and after months of slower trade with Sierra Leone, there are already reports of food shortages and discussion of the need for food drops. Quarantine measures will further cut off rural areas and restrict trade with Monrovia.

The unprecedented spread to a major urban centre is changing local transportation. Taxis have reduced the number of passengers they will hold from six to four in order to reduce physical contact, while also nearly doubling the cost to passengers.

Consumers have stocked up on food and essential goods, pushing up their prices, but they are reducing their purchases of non-essential goods. The temporary closure of Government offices for all but core staff has reduced sales at shops and from traders in central Monrovia. This all contributes to lower incomes and worsening purchasing power, which affects Liberia’s poor the most.

Added to this is the large-scale departure of much of the substantial expatriate community and Liberians who had been gradually returning after the war. Not only will the country lose their skills in the private sector and donor projects, but the service economy that has developed to meet their higher incomes is suffering from a substantial drop in activity. Hotels and restaurants are increasingly vacant. One of Monrovia’s most popular hotels reports only a 30% occupancy rate, with the few remaining guests from the Center for Disease Control (CDC), World Health Organization (WHO), and similar health agencies. Real estate owners will suffer the impact slower, with many expatriates holding year-long leases paid up front.

The concessions sector, with some $16 billion in foreign direct investment commitments, has led aggregate growth in Liberia since the end of the war, but it has not escaped the crisis. Iron ore has been the largest export over the past two years due to production from the Arcelor Mittal mine.

While the company is continuing production and still expects to produce 5 million tonnes of iron ore this year, its expansion from 5 to 15 million tonnes by the end of 2015 has been delayed after the 15 contractors involved evacuated their 645 employees. China Union, which was expected to produce 500,000 tonnes of iron ore this year, has temporarily halted operations, following reports of six suspected cases of Ebola at its company-run hospital.

The palm oil sector has had similarly mixed activity. Golden Veroleum, with operations in Liberia’s southeast, which has so far largely avoided the Ebola outbreak, is continuing operations, while taking precautions and granting leave to some staff based in Monrovia. However, Sime Darby, whose activities are near several affected areas, is slowing operations, although it will continue paying its 3,000 workers.

Rubber production, Liberia’s second-leading export, has mostly continued activities, although recent Ebola cases in Kakata in the centre of the rubber production region could significantly slow production. Timber production, which has dropped since 2013 due to governance issues and transportation bottlenecks, is based in the largely unaffected southeast and could avoid a significant impact.

The economic slowdown is reducing Government receipts after already experiencing revenue shortfalls over the past year. Tax revenues were reduced by $12 million between April and June, and have fallen further since the end of July when the outbreak escalated. This will make it significantly more challenging to fund the Government’s proposed a $20.9-million emergency response plan, and its $559-million draft Fiscal Year 2014/15 Budget will have to be revised. The budget had increased security expenditure to offset the United Nations Mission in Liberia (UNMIL) drawdown, which will be necessary considering the significant military activities involved in containing the outbreak. While the Government has one of largest payrolls as a percent of GDP in the region and there are serious deficiencies in the system, the payroll also provides income to around 40,000 households. Continuing to pay Government workers will be critical during the crisis to sustain economic activity. Potentially re-allocating some of the $18.25 million budgeted for District Development Funds could provide some needed fiscal space.

Slowing public and private investment could also affect medium-term growth. The evacuation of skilled staff and contractors and restricted movements, if prolonged, will delay existing investment projects, as is being seen with Arcelor Mittal and oil exploration. In light of the considerable uncertainty, the local business community is waiting to see how the situation evolves before making further investment and expansion, preferring to leave funds offshore in Lebanon or the United States. Slowing investment, especially from smaller businesses and on Government energy and roads projects, would reduce the prospects for employment-generating, inclusive growth.

The perception of a return to instability in the region may take years to overcome. Liberia has spent 10 years of peace working to move beyond the memories and reputation of its brutal civil war, but this episode will revive those memories and add an additional layer of stigma. This will not only affect investors and the broader international community, but also Liberians abroad. The Liberian diaspora had been gradually returning since the war, bringing skills and resources, but this crisis has seen many leave again. With their families often still residing in the United States, they may hesitate to return once again. This will reduce the middle class of the country, which is essential to develop the economy, as well as to rebuild Government services.

Perception is equally important for Liberians at home. Already distrustful of the medical system, a Government that continues to face governance challenges, and the international community, the likelihood of unrest will increase the longer the crisis unfolds, service provision is interrupted, and as the economic and social damage increases. With 78% of the labour force only holding “vulnerable employment” without assurance of a salary, the large number of subsistence farmers and traders relying on small margins – while owning only modest assets and little savings – will not be able to cushion the downturn easily. Stability had been their opportunity to make modest progress and to gradually transition towards longer term perspectives. The poor will be hit hardest by the lack of access to medical facilities for treatable illnesses, unnecessarily increasing hardship and mortality. With even schools closed and soccer matches cancelled, an otherwise restive youth has few distractions. An armed mob’s looting of an Ebola clinic in West Point, chanting “there is no Ebola!” is just one of many instances highlighting local suspicion and the potential for disorder. International support must move rapidly and decisively to contain the disease and mitigate its economic and social impact. The Ebola crisis has been terrifying, and while the economic damage may be less striking, it will affect many more lives and increase the fragility of a region that was eager to move beyond its history of conflict.