As Ebola Pingpongs In Liberia, Cases Disappear Into The Jungle

Nov 25, 2014
Originally published on January 8, 2015 9:47 am

There's a new phase of Ebola in Liberia. Epidemiologists call it pingponging.

Back in March, the disease was found in the rural areas. Then as people came to the capital to seek care, it started growing exponentially there. Now, some sick people are going back to their villages, and the disease has pingponged to the rural areas again.

So that's where we're headed — into the hot, thick jungle of Liberia to investigate a new Ebola hotspot.

Our day with the team of Ebola investigators starts at 3 a.m. The team has been told there's a woman with Ebola out there who hasn't been treated. She could be spreading the disease.

We drive five hours from Liberia's capital, Monrovia, and stop at a small, rural clinic that looks something more like a house with a few rooms and no electricity. The team has people from the World Health Organization, the African Union, Doctors Without Borders and the Liberian Ministry of Health.

At the clinic, the head nurse says she has also heard the rumors of a sick woman. But the nurse hasn't seen her. The nurse shows us a hand-drawn map on the wall of where we need to go to find the woman. Our destination, she says, is a village called Fermaneeta.

It's the last village at the end of a thin black line on the map. A thin black line means the only way to get there is to walk, down a long footpath into the jungle. Fours hours each way.

As we walk, Mutaawe Lubogo from the African Union says there are several options for the woman if she has symptoms. If she's very sick, they can help set up a community quarantine in the village and try to come back the next day with supplies.

If the woman is still in the early stages of Ebola, she can walk back to the clinic, where an ambulance can pick her up.

Lubogo is from Uganda and worked on the 2007 Ebola outbreak there.

"You're talking to someone who has seen it before," Lubogo says. But in Uganda, Ebola was confined to the rural areas, and that's where it ended. In Liberia, there's pingponging.

"If I fall sick, I have to come to the rural area, where I have my parents, to my family to give me care," Lubogo says.

This is how pingponging works, he says. People go back and forth between the city where there's commerce, and the village where there's family. And a few of them take Ebola with them.

Out where we're walking, a village is basically a clearing in the jungle, with 10 or 20 huts. The walls of the huts are made of mud; the roofs are made of branches and leaves. Each village has a well, a fire pit for cooking and small fields nearby to grow food.

Each village is about an hour from the next one. At the fourth one, we find a clue. The team meets a man who people say is a traditional healer — he rubs herbs on sick people. He supposedly cared for the woman who's rumored to have Ebola.

The team lists off the names of people who have tested positive for Ebola. The man says he knows a lot of them. But he denies that he's a healer. He won't even admit that he has touched or treated any of them.

This is called contact tracing. If you're doing it in Dallas, Texas, you get addresses and phone numbers. Out here it's different. We leave the man and keep on walking. We finally make it to the village where the woman is supposed to be.

At first, the village is pretty quiet. There's laundry drying in the sun. People start to gather around the team. They put their hands in the air, as if they're being accused of something. Then they all start talking at once.

The group is standing in front of a wooden door to a hut where the woman who's thought to have Ebola stays. The door is closed. No one is opening the door.

The people in the village say the woman is gone. Many members of the Ebola team think the villagers are hiding something. Maybe the sick woman is behind that door. Maybe she has already died. If she has or had Ebola, in any case, she is very contagious.

Emmanuel Dweh, one of the team leaders, warns people not to hide a sick person. If they do, he says, they will get sick themselves. But the people are adamant that the woman isn't there. After that, there's not much more for the team to do.

So we start back out into the jungle. It's four more hours back to the clinic.

On the way, we pick up the man thought to be the traditional healer because he treated and touched people with Ebola. He has agreed to come with us.

"We have to make the monkey bridge by dark," Dweh keeps telling us. That's the last bridge, the biggest bridge. It's two bamboo poles over a dark muddy river.

Once we get to the clinic, the plan is to have an ambulance take the alleged traditional healer to a stadium where health workers monitor people who might have Ebola. If he doesn't show signs of Ebola after 21 days, he'll be let go.

But that night, the road to the clinic goes out and the ambulance can't reach the traditional healer. The man who might have Ebola goes back to his village.

This is why it's so difficult to stop Ebola. These places are very hard to reach. The roads are bad. There's no electricity, no phone coverage.

And once you finally get to where you're going, you have no idea what you're going to find.

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Transcript

DAVID GREENE, HOST:

In West Africa, medical experts have noticed a worrisome trend in the spread of Ebola. The virus is clustering in cities and then ping-ponging back out to rural areas. Health officials are struggling with how to stop Ebola in remote areas. NPR's Kelly McEvers recently went with a team of outbreak investigators tracking a case of Ebola deep in the Liberian jungle.

KELLY MCEVERS, BYLINE: The day starts at 3 a.m. Drive five hours from the capital, then stop at a small rural clinic in central Liberia. When I say small rural clinic, I mean something more like a house with a few rooms and no electricity.

UNIDENTIFIED NURSE: You understand, right?

