TIME ebola

Faster Ebola Tests Could Help Stem the Outbreak in West Africa

Liberia Races To Expand Ebola Treatment Facilities, As U.S. Troops Arrive
A health worker in Paynesville, Liberia, carries a girl awaiting her test results John Moore—Getty Images

Better Ebola testing in West Africa would save lives and could help bring an end to the outbreak

The dying at the tin-roofed clinic in the rural Kono district of Sierra Leone comes at a ruthless pace. In the first two weeks of October, 20 out of the 22 patients seeking treatment for Ebola died. That fatality rate, high even by the lethal standards of Ebola, could easily be brought down, says Dan Kelly, an infectious-disease doctor who is currently in Kono with the Wellbody Alliance, a medical nonprofit organisation he set up eight years ago. “The ability to test for Ebola, to test quickly, has become ever more important,” says Kelly, who believes the high death toll in the Kono clinic was due in part to the fact that there is no place to test for Ebola in the entire district. Instead, blood samples from suspected Ebola patients have to be sent to the capital over rutted mud roads that are often washed out by rain. “Even if we have the best treatments available, without a timely diagnosis people are still going to die,” says Kelly.

Work out quickly who does and does not have Ebola and you’ll get a long way toward stopping an outbreak that has killed at least 4,877 and infected thousands more. Right now that simple proposition can feel like a fantasy. In Guinea, Sierra Leone and Liberia, the three countries with the most cases, the need for rapid test results far outpaces the capacity to carry them out.

That means patients often aren’t getting treatment until it’s too late, when the disease has ravaged their bodies beyond repair, and when they may have already infected friends and family. “If patients are promptly diagnosed and receive aggressive supportive care, the great majority, as many as 90%, should survive,” wrote the global health expert Paul Farmer in a recent issue of the London Review of Books.

Even in a top U.S. laboratory it can take up to eight hours to search a blood sample for Ebola through an expensive and complex array of technical hardware and computer software called a polymerase chain reaction (PCR) test. The U.S. Centers for Disease Control and Prevention and the U.S. military have helped by setting up four additional labs in West Africa over the past six months—Liberia now has a total of five, Sierra Leone four and Guinea three—but capacity is still limited to about 100 tests per lab per day, not nearly enough to cope with an epidemic that could grow to 10,000 new cases a week by December, according to the World Health Organization. Laurie Garrett, an expert on Ebola at the Council on Foreign Relations and author of The Coming Plague: Newly Emerging Diseases in a World Out of Balance, says that number could be brought down through better testing. “The only thing that makes a dent when you model what is going on with the epidemic now and what it looks like in two months, is being able to separate the infected from the non-infected.”

Health care workers on the ground say that more PCR labs are urgently needed. “Crushing this epidemic means getting 70% of the population with Ebola into isolation and care,” Kelly says. That could be achieved, he believes, by putting a PCR lab in every district.

The challenges don’t stop there. Testing can create risks even as it offers solutions. Medical personnel must draw blood from patients for a PCR test, a potentially lethal process for caregivers. “Taking samples is extremely dangerous,” says Dr. Estrella Lasry, a tropical medicine adviser in Liberia for Doctors Without Borders (MSF). At any time you risk a needlestick injury that can expose you to the virus.”

And then there’s the risk that patients without Ebola are being exposed to patients with the disease. Lasry estimates that 30% to 50% of people coming into the MSF clinics end up testing negative for Ebola and instead have other illnesses like malaria that have similar early symptoms. All those being tested for Ebola must wait in holding centers for their results, to ensure they don’t have an opportunity to infect others back at home if they test positive. That means patients with other illnesses must wait among patients with Ebola, increasing the chances of transmission.

Kelly hopes researchers can develop a test that could give readings at a clinic immediately and wouldn’t require trained technicians to interpret the results. “It would be a game changer if you could immediately identify patients needing quarantine from those who do not,” he says. Several versions of so-called point-of-care rapid diagnostic tests are already in development, but while some are at the testing stage, it is not clear when they could actually be used on the ground.

