Roles and strategies of international humanitarian organisations in handling the Liberia Ebola outbreak

Background In Early August 2014, the World Health Organisation declared an Ebola Virus Disease (EVD) outbreak in the region of West Africa. The West African EVD outbreak was the largest, most severe, and complex in the nearly four-decade history of this disease. The management of EVD cases in Liberia was similar to the other affected West African countries. Methods We reviewed the method and strategies used by some of the international humanitarian organisations in handling the 2013-2016 Ebola outbreak in Liberia. This report is a collection of personal field experiences in Liberia as well as personal interviews of healthcare personnel working for some of these international organisations working on the Ebola emergency in Liberia. Findings Medecins Sans Frontieres (MSF) was the first humanitarian NGO to deploy medical staff to the field in Liberia during the 2013-2016 EVD outbreak. MSF staffs were already operating in Liberia even before the declaration of the outbreak in August 2014. Conclusions The slow response by the international humanitarian organisations to lend their support in bringing the EVD outbreak to and exhibited the fear the international community have for deadly infectious diseases more than armed conflicts. Recommendations We recommend regularly training in public health emergency preparedness for third world countries that are highly susceptible to health emergencies such as Ebola outbreak to help prepared them ahead of such outbreak.


Background
In Early August 2014, the World Health Organisation declared an Ebola Virus Disease (EVD) outbreak in the region of West Africa 1 . The West African EVD outbreak was the largest, most severe, and complex in the nearly four-decade history of this disease. More than 22,000 people were infected and more than 8,810 deaths recorded in nine countries 2 . The EVD outbreak did not only weaken the fragile health systems off the affected countries in West Africa, but had its toll on the their economy due to border closure. 3 The health systems of Liberia, Sierra Leone and Guinea have been suffering because of armed conflict that occurred over a period of 10 years till 2002. This conflict made their health care services and infrastructure malfunctioned to an extent that Liberia have an availability of one doctor and Sierra Leone two doctors for every 100,000 patients 3,4 .
Health workers in the affected countries were amongst those greatest hit by the 2013-2016 EVD outbreak; mainly because of lack of or no proper infection, prevention and control (IPC) measures.
Additionally, many infected people at the time were afraid to go for EVD screen at health facilities which will see them become treated for the infection due to stigmatization.

Ebola And The Liberia Situation
The management of EVD cases in Liberia was similar to the other affected West African countries.
During the peak of the EVD outbreak, Liberia health workers at one stage refused to go to work unless the country's health ministry provides them with proper IPC equipment. This non-compliance by health workers in Liberia resulted in the closure of at least 65% of the health facilities in Liberia 4 . This periodic refusal to work by healthcare workers in Liberia also resulted in more deaths of people who were suffering from preventable and treatable disease such as malaria, diarrhoea typhoid. There were some attempts by the Liberian Ministry of Health to restore basic health care services during the EVD outbreak; but this was not welcomed by many humanitarian Non-Governmental Organisation (NGOs) because they considered it as a developmental intervention rather than a direct Ebola emergency intervention 5,6,7 .
The Humanitarian Implementation Plan (HIP) of the European Commission of Humanitarian Aid and Civil Protection (ECHO) categorized the needs of countries affected by the 2013-2016 EVD outbreak into health facility which importing staffs with medical background from non-affected countries to assist local health workers, and using "Personal Protective Equipment" (PPE); and community levels. MSF Public Health Specialist, the organisation's response was providing "symptomatic care, supportive care, presumptive care, nutritional support and psychosocial counselling". Majority of the people who were affected by the 2013-2016 EVD were healthcare workers.
The lack of the necessary logistics to handle EVD cases by these healthcare workers made them to be over-exposed to the infection which greatly affected their staff strength and led to a cycle of new and more EVD cases and deaths. As a way of directly mitigating the impact of EVD on the healthcare system, MSF

Evaluation Of Ebola Response In Liberia
The evaluation of the response to the EVD outbreak in Liberia was done by specialists after the outbreak has ended. Serious criticisms were levelled against the international organisations for their slow and late response towards the outbreak in Liberia. 34 Three reasons were forwarded for the for the slow and late response towards the Ebola outbreak in Liberia: donor fatigue, Africa indifference factor and underestimation of the EVD outbreak. 35  safely, detect, investigate and report potential EVD cases, and to mount an effective response during the 2013-2016 EVD outbreak emphasises the significance of emergency preparedness. 37 The Liberia EVD outbreak shows that for preparedness to be effective basic healthcare services and facilities should be at hand in the affected countries prior to the situation becoming worst. Preparedness could also come to mean that the multinational pharmaceutical companies should be working ahead to manufacture effective vaccine and medication 38 .
The slow response by the international humanitarian organisations to lend their support in bringing the EVD outbreak to and exhibited the fear the international community have for deadly infectious diseases more than armed conflicts. This fear was triggered when governments of neighbouring countries closed their borders and prevented their national airlines from flying through the EVD 9 affected countries.

Declarations
Ethics approval and consent to participate The Ethics and Scientific Review Committee of the Njala University in Sierra Leone approved this study and provided ethical clearance for conducting this study.

Consent for publication
Not Applicable Availability of data and materials

No applicable
Competing interests All authors declared they have no competing interest.

Funding
No part of this study received funding or compensation whatsoever during its conception, execution or for publication.
Authors' contribution JBK and AA conceived and designed this study as well as organized the conduct of this research in the research field. JBK and AA drafted the manuscript. JBK and AA critically reviewed and revised the manuscript. JBK obtained ethical clearance.