The Ebola situation has improved in Lofa County and Médecins Sans Frontières (MSF) has decided to withdraw from the area. New actors have arrived to help and since 30 October there have been no more Ebola patients in the Ebola Management Centre (EMC) in Foya. The success of MSF’s intervention in northern Liberia can be considered a model of response, benefiting from a comprehensive approach and constant community involvement.

When MSF took over the management of the EMC in Foya in August 2014, the teams were not only faced with an overflowing patient load of up to 130 people a day but also had to deal with the population’s fear, denial and misinformation, as they had never experienced an Ebola outbreak before. Soon it became clear that the intervention could not only focus on isolating patients but that MSF needed to take a comprehensive and transparent approach if the virus was to be contained. Hence, the teams started to work on all six pillars of Ebola management, including isolation, outreach, safe burials, health promotion, psycho-social support and contact tracing. Ebola deeply affects family and community structures, forcing people to stop the most natural gestures like caring for their sick relatives or paying their last respects to the deceased.

We are convinced that our all-encompassing approach, including open and transparent cooperation with communities, local authorities and partners, has led to this impressive reduction in the number of cases in Lofa County,” says Ettore Mazzanti, MSF Project Coordinator in Foya. “Trust and the understanding of the communities have been very important for the acceptance of our medical activities and, ultimately, in successfully containing the virus. Without understanding and adapted coping behaviours, it is impossible to reach zero cases.”

As no new Ebola patients had been reported at the EMC since 30 October and new actors had arrived in the area ready to take over remaining activities and surveillance, MSF decided to withdraw from Lofa County and redirect its efforts to areas with greater unmet needs. In the last few months, in preparation for departure, the team started reorganising the EMC by gradually decreasing bed capacity from 85 to 10 beds and by reducing the number of national and international staff.

Supporting the health centres so they can reopen safely

To support the local health system, MSF donated Ebola protection kits to health structures and focused on training health staff in the districts of Foya, Kolahun and Vahun in Ebola patient care, including case definition, isolation and supportive care, as well as on protective measures and infection control. In Lofa County, as in the rest of Liberia, the entire health system has collapsed as a result of the epidemic. Many health workers have died, most hospitals and clinics remain closed and the safe reopening of essential health services is one of the most urgent needs at the moment.

“Health workers have been decimated by the epidemic and we must ensure that the remaining staff can return to work with confidence”, says Mazzanti.

Health promotion and mental health activities were slowly reduced as well, as more and more local NGOs became active in the area. By 10 December, all MSF activities in these areas had ceased, as they had been completed and handed over to the Ministry of Health and its partners.

“It is great to see that life has almost returned to normal around here but there are definitely mixed feelings in the Lofa community,” observes Mazzanti. “On the one hand, with MSF moving out, people are confident that the situation has improved. But on the other hand, people are concerned about the situation in bordering Guinea and Sierra Leone, where the outbreak is still ongoing. Also, with Christmas coming, people will be travelling a lot and there will be more gatherings, meaning that the risks of contamination will increase. We must definitely not lower our guard and we must remain vigilant.”

The Foya Model – a comprehensive, transparent response

When MSF took over the Foya Ebola Management Centre in August, community engagement was prioritised alongside medical activities. Together, these activities have been key in gaining the acceptance of the community, and have encouraged the adoption of Ebola prevention behaviours such as hand washing with soap, social distancing and calling the MSF hotline regarding any suspected cases.

• We re-designed the Ebola Management Centre to maximize transparency in a safe way, to address rumours about what may be happening inside and to de-mystify our work. This involved removing high barrier fences and replacing them with lower, see-through fences so that the people outside were able to see how the centre was run. Prior to this, there had been an air of suspicion about what was going on behind our walls. People went in but were rarely seen coming out again.
• Special corridors were designed to ease the interaction with patients in the high risk zone, without the obligation for health staff to wear full personal protective equipment. Such small details make a huge difference in terms of relieving stress and enhancing proximity.
• We employed a team of psycho-social counsellors to ensure that patients and their families were supported and kept well informed. The team encouraged and facilitated safe visits of family members to patients inside the centre, and passed messages to those not well enough to receive visitors. A mobile phone was also made available within the confirmed area so that patients from further away could keep in touch with family and friends.
• We provided safe burials that were conducted in a manner that respected, as much as possible, traditional customs and fully involved family and friends. Families were informed of the death by the psycho-social team, who invited them to come to the centre if possible so that the news could be relayed in person. They then discussed burial wishes with the family, explaining that for safety reasons not all customs could be respected.
• Before going to the cemetery, a hygienist would enter the morgue, bring the body bag out and allow the family to see the deceased’s face from a safe viewing distance. Many relatives like to take photographs to remember the deceased and also to share with those not present. Some families bring a bag of the person’s best clothes so that they can be buried with them – they are not able to dress the body as they would traditionally, but part of the tradition is kept intact. If desired by the family, services can be arranged with prayers and speeches at the burial, and the family can provide a coffin for the protective body bag to lie in.
• We invested in comprehensive health promotion and communications activities, speaking to communities in their local languages and spreading Ebola awareness messages, as well as informing people that the earlier they seek care at the centre, the better their chances of survival. Twice weekly phone-in radio shows were held in two of the districts so that members of the public could call and ask the health promotion team questions.