One U.S. company, Corgenix, received a $2.9 million grant in June from the National Institutes of Health to perfect its prototype, a pregnancy-test-style slip of paper that reveals a dark red line within 15 minutes when exposed to a drop of Ebola-infected blood. Instead of needles and syringes, test takers need only a pinprick to get the sample, much like an insulin test for diabetes patients. These tests, which would cost anywhere from $2 to $10 (PCR tests average about $100 each) could also be used in airports to confirm whether someone with symptoms has Ebola.

If the Corgenix test had been available, says one of its lead researchers, Robert F. Garry, a professor of microbiology and immunology at Tulane University School of Medicine in New Orleans, it might have helped diagnose Amber Vinson, an American nurse infected with Ebola, before she boarded a flight from Cleveland to Dallas on Oct. 13. “This is a test that could be used anywhere you would want to test for Ebola,” says Garry. “Anyone could use it, and anyone could read it.”

With the epidemic worsening in West Africa, medical staff in Ebola-hit countries can’t afford to wait for companies like Corgenix to bring their product to market. Kelly has been hearing about better, faster tests almost since he started working on Ebola in June. He fears that pinning hopes on future technologies undermines efforts to ramp up testing facilities. “Everyone says they have a new test, but at this point I’m like, ‘Show me the money,’” says Kelly. “ We already have a working technology that is deployable. Get me a PCR in every district capital, and then we can start talking about faster tests.”

Garry says he has people in every U.S. time zone working “as fast as humanly possible” to get the Corgenix test out. “We want to make an impact on this outbreak,” he says. “With enough tests, we can shut it down it down.” Without them, Ebola may be here to stay.

TIME South Africa

Heated Reaction in South Africa to Pistorius Sentence

Oscar Pistorius after he is sentenced at the Pretoria High Court on October 21, 2014, in Pretoria, South Africa.
Oscar Pistorius after he is sentenced at the Pretoria High Court on October 21, 2014, in Pretoria, South Africa. Herman Verwey—Getty Images

The six-time Paralympic medal-winning athlete is sentenced to five years in the shooting death of girlfriend Reeva Steenkamp, eliciting charges of injustice in his native South Africa

When the judge sentenced Oscar Pistorius to five years in jail for killing his girlfriend, his reaction was muted. The response elsewhere in South Africa was not. “Five years for murder?” screeched one angry caller to a local radio talkshow. Twitter lit up with angry condemnations of the judge, some commentators going so far as to suggest that all murderers would be so lucky to have her presiding over their case.

After all the drama of a trial that evoked Hollywood theatrics and a blockbuster viewership over the course of its seven-month-run, Judge Thokozile Masipa finally delivered her sentence Tuesday morning in the courtroom in Pretoria, condemning Pistorius to five years in prison for killing his girlfriend, 29-year-old law graduate and model Reeva Steenkamp in what he described as a tragic mistake. Pistorius wiped his eyes upon hearing his sentence and reached for the hands of family members gathered behind him.

Pistorius, 27, killed Steenkamp on Valentine’s Day last year, shooting her four times through a closed bathroom door in his home. He testified that he had mistaken her for a nighttime intruder. Immediately following his sentencing he was escorted out of the packed court, down a flight of stairs and into the court’s detention center to await transport to the prison.

On Sept. 12 Masipa convicted Pistorius of culpable homicide, a crime similar to manslaughter, but acquitted him of murder at the conclusion of a trial that had become an international spectacle. Pistorius, a double amputee dubbed the “Bladerunner” for his athletic prowess on blade-shaped prosthetic limbs, alternately wept, vomited and collapsed at various points of the trial as the prosecutor presented graphic evidence taken from the scene of the crime and asked Pistorius to recount, in agonizing detail, the events of the night his girlfriend was shot. The prosecution accused Pistorius of murdering Steenkamp in a fit of rage.

In sentencing Pistorius to five years imprisonment, Masipa split the difference between the prosecution’s argument for 10 years and the defense’s case that any jail term would be an unjust punishment for a double-amputee in a violent prison system where Pistorius could be subjected to abuse because of his disability. His lawyers had argued for a three-year probation period of house arrest and community service.

The Steenkamp family appeared to be satisfied, with family lawyer Dup De Bruyn saying that it was “the right sentence,” and that “justice was served,” according to Reuters, suggesting that an appeal is unlikely. Public reaction has been much more heated. Radio talk shows were inundated with angry callers lambasting the judge. “Lady justice just had her legs amputated,” shouted one irate caller. Another cursed Masipa on air, prompting a flurry of Twitter comments over the inappropriateness of denigrating a judge, no matter the reason.

