The global response to the Ebola virus in Liberia is being hampered by poor coordination and serious disagreements between Liberian officials and the donors and health agencies fighting the epidemic, according to minutes of top-level meetings and interviews with participants.
Even now, three months after donors began pouring resources into Liberia, many confirmed cases still go unreported, countries refuse to change plans to erect field hospitals in the wrong places, families cannot find out whether their relatives in treatment are alive or dead, health workers sent to take temperatures sometimes lack thermometers, and bodies have been cremated because a larger cemetery was not yet open.
The detailed accounts of high-level meetings obtained by The New York Times, the most recent from Monday, lift the veil on the messy and contentious process of running the sprawling response to Liberia’s epidemic, one that now involves more than a hundred government agencies, charities and donors from around the world.
Despite these problems, with help from donors, Liberia, one of the three most afflicted West African countries, and the one with the highest death toll, has seen new cases drop to about 20 a day from about 100 a day two months ago. Experts attribute that to fearful Liberians touching one another less, more safe burials of bodies and distribution of protective gear to health care workers. But they also warn that cases are now holding steady and could explode again.
Participants in the meetings of the Incident Management System — which replaced the National Ebola Task Force — said the atmosphere in the meetings in the Liberian capital, Monrovia, should not be characterized as chaotic or bogged down in bickering, instead calling them “collegial” and “effective,” although one who spoke on condition of anonymity described “showmanship and political posturing.” Senior officials of the Centers for Disease Control and Prevention who attended — Dr. Frank J. Mahoney and Dr. Kevin M. De Cock — said in an email that there were “differences of opinion — accompanied by passionate discussions.”
At the meeting on Monday, Dr. De Cock cited serious logistics problems, including regular hospitals that cannot separate out Ebola patients, counties with no ambulances and temperature takers with no thermometers.
On Nov. 12, the representative of the United Nations secretary general complained that “hundreds” of vehicles had been made available but there was always a shortage. Asking where they are, he added: “The recipient also has to be accountable, just as the donor.”
Also, the support documents with the minutes indicate that there is no national plan for Ebola survivors — either for reuniting them with their families or for using them to do nursing tasks because they are thought to be immune.
A report on the issue reads: “The current and planned work presented by the partners and government for survivors can be characterized as fragmented and lacking in scope, scale, comprehensiveness, evidence base and survivor-driven programming.”
American military helicopters ferrying doctors to remote areas were forbidden to fly back not only patients but even blood samples; recently samples from a village had to be walked to a road four hours away. At Monday’s meeting, according to the minutes, Dr. De Cock called this “unacceptable,” adding, “This has to change this week.”
Dr. Hans Rosling, a Swedish epidemiologist and consultant to Liberia’s Health Ministry, said that the helicopter order came “from somewhere in America.” In an interview, he cited problems not listed in the minutes: one Asian and two European donor countries are insisting on building new Ebola field hospitals in Monrovia, where hospitals have empty beds, rather than in remote counties where beds are desperately needed; they insisted because they announced those plans two months ago, he said. The national case count was not reported for two days recently because the government employee compiling it went unpaid and stopped working. The minutes of the Incident Management System were made available along with PowerPoint files and other documents by an expert who said the disorganization of the Ebola effort should be made public.
The meetings are usually led by Tolbert Nyenswah, the deputy health minister, and include representatives from the Centers for Disease Control, the World Health Organization, the World Bank, the United Nations Mission for Ebola Emergency Response, numerous United Nations agencies, the United States Agency for International Development, the United States Army, Doctors Without Borders and medical, aid or military representatives from many other countries. Dr. Nyenswah and other ministry officials could not be reached for comment; Dr. Rosling has worked with the ministry since October.
The minutes make it clear that accuracy of the national case count is shaky.
On Nov. 5, Dr. Rosling said, “We are absolutely sure that we cannot be sure about the data.”
In an interview, he said that to improve reporting of cases, he gave a $13,000 Swedish government grant to “a chronically honest church lady” to buy cellphone scratch cards for health officials in remote areas. The C.D.C. is bringing satellite phones to areas that lack cellular service.
Despite problems, he said, the response is going better than he had hoped. He compared it to Dunkirk, the hasty 1940 evacuation of British and French troops from France, which he described as “chaotic, but a success.”
In the minutes, Liberian officials regularly complain about the donors, and the donors argue back. On Nov. 12, James Dorbor Jallah, the task force’s deputy manager, said: “People will sit in D.C. or Geneva and want to direct what is happening here.”
The health minister, Dr. Walter T. Gwenigale, backed him up, complaining that “the U.N. and other agencies got their money before the ink was even dry,” while, he said, a group run by a Liberian pastor to teach rural people about Ebola “has not gotten one cent.”
On Sunday, President Ellen Johnson Sirleaf replaced Dr. Gwenigale without explaining why, but said he would remain an adviser. Dr. Emmanuel T. Dolo, Ms. Johnson Sirleaf’s youth adviser, complained that the donors were “showing a level of disrespect” by judging Liberian community groups by “harsh standards” and “Western standards.”
At the same meeting, Mr. Nyenswah, the deputy health minister, pointed to his government’s “team leaders” and warned, “Partners in the room have not been engaging them and involving them in strategy — but you have to.”
A representative of the United Nations Children’s Fund replied that the local pastor needed to prove he could do the work.
Two days later, Shiyong Wang, the World Bank representative, confirmed that United Nations agencies had received nearly all their money and that the Liberian government had received only 7 percent of the $23 million allotted to it. But, he said, the government had not produced required documentation — not even, for example, names of dead health workers whose families awaited compensation. He criticized the government’s “overly complex and bureaucratic approval process,” including three signatures on each document.
Dr. Rosling said the three signatures were an anticorruption measure. Beneficiary lists are hard to produce, he said, when Liberians have children whose births are often not officially recorded. And it was “arrogant,” he said, for donors, for example, to assign contracts to operate field hospitals without Health Ministry permission.
The Nov. 12 meeting appeared to end on a bitter note, with Mr. Nyenswah telling every agency to document within 48 hours what people it had and what their jobs were. “If you don’t give us this list,” he concluded, “you are not allowed in this meeting.”
The meeting of Nov. 14 opens with Mr. Nyenswah reminding scientists not to do research without permission from a government ethics review board. On Nov. 17, Dr. Dolo complains that “There are a lot of people in this room who never contribute anything to this meeting.”
A version of this article appears in print on November 20, 2014, on page A1 of the New York edition with the headline: Internal Discord Hampers a Fight Against Ebola.
Source: http://www.nytimes.com/2014/11/20/world/africa/ebola-response-in-liberia-is-hampered-by-infighting-.html?_r=0
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