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Rebecca Robinson does not wear gloves on the job. A misstep while removing them, she says, could increase the risk of infecting herself with Ebola. Instead, she dons a rain jacket and boots and clutches a bottle of hand sanitizer as she travels by motorbike from house to house in Liberia's capital city of Monrovia. Her objective: to help trace the complex web of Ebola’s spread and to instruct apparently healthy people who may have had contact with an infected person to stay home for 21 days. Such quarantines, the Liberian government says, are a precautionary step to keep the virus from potentially moving even farther afield.
Robinson is one of the thousands of people working to quell the Ebola epidemic in west Africa through an age-old public health practice called contact tracing. She interviews people who may have potentially been exposed to others infected with the virus and instructs them on how to monitor for symptoms like fever and how to prevent the disease’s spread. In many cases, she tells people they must stay at home to quarantine themselves from others.
Her days are draining. At first she worked along the porous border with Guinea but since August she has been tracing contacts in the nation’s capital. At 8 A.M. each morning she meets with other health care workers before embarking on a full day of Ebola tracking. During that daily meeting she receives a list of households that need to be visited (culled from reports that came into an emergency Ebola hotline), talks with the others about the challenges she encountered the prior day and then sets off on her motorbike. Robinson is part of a four-person team that works together canvassing neighborhoods. Before she signed on to help with the Ebola response she had been a student, earning a certificate in public health. Now, at age 32, she has lost an uncle and some close friends to the epidemic.
“I will do this until Ebola is gone,” she says, but she has few tools to assist her in the fight. Robinson must ask people if they have fevers but she does not have a thermometer, instead she simply asks them if their skin is hot. She has no face mask for when she encounters ill patients, rather she stands a meter away from individuals. “I feel I’m safe since I’m standing that far away,” she says. And, against a backdrop where there is little available data on how long the virus can live on surfaces, she does not have any gloves. “We were told gloves were dangerous because we could infect ourselves, so we wash our hands instead and stand three feet away.” Ebola, which has killed more than 5,000 people in Guinea, Liberia and Sierra Leone during the current outbreak, is not considered contagious until an infected patient develops symptoms such as a fever and vomiting. Then if another person comes into direct contact with the bodily fluids (primarily blood, vomit or diarrhea) of that Ebola patient, she or he can get infected.
There are other reasons her job is far from easy. Even experienced health care workers can have trouble traversing impassable roads in certain areas of Liberia, especially during intense rains, which occur from May to November. But their most formidable challenge, she and other interviewed contact tracers say, remains denial. Eight months into Liberia’s outbreak people still hide their sick or refuse to believe that the disease is wreaking havoc in their communities. And as the number of cases of Ebola in Liberia fall, ensuring further progress against the virus hinges on ramping up the tracking of individual cases and people they may have infected.
And sometimes she gets threatened. In one case, she says, three members of one family died from Ebola but the remaining relatives refused to accept that it was the killer. When she told them that they would need to stay at home for 21 days, they became quite aggressive. They threatened, she says, to take sticks and beat her or anyone that tried to keep them from leaving their home. Being quarantined at home can have serious repercussions. Quarantined families sometimes worry about running out of food, losing their jobs or what kind of treatment they will face from their communities after being linked to Ebola. Plus, no one enjoys being forcibly isolated.
At last, Robinson threatened to call the police and they agreed to remain home. The government, she told them, would provide them with food during their period of isolation. In some areas, however, people have threatened to break out of isolation because of lack of food, according to local media reports.
Samuel Zazay, who helps oversee contact tracing for Grand Cape Mount, a county along Liberia’s northwestern coast, some 100 kilometers from Monrovia, says that in recent months Ebola has only tightened its grip in his area. Although many parts of the country have made strides with the outbreak overall, cases in his county have risen in recent months. In September there were only seven Ebola cases there, but the toll jumped to 57 in October and there have already been 23 suspected or confirmed cases in November.
Volunteers and workers in Grand Cape Mount now conduct several interviews each day with those who may have been exposed to Ebola-symptomatic people and thus are at risk themselves, he says. Zazay, alongside a fleet of community health volunteers and district health offices, is having “serious problems” now, he says. The total number of cases in that county has climbed above 90.
The World Health Organization reports that there are about 7,000 Ebola cases in Liberia now with 2,964 deaths. Hundreds of new cases continue to spring up each week. “We are nowhere near out of the woods yet in west Africa,” Pres. Barak Obama said on November 18 before meeting with public health experts to discuss the crisis. The White House is asking Congress for an additional $6.2 billion to help combat Ebola globally and ramp up its preparedness in the U.S. “The good news is,” he said, “in parts of Liberia, our efforts, both civilian and military, are really paying dividends.”
The bad news is even as international forces move in to try to quash the virus, it moves faster than responders. In these areas of west Africa “Ebola is not staying in one county,” Rabih Torbay, international operations senior vice president for the International Medical Corps testified before a congressional panel on November 18. Just as an Ebola treatment center is completed, he says, the virus may rapidly move to another county. And the current design of such treatment centers are best fitted to be temporary—there is not much point in leaving them behind to be treatment centers for other maladies, he said.
“Everything is overshadowed by Ebola virus disease now,” says Zazay. He is employed by the country’s Ministry of Health and Social Welfare to also conduct disease surveillance for other maladies including measles and polio—but the fight against the malady has become all-consuming, he says. Now, he will only note other diseases if he comes across them as he monitors the epidemic’s steady progress. Stigma, too, has also hurt their community health care worker recruitment. Individuals have been reluctant to do Ebola work because they know they might be shunned by their neighbors or feared by their communities, he says.
Depending on how many community health workers are available, Zazay says, they tweak their plans about how many households each individual must visit on a day-to-day basis. Right now each volunteer visits 10 contacts each day, he says. Yet all too often when the volunteer arrives at a person’s house, no one is home. “Denial remains high,” Zazay says. “People do not believe what they see.”