It is likely that Pistorius will be paroled after serving at least one sixth of his sentence — 10 months — according to legal analysts, prompting sarcasm from one math-impaired Twitter commentator: “Three women are killed by their partners every day in [South Africa]. I guess an 8-month sentence will help fight this,” tweeted@ justicemalala.

Meanwhile, the International Paralympic Committee, which has awarded Pistorius six medals throughout his career, says that he will be banned from competing for five years, even if he is paroled early. Given the high profile nature of both Pistorius and Steenkamp, it was a given that no matter the sentence, people would be angry. Twitter commentator @ZuBeFly summed it up best: “Only way I’d feel 100% satisfied is if any type of sentence the judge passed would bring Reeva back. No winners here either way.”

Read next: Oscar Pistorius Gets 5 Years for the Culpable Homicide of Reeva Steenkamp

TIME ebola

Why Protective Gear Is Sometimes Not Enough in the Fight Against Ebola

Health workers receive assistance with putting on their protective gear before entering the high-risk zone at the Bong County Ebola Treatment Unit near Gbarnga in rural Bong County, Liberia, Oct. 5, 2014.
Health workers receive assistance with putting on their protective gear before entering the high-risk zone at the Bong County Ebola Treatment Unit near Gbarnga in rural Bong County, Liberia, Oct. 5, 2014. Daniel Berehulak—The New York Times/Redux

Human error can endanger even the most experienced health care workers in the fight against Ebola

When it comes to Ebola, the full-body Personal Protective Equipment [PPE] suit is probably the best way to prevent infection. But a PPE can also be one of the easiest ways to get Ebola. A PPE is usually made up of a full-body, impermeable suit with a hood, rubber boots covered by Tyvek booties, multiple pairs of surgical gloves, a surgical mask over the nose and mouth, a plastic bib, goggles, a plastic apron and a lot of duct tape. There is a reason why they are nicknamed moon suits: worn properly, they shouldn’t show an inch of skin. Putting them on right requires two people and about 10 minutes. Taking them off, in even the best of circumstances, is a clumsy, arduous process with multiple opportunities to make a lethal mistake.

It is not yet clear how, exactly, two health care workers at a Dallas hospital tending Thomas Eric Duncan, the first man to be diagnosed with Ebola in the United States, caught the disease, but health authorities are looking closely at the protective measures used at the hospital, and whether or not they were sufficient. Meanwhile, in Spain, where a nurse, Teresa Romero Ramos, is being treated for Ebola that she caught from a patient recently returned from Sierra Leone, officials are questioning whether or not she wore her PPE properly. On a Spanish television program quoted by the New York Times, Madrid’s regional health minister, Javier Rodríguez, questioned the need for extensive training on using the PPEs. “You don’t need a master’s degree to explain to someone how you should put on or take off” a protective suit, he said.

Maybe not, but no matter how experienced and qualified you are in putting on and taking off a PPE there is always room for error. I recently spent two weeks in Monrovia, Liberia, reporting on Ebola, and climbing into, and out of, PPEs on a regular basis, and I am still not sure I ever got it right. I was trained by the best, too: the Red Cross Dead Body Management teams, the guys responsible for picking up deceased Ebola victims and transporting them to the crematorium for safe disposal. An Ebola patient is at his most infective in the hours and days after death, when the virus swarms the skin and bodily fluids.

When the Dead Body Management team workers finish zipping a corpse into a double-sealed body bag they undergo an extensive decontamination process that best resembles a military drill in its precision and attention to detail. Each worker is paired with a sanitizer, a man wearing a backpack sprayer filled with a chlorine and water solution. The process is initiated with a good dousing of chlorine solution and a vigorous washing of the gloved hands. The worker removes his goggles, which are sprayed thoroughly and then discarded. His hands are sprayed again. Then the hood goes down, and the zipper is sprayed, as are the hands for another time. He unzips, and his hands are sprayed yet again. Then he has to shrug out of the suit without allowing any of the external surfaces to come into contact with his hands or the clothing underneath. And so it goes, layer after layer until the worker is left standing in boots, medical scrubs, and the last pair of gloves. Again he is liberally sprayed down with the chlorine solution, at which point he has to jigger off his gloves in a way that ensures that the surface does not come into contact with the skin.