MCEVERS: Inside the clinic, the head nurse confirms what the team has already heard. There's a woman in the area who's rumored to have Ebola. The nurse shows one of the investigators a hand-drawn map of where we need to go to find that woman.

UNIDENTIFIED MAN #1: (Foreign language spoken).

MCEVERS: Ferma’eeta, it's the last village at the end of a thin, black line on the map. A thin, black line means the only way to get there is to walk down a long footpath into the hot, thick jungle four hours each way. As we walk, I ask epidemiologist Mutaawe Lubogo from the African Union if we know whether the woman has symptoms.

MUTAAWE LUBOGO: It's not clear whether she has symptoms or not. But any contact, you have to follow up for 21 days.

MCEVERS: So what are the different ranges of responses that you could have for this person if she does in fact have symptoms?

LUBOGO: As of now, the only thing we could do is to identify them early when they still have strength to walk.

MCEVERS: If they're early enough, they could walk to the closest point where a vehicle could pick them up, so like the walking we're doing now - which is not easy, let me just say. You know, we just went over a bridge basically made out of sticks. I'm trying to imagine a patient going through this.

LUBOGO: Especially if it was the rainy season.

MCEVERS: Right. And they were sick.

LUBOGO: And when you are sick...

MCEVERS: This is no good.

Lubogo is from Uganda. He worked in the 2007 Ebola outbreak there.

LUBOGO: You're talking to someone who has seen it before. Only difference is in Uganda, Ebola confined to rural areas.

MCEVERS: I mean, but now it seems like the issue in Liberia is that it is becoming rural again.

LUBOGO: If I fall sick, I have to come to a rural area where I have my parents, my relatives to give me care.

MCEVERS: This is how ping-ponging works. People go back and forth between the city, where there's commerce, and the village, where there's family. And a few of them take Ebola with them. Out here a village is basically a clearing in the jungle - 10 or 20 huts with walls of mud and roofs of branches and leaves. Each village has a well, a fire pit for cooking and small fields nearby to grow food. Each village is about an hour from the next one. At the fourth one, we find a clue. The team finds a man who people say is a traditional healer. He supposedly cared for the woman who people think has Ebola and for other people with Ebola. The team lists off the names of people who've tested positive for Ebola.

UNIDENTIFIED MAN #2: Yeah, yeah, I know Sahawali (ph).

LUBOGO: You knew Sahawali?

UNIDENTIFIED MAN #2: Yes.

MCEVERS: The man says he knows a lot of these people. He denies that he's a healer. He won't even admit that he's touched or treated any of them. This is called contact tracing. If you're doing it in Dallas, you get addresses and phone numbers. Out here, it's different. We leave the man and keep on walking. We finally make it to the village where the woman's supposed to be.

So here we are. We have been walking for four hours. Yeah, gone through five villages, heard all kinds of rumors. Now we're going to see what's going on, see if she's here, see if she's sick and what kind of treatment can be given to her if any. The village is pretty quiet - some laundry drying in the sun. People are gathered around the team. It's always kind of sensitive. People hold up their hands as if they're being accused of something. Then they all talk at once.

(CROSSTALK IN FOREIGN LANGUAGE)

MCEVERS: The group is standing in front of a wooden door to a hut where the woman stays. The door is closed. No one is opening the door. I walk off to the side.

So they say the woman is gone. We'll find out more details later, but all this way to find somebody who maybe was sick, and she's not even here - or if she is, she's in hiding.

Maybe behind that door, or worse, she's dying somewhere in the jungle or already dead. If either of those last things are true, she is very contagious. Whatever it is, most of the outbreak investigation team thinks the people in the village are hiding something. Here's county health official Emmanuel Dweh talking to them.

EMMANUEL DWEH: If what you're telling us the truth, then truth. But I will not advise you to keep sick person to your village. If you wait until the person dies, then you killed that person. Do you understand me clearly?

UNIDENTIFIED VILLAGE RESIDENTS: (Foreign language spoken).

MCEVERS: We understand, they say. At this point, there's not much more the team can do.

And now we're going back out, back down the road.

Four more hours back out of the jungle. On the way, we pick up the man who's thought to be the traditional healer who treated and touched people with Ebola. He's agreed to come with us. We have to make the monkey bridge by dark, Emmanuel Dweh keeps saying. That's the last bridge - the biggest bridge. It's two bamboo poles over a dark, muddy river. The plan once we get to the clinic is to have an ambulance take the alleged traditional healer to a stadium where they monitor people who might have Ebola. If he's OK after 21 days, he'll be let go. But that night, the road to the clinic goes out, and the ambulance can't reach him. The man who might have Ebola goes back to his village.

This is why it's so difficult to stop Ebola. These places are very hard to reach. The roads are bad, there's no electricity, no phone coverage. And once you finally get to where you're going, you have no idea what you're going to find. Kelly McEvers, NPR News, Monrovia.

GREENE: And we have a way for you to get a vivid picture from Kelly's story. You can see pictures of the monkey bridge and other pictures at our Goats and Soda blog at npr.org. And we should say, NPR producer Rebecca Hersher contributed to that story. Transcript provided by NPR, Copyright NPR.