MONROVIA, Liberia — Muhammed Sheriff’s pregnant sister didn’t have Ebola, but you could say Ebola killed her.
Fatuma Fofana was 34 and had already given birth to five children, so she knew the pain that hit her belly two weeks ago wasn’t normal. Everyone who heard her crying — “howling,” her brother says — knew it wasn’t normal too.
So Sheriff took his older sister to a nearby clinic. They refused her. Pregnancy is a bloody, messy business, and the clinic staff was terrified that she might be infected with Ebola, a rare but deadly virus that has burned through the bush and lodged in the capital cities of three West African countries.
Fofana didn’t have Ebola, but that didn’t matter at the clinic — or at the two other health facilities they went to. At the fourth, an attendant let them in, but there was nothing to be done. Fofana’s baby was already dead in her womb, and the attendant had too little training and too few supplies to handle it.
What the clinic did have was doctors’ telephone numbers, so Sheriff called. And called. And called. He was ready to ply them with cash — it’s costly to bring a doctor from his home for private clinic work, and for the task, Sheriff had collected nearly $400, a small fortune in Liberia.
But no one wanted his money. In fact, not one of the three doctors he called even answered the phone.
“The money they could charge, we could make available,” Sheriff said, in a voice that still pleads for any other outcome, two full weeks after his sister’s death. “But there was no one who would do the job. They couldn’t come, even for money.”
Fofana is not the only mother-to-be lost to the Ebola panic that has gripped Liberia. On Wednesday, a pregnant woman near the capital, Monrovia, died of labor complications because she couldn’t find a clinic to treat her. Last week, a woman died of a miscarriage for the same reason.
The story repeats as families tell of loved ones dying of malaria, diabetes, or diseases they know only by the symptoms doctors used to treat — a swollen foot, a shaking disorder.
This is the world’s biggest outbreak of Ebola — and the first ever in West Africa — and Liberia has been hard hit. The virus first appeared here in the rural north in April, raising alarm but seeming to taper off. Then it reignited in Monrovia, where Liberian and international public health officials have struggled to control its spread. The most recent figures from the World Health Organization report 786 cases and 413 deaths in Liberia alone, and more than 2,000 cases and 1,100 deaths in all affected countries.
People are terrified. The virus is transmitted through bodily fluids, has no cure, and kills patients in a mere few weeks. But many Liberians deny the virus exists and resist health care workers. Some think Ebola is sorcery. Others think it’s a government plot to enrich the president or health workers. Others simply can’t reconcile what they see with what they’re told: Bleeding from all over the body is the most famous symptom of Ebola. But in this outbreak, just as many people never bleed at all, though specialists don’t understand why — and relatives decide it’s something else.
Denial, or explanations like sorcery such as these, are common in Ebola outbreaks; anthropologists have documented both in Congo, in 2003, and Uganda, in 2000, the last two places Ebola appeared. But Ebola is not common here. It’s never been seen in West Africa, and that means that for most Liberians — already distrustful of their political elite, already weary from the civil war, a decade ago — the fear, the paranoia, is the most real part of Ebola.
All these things are whirling together in Liberia. And that’s when Ebola can kill you even when you don’t have Ebola. Fear of disease couples with so much dire need. Over and over again, health workers say the same thing: “You don’t know who is who.”
So it’s safer not to help anyone at all.
Liberia’s President Ellen Johnson Sirleaf foresaw precisely this problem. “The epidemic is having a chilling effect on the overall health care delivery,” Sireaf said, when she declared a state of emergency nearly two weeks ago. “Out of fear of being infected with the disease, health care practitioners are afraid to accept new patients, especially in community clinics all across the country. Consequently, many common diseases which are especially prevalent during the rainy season, such as malaria, typhoid, and common cold, are going untreated and may lead to unnecessary and preventable deaths.”
She overlooked pregnancy. Liberia has one of the highest rates of maternal death in the world. Giving birth here is always risky, even when you can count on a clinic being open.