Each organization, be it the Red Cross or Médecins Sans Frontières [MSF], has a similar ritual, even if small details vary. Still, mistakes are made. Even MSF, which has spearheaded the Ebola response in west Africa since day one, and probably knows more than any other organization about how to prevent infection, has seen two international health workers sickened with the disease. A United Nations medical worker infected in Liberia and transported to Germany for care died on Oct. 13. A doctor working for an Italian medical charity contracted Ebola last month, and is still receiving treatment in Germany.

The gear works, but the possibility of human error is still high, especially when working in a high-stress environment, when fatigue and fear stalk every move. PPEs can also provide a dangerously false sense of security. When they are not put on right, or if they are taken off incorrectly, they may as well not be there at all.

If you are lucky the droplet of sweat dropping into your eye as you remove your goggles without bending over first didn’t pass over some Ebola-contaminated material on your hood. I met one health care worker who thinks he caught Ebola when a young patient vomited on him, and the vomit passed through a chink in his Tyvek armor, where his suit didn’t entirely zip up over his mask. Both he and the patient survived. Which is why having the right kind of protection is only the beginning. There needs to be training, and it has to be drilled in daily. There needs to be a buddy system, in which one health care worker is always watching the other, to ensure that the protective gear is on correctly, and that it is taken off correctly. But there will always be mistakes. Ebola will get through. The important thing is to be ready when it does.

TIME ebola

Ebola Health Care Workers Face Hard Choices

A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment center on Oct. 5, 2014 in Paynesville, Liberia.
A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment center on Oct. 5, 2014, in Paynesville, Liberia John Moore—Getty Images

The risks to doctors and nurses are never far from their minds

For Laura Duggan, going to Sierra Leone to care for patients with Ebola wasn’t so much a choice as a moral responsibility. “This is one of the biggest public-health emergencies of our time,” Duggan, a 34-year-old Irish nurse, told TIME as she prepares to leave London. “I’m trained to do this and there’s a great need. I couldn’t sit here and not go.”

Duggan had done her research, and knew the challenges: fatigue, long hot days spent working in sweltering biohazard suits, and the emotional toll of watching more than half her patients die no matter how heroic her efforts. But as for catching the disease itself, she wasn’t worried. Ebola is only spread through contact with infected bodily fluids. Duggan was confident that as long as she followed basic self-protection protocols, she would stay safe. But then, on Oct. 6, a nursing assistant in Madrid contracted Ebola from a priest who had recently returned from Sierra Leone. A week later, an American nurse treating a Liberian man in Dallas who died of Ebola also tested positive for the virus. Duggan’s partner, a Spaniard, pointed out that the Spanish nurse had been following the same rules, and still got sick. “He was getting a little nervous and saying, ‘Well, if she followed procedure and you’re saying you’ll follow procedure, then what happened? Why has she become infected?’” Duggan recalled. “That was my first little wobble and I kind of just went, Oh God.”

Despite pledges of support and widespread international concern, the Ebola epidemic in the West African nations of Liberia, Sierra Leone and Guinea is rapidly outpacing all efforts to contain it. As of Oct. 10, the number of cases had topped 8,399, with 4,033 deaths. With local populations of doctors and health care professionals cut down by disease and fear, and with those that remain overwhelmed, it is essential that their ranks be filled with international volunteers who can treat the ill and help prevent Ebola’s spread. But finding qualified doctors and nurses willing to face the risks, as well as repercussions back home, is “a challenge,” says Eric Talbert, the USA executive director for Emergency, an international medical organization that is setting up a 100-bed Ebola treatment center in Sierra Leone. “There is a significant fear factor. They are putting their lives on the line for people they have not met. It’s a courageous ask.”

(PHOTOS: See How A Photographer Is Covering Ebola’s Deadly Spread)

Never has the need been so great, and it looked like it might be exacerbated Monday when health care workers in Liberia signaled they would strike to protest conditions and pay — although many workers ended up defying the call to strike).

