Forty-two days after the last Ebola patient in Liberia was buried, the World Health Organization (WHO) has declared the country free of the virus, calling it a “monumental achievement” for a country that suffered the highest number of deaths in the “largest, longest, and most complex [Ebola] outbreak” in history.
The country’s last victim, according to the WHO, was a Monrovia-area woman who died on March 27 and whose case remains under investigation. After close monitoring, the WHO noted, none of the 332 people who may have been exposed the the woman have developed symptoms.
The announcement marks a return from the brink for Liberia. During the outbreak’s peak in August and September, the country was reporting an average of 400 new cases every week.
At the time, WHO said, the virus paralyzed the country of 4.2 million people, leading to canceled flights, fuel shortages, and the closing of schools, businesses and healthcare facilities. In the capital city of Monrovia, reports emerged of locals dumping the bodies of suspected victims in the streets while hospitals shuttered because health workers were too frightened to work.
With the nightmare fresh in their memories, officials urged residents not to let their guard down in Ebola’s absence.
“We’re proud of what we collectively managed to do but we need to remain vigilant,” said Peter Jan Graaff, the United Nations secretary-general’s acting special representative and head of the U.N. Mission for Ebola Emergency Response (UNMEER). “The virus is not yet out of the region and as long as the virus is in the region we’re still all of us potentially at risk.”
Liberian President Ellen Johnson Sirleaf on Saturday referred to the devastation endured by her country as “a scar on the conscience of the world,” according to the Associated Press. For some survivors, she added, “The pain and grief will take a generation to heal.”
More people were killed in Liberia than any other nation: with over 4,700 fatalities, Liberia’s death toll accounts for almost half of the 10,600 total deaths that have been confirmed since the Ebola epidemic first broke out in Guinea in December 2013.
Civil war and chronic poverty left a shortage of doctors and nurses in West Africa when Ebola swept through region last year. Early on, health workers didn’t realize they were dealing with an Ebola outbreak and when seemed to diminish, officials became overconfident. By the time the virus made the leap from rural villages to crowded cities, health workers spent grueling months struggling to catch up.
During the peak of the outbreak, the capital city Monrovia “was the setting for some of the most tragic scenes from West Africa’s outbreak: gates locked at overflowing treatment centers, patients dying on the hospital grounds, and bodies that were sometimes not collected for days,” the WHO said. While transmission was most intense in Monrovia, cases were reported in each of the country’s 15 counties, according to the WHO.
To help stop the spread of the virus, schools were closed and public gatherings were banned. Ambulances struggled to reach patients on time. In some cases community members left bodies in the streets; in others family members carried their loved ones to the hospital in wheelbarrows.
Survivors of the disease told horror stories of the conditions inside treatment units, with people suffering and dying next to them, or mothers dying, leaving sick children behind. Other patients often stepped in to help when children were left alone in treatment centers.
As late as September, the world’s response had lagged disastrously behind, and the lack of sufficient beds in treatment units resulted in a failure to avert thousands of deaths.
“At one point, virtually no treatment beds for Ebola patients were available anywhere in the country. With infectious cases and corpses remaining in homes and communities, almost guaranteeing further infections, some expressed concern that the virus might become endemic in Liberia, adding another — and especially severe — permanent threat to health,” the WHO said.
Liberia’s victory is tentative. With the virus continuing to spread in neighboring Guinea and Sierra Leone, the WHO has called for cautious optimism, warning that months of hard work could be undone if a single infected individual slips across the border. Health officials plan to continue monitoring border areas for sick travelers, “testing all dead bodies for the virus and conducting burials with specially trained teams wearing full protective gear,” according to the New York Times.
Medical experts and aid organizations that helped with Liberia’s fight against Ebola are also warning against complacency and urging the international community to learn from the mistakes that were made so we are better prepared for the next major epidemic.
“If the world had mobilized rapidly and decisively, we could have saved 10,000 lives, great human hardship, and enormous health and social costs in three of the poorest countries in the world,” Dr. Larry Gostin, faculty director of the O’Neill Institute for National & Global Health Law at Georgetown University, told CNN.
The U.K. and U.S., in particular, were accused of initially ignoring the crisis and focusing on domestic panic; blocking flights and quarantining returning health workers. The WHO has also faced intense criticism for its handling of the Ebola crisis and for ignoring initial warnings from organizations such as Doctors Without Borders about the magnitude of the outbreak.
By the time the WHO officially confirmed the Ebola outbreak in late March 2014, the deadly virus had been circulating in Guinea for three months and infections had already been exported to Liberia and Sierra Leone, where the virus wasn’t detected until infections spilled into capital cities and quickly overwhelmed responders.
“The world, including WHO, was too slow to see what was unfolding before us. Ebola is a tragedy that has taught the world, including WHO, many lessons also about how to prevent similar events in the future. … Never again should the world be caught by surprise, unprepared,” said WHO Director-General Dr. Margaret Chan, acknowledging that the agency was far too slow to grasp the significance of the Ebola outbreak.
The WHO has since proposed major reforms aimed at strengthening their ability to respond to emergencies, starting with an internal and external review to identify exactly what went wrong.
Still, some experts are concerned that this won’t be enough. “I believe firmly that the world remains unprepared for the next epidemic,” Dr. Gostin told CNN. “The next epidemic, moreover, could be far worse than Ebola, and we are not well prepared.”
Learning from the past, preparing for the future
There has also been concern about a lack of published research into the virus, leaving many unanswered questions with critical implications for future prevention. “[W]e have a moral responsibility to its future victims to learn as much as we can now about Ebola from this current epidemic,” says Dr. Adam Levine, an Assistant Professor of Emergency Medicine and Director of the Global Emergency Medicine Fellowship at Brown University, and the Principal Investigator for the International Medical Corps Ebola Research Team. He continues:
Hundreds of thousands of pages of epidemiological, clinical, and laboratory data currently lie scattered across West Africa, piled up in various ETUs [Ebola Treatment Units], mobile laboratories, and local government offices. Within those stacks of chlorine-stained paper lie more information than has ever been generated in the history of the world about Ebola. Information such as the factors that lead to contracting the disease and those that increase its mortality; the severity and time course of its symptoms; the treatments that work and don’t work; and the management strategies that produce the best outcomes can all be gleaned from this data. If not collected soon, entered into electronic databases, and aggregated and analyzed in a secure and responsible way, then all of this knowledge will be lost, leaving us back at square one when the next epidemic strikes.
Newly-discovered evidence demonstrates that we still have much to learn about the virus. Last month the WHO urged Ebola survivors to abstain from having sex or to use condoms “until further notice” after a sample of a Liberian man’s semen tested positive six months after he was considered free of the virus. Previous advice to survivors was to abstain from sex for three months. Additionally, there is evidence that the virus may survive in ocular (eye) fluid as well as semen, paving the way for another transmission path in the infection chain.
“We must remember that even after the last patient is discharged from the last ETU in West Africa, Ebola will still not be gone,” warned Dr. Levine. “It will continue to persist in its natural reservoirs across sub-Saharan Africa, waiting for the right set of circumstances to reemerge, like some mythical beast from an ancient fairytale.”