The women serving the maternity ward at a clinic in West Point keep coming to work — for now. West Point is a densely packed informal neighborhood (or “slum”) that just this week has become a hotspot of Ebola in Monrovia. In a normal week, before Ebola, the maternity ward might see 10 or 15 births. Now, they’re seeing only one or two — and not all of them stay until they give birth.
“People won’t go to the hospital, the clinic. They say that when you go to the hospital, the nurses kill you. I tell them, ‘So who’s killing the nurses?’” said Comfort Tapeh, who has worked in the ward for 10 years.
At least 36 health care workers have died of the disease, and hospitals and clinics have shut their doors. Only this week did two of Monrovia’s biggest hospitals partially re-open, one only for emergency cases. Everyone is still struggling to find basic supplies.
Fatou Sheriff, who works at the West Point clinic too, has heard even more cynical rumors. “They say the health care workers are working with the world organizations to bring in money, and then they are all eating the money,” she said.
Sometimes, fear gets the better even of those patients who brave the clinic. Last night in the West Point maternity ward, a woman in labor spiked a fever. The staff wanted to medicate her, but the woman resisted.
“My husband told me I shouldn’t take any injections here!” the woman yelled. The staff called the husband, and he also refused to let her have the medication. Later, he came to the clinic and took the woman home.
“She will die. With a fever like that, she will definitely die. Maybe the baby too,” said Jemimah Kargbo, who was on duty when the woman left.
Even successful home births are risky. “You don’t know where those tools are coming from,” said Sheriff. “It’s a good way to get HIV.”
The maternity ward is part of a larger clinic, and sometimes the women of the maternity ward see weak patients with red eyes, another telltale symptom, trying to find treatment. The clinic immediately turns them away.
“We are afraid-o, sister,” said Tarpeh, the nurse. “If I had money to sustain my family for six months, I would go home. I’m not lying to you.”
Tarpeh is wearing the kit she says the health ministry issued her as Ebola protection: a thin plastic blue poncho and rubber gloves. She has tied a rubber band around the rubber gloves, an ad hoc seal between her wrists and her arms. She wears her own pink scrubs and rubber loafers that leave her ankles and the tops of her feet exposed. She has wrapped her head in a shower cap.
Kargbo wears a thin sea-green suit of the purled polyester-cotton so common in hospitals. It zips up the front and offers a pointed hood, a final gift from an American doctor who used to help on fistula cases but left when Ebola hit. Kargbo doesn’t trust it, anyway. “When someone vomits on me, what is going to happen?” she asks. “It’s going to go through.”
Lucy Barh, the president of the Liberia Midwifery Association, says these feelings are common to the midwives she leads. “That’s why some of the clinics are closed — fear, fear, fear. There’s no protective equipment, and the lives of those health care workers are threatened.”
Barh works in the maternity ward at Redemption Hospital — a hospital that was closed when Fatuma Fofana went there to deliver her baby. The facility shut its doors after a pregnant woman, possibly Ebola-infected, died there in late July. The community blamed the health workers for the death and attacked the hospital, Barh said.
“They said the hospital killed her, and they stormed the hospital,” she said. “The police had to come to our rescue. Then we had to close the hospital for two weeks.”
Redemption re-opened on Monday, after a youth leader pled that the community needed a functioning health facility. This week, Barh and a much-reduced staff delivered five babies — an incredibly low number in a facility that usually sees 300 births a month.
Sheriff, whose sister died in childbirth, sees the closure of the health facilities as a betrayal. “We never imagined they could close the clinics, the small community clinics,” Sheriff said. The order to shut the government hospitals, he said, “scares the other community [clinics, which think] ‘If they closed, what are we doing?’”
“It deprives us of our rights,” he said. “You have a pregnant woman who died just because she couldn’t be treated.”
Kargbo, meanwhile, has had enough. On Saturday night, a mob destroyed a makeshift health center where suspected Ebola patients were waiting for test results and referrals to isolation treatment wards; it chanted that Ebola was a hoax.
“They will get sick, get fever and come to the hospital. And I’m not going to be there for them,” Kargbo said.
Or maybe for anyone else.
“I don’t want to lie to you,” Kargbo said. “At the end of the month, if there’s no change, I’m going to sit at home.”