"The MSF staff are working non-stop to treat the wounded civilians who manage to make it to our hospitals, but it saddens me to think about how many people must be dying from wounds or from cholera or other illnesses because they have no way to safely get to the very few medical facilities that are still functioning in the city. I can only hope to go back as soon as possible to do what I can." - said Mathias Formelius, a German nurse working with MSF in Monrovia.

"The hardest thing about treating cholera is seeing the small children who are so ill and must be isolated from their parents so that they don't give them the disease," said Mathias Formelius, a German nurse sent to Liberia to help MSF combat an outbreak of cholera in the capital of Monrovia. "They cry for their mothers non-stop, but luckily the treatment is short and in only a few days the kids are feeling better and can go home." Cholera is a deadly and highly contagious disease that spreads quickly when people are living in cramped conditions without clean water or proper sanitation.

In the past two months, intensified fighting between Liberian government forces and LURD rebels has sent tens of thousands of Liberians flooding into the capital and camps in surrounding Montserrado County in search of safety. The crowded camps, abandoned buildings, and stadiums where the displaced have taken shelter are the perfect breeding ground for a serious cholera outbreak.

Sharp rise in an endemic situation Cholera is endemic in Monrovia but a sharp increase has been noted since the beginning of the crisis due to the massive displacements and the very poor sanitation conditions in the places where people sought shelter. In July, three cholera treatment centers set up by MSF in the capital were already treating over 300 cases per week.

By mid July, the Liberian Ministry of Health had declared the epidemic official and asked MSF to take charge of coordinating cholera surveillance and treatment in the city. Monitoring the spread of cholera is as crucial as quickly identifying and treating people suspected of having the disease.

By setting up a system of cholera treatment units (CTUs), with a capacity of 400 beds in the city, MSF staff working in six clinics and two hospitals in Monrovia and three camps for displaced persons in nearby Montserrado County hoped to stem the spread of the disease by immediately referring patients complaining of cholera symptoms to a CTU for observation, isolation and treatment.

Severe dehydration brought on by the acute diarrhea and vomiting associated with cholera, particularly in children and adults already suffering from poor nutrition and a lack of adequate water, often proves deadly for those who contract the disease. It is critical that anyone suspected of having cholera be rehydrated quickly with oral rehydration salts (ORS), or with Ringer's lactate, administered either orally or intravenously for patients who cannot drink.

"Treating cholera is simple," explained Formelius, "but controlling the spread of the disease is not, especially in the extremely poor sanitary conditions existing in Monrovia today." Treatment facilities required Setting up a CTU requires building a facility apart from the general population and especially away from health structures where patients already weakened by other illnesses are especially susceptible to the disease. In response to the first sign of a cholera outbreak in June, MSF established CTUs with a total capacity to treat over 250 patients at the John F Kennedy Hospital, the Samuel K Doe Stadium - where over 20,000 displaced Liberians were living - and one on Randal Street in the heart of the city.

"Although I have worked as an emergency room nurse in Germany and volunteered with MSF in the field before, I felt pretty useless when I first started working in Monrovia," said Formelius. "The Liberian nurses and supervisors in the two cholera treatment units I was responsible for were already doing an incredible job caring for patients. But, this also gave me the confidence and time to get working on a new facility on United Nations Drive where we would be able to treat an additional 300 patients.

"While the MSF logistics team set to work building special beds for the new CTU, Mathias interviewed potential staff, as operating a CTU requires health workers and cleaners dedicated to round-the-clock patient care and disinfection measures. "I had no problem recruiting the people I needed, and with the beds in place in UN Drive, the CTU was up and running just a few days after I arrived," continued Formelius. "Unfortunately, just three days after the UN Drive CTU opened, fighting broke out close to the unit and we were forced to transfer patients and staff to Randal Street.

By Saturday afternoon, the fighting had reached the city and we had to abandon the Randal Street CTU as well and move some 48 patients plus our staff to what we hoped would be a more protected area right inside the MSF compound." To house the cholera patients, many of them small children, MSF logisticians quickly erected four tents in the parking lot of the MSF office compound in the Mamba Point area of the city where MSF was already running one of two houses-turned-hospitals set up after fighting in June forced MSF to stop working in Redemption Hospital, the last fully functioning public hospital in the country. "You can't spread cholera patients all over the place in or near a hospital because one cholera case in a hospital can be a disaster," said Formelius.

"So we made sure there was proper separation and disinfection between the cholera tents and the hospital entrance." As fighting over the weekend grew heavy in the city and dozens of wounded civilians poured into the two MSF hospitals in Mamba Point, over 100 MSF Liberian staffers also crowded into the MSF compound for safety. "Some patients who recovered left, or were picked up, but it was difficult to tell them to go, even though we desperately needed the space and did not know how long we would have enough food and water for everyone," explained Formelius.

"How can you say, 'Okay, you survived cholera, now please go out on the street where you might be killed by a bullet or mortar.'"
"Cholera patients get better fast, so in a couple of days we needed just one tent for the worst patients," continued Formelius. "We put the less severe cases and the children who had recovered in the office lobby and by Monday the place resembled a small nursery with little kids everywhere.

Some parents braved the streets to pick up their children, but many probably felt their children were safer staying with us in the compound." "Some patients who recovered left, or were picked up, but it was difficult to tell them to go, even though we desperately needed the space and did not know how long we would have enough food and water for everyone," explained Formelius.

"How can you say, 'Okay, you survived cholera, now please go out on the street where you might be killed by a bullet or mortar.'" With plenty of staff on hand to take care of the remaining cholera patients and work in the hospitals, MSF decided that the security situation in Mamba Point had deteriorated to such a degree that Matias and four other international MSF volunteers should leave the country in an evacuation being organized via helicopter from the US Embassy compound nearby.

"Heavy shelling started very close by just as the other MSFers and I were running to the helipad. We quickly took cover in a garden shelter in the compound and stayed there for about half an hour until we could get back to the embassy." Mortars and shooting in the civilian area near the embassy was so intense that on Monday alone the two MSF hospitals in Mamba Point received 155 wounded civilians, many from a mortar blast that hit a building in the US embassy compound where thousands of displaced Liberians had sought safety.

Matias and the rest of the MSF evacuees remained in the US embassy compound for the next three days until they could safely leave by helicopter for Freetown, Sierra Leone. "The hardest thing now is waiting to be able to return and thinking about what is happening to Liberians who are caught in the middle of the fighting," said Formelius from Freetown.

"The MSF staff are working non-stop to treat the wounded civilians who manage to make it to our hospitals, but it saddens me to think about how many people must be dying from wounds or from cholera or other illnesses because they have no way to safely get to the very few medical facilities that are still functioning in the city. I can only hope to go back as soon as possible to do what I can."