Calling the Ebola outbreak in West Africa a “tragedy not seen in modern times,” at the annual meeting of the International Monetary Fund and the World Bank on Oct. 9, Sierra Leone’s President Ernest Bai Koroma said, via video link, that his country would need 750 doctors and 3,000 nurses to treat the anticipated caseload.

As the numbers climb in West Africa, so too does the chance that more cases will be exported abroad, raising the likelihood that doctors and nurses around the world will find themselves faced with Ebola. “There is no doubt that we will see more cases of health workers getting sick” in West Africa, and those volunteers will have to go home for treatment, says Heather Etienne, a registered nurse from Texas who is on her way to Sierra Leone to work in an Emergency Ebola treatment center. So far, 416 health workers have been infected with Ebola in West Africa, and 233 have died, a sobering outcome. “You have to be comfortable with some amount of risk before doing something like this. You don’t have to be at peace with the idea of your death, but you shouldn’t be too uncomfortable with the concept either,” Etienne says.

(PHOTOS: Inside the Ebola Crisis: The Images That Moved Them Most)

Having the wrong people could be just as bad as — if not worse than — not having enough, Talbert says. Ideally, volunteers would be willing to commit to a length of time that would make their training and airfare expenses worthwhile. They should have experience in the region, says Talbert, “so they know what they are getting into,” and experience working with highly infectious diseases, “because making mistakes can be lethal.” And because the risk of burnout is so high, there needs to be enough workers to fill a continuously rotating roster. Health care workers in Ebola treatment centers work under extreme duress, sweltering under layers of protective plastic to take care of patients who have a high chance of dying. “It takes a physical and emotional toll. Nobody can do that for too long,” Talbert says.

Umar Ahmad, a 29-year-old junior doctor at the Royal London Hospital in Whitechapel, who recently completed a three-month program at the London School of Hygiene and Tropical Medicine, is ready to take up the challenge, but he is finding it hard to take a few months away from a full time job. “There are plenty of doctors that would volunteer, but the issue is, what it actually means is that you take a financial hit, a career hit,” Ahmad says. “For lots of people, they’ve got responsibilities and they can’t justify it.”

For Etienne, the nurse from Texas, getting time off wasn’t an issue. Even though many of her colleagues told her she was “insane” for going to Sierra Leone, her superiors were supportive. Her main concern is about what happens when she comes back. As a nurse, she well understands the fear and stigma brought on by Ebola. Upon her return she intends to observe an informal self-quarantine, staying away from her hospital for 21 days, the incubation period for Ebola. “Given how jittery everyone is these days, they don’t really need me at the patient desk, only to have someone say, ‘Oh, you just got back from Sierra Leone. Get me out of here!’” she says.

Clare Parsons, a 28-year-old doctor who is leaving for a one-month stint with the King’s Sierra Leone Partnership, an initiative of King’s Centre for Global Health in London, shares those concerns. Even if she displays none of the symptoms of Ebola, she is planning to lay low at home for a few weeks, just in case. “Obviously I don’t want to go gallivanting around London and be known as the person that spread [Ebola] all over the London Underground,” she says.

Duggan, the Irish nurse, finally decided to go through with her mission despite her concerns, and left on Oct. 13 to work with Doctors Without Borders for six weeks. She is still afraid, she said, but she keeps reminding herself to go back to the facts and follow the procedures. In the end, she said, nursing, wherever it is, “is my job, and something that I’ve been trained to do.” Experience in other international aid missions has taught her that international health workers can sometimes be a breed apart. “You have a very high concentration of people who are willing to make a sacrifice and put themselves at risk for the need of others,” she said.

If Ebola is to be defeated, she, and several thousand more like her, will have to join their ranks.

Read next: CDC Chief Urges U.S. Hospitals to ‘Think Ebola’

TIME Nobel Peace Prize

Malala Yousafzai and Kailash Satyarthi Win Nobel Peace Prize

The prize was awarded to them for their efforts in the education of women and against the exploitation of children respectively

Exactly two years and a day after Taliban gunmen shot her in the head for daring to speak up for the rights of a girl to get an education, Malala Yousafzai of Pakistan was awarded the Nobel Peace prize Friday. She shares the award with veteran children’s rights campaigner Kailash Satyarthi, 60, from neighboring India.

Both Yousafzai and Satyarthi were lauded “for their struggle against the suppression of children and young people and for the right of all children to education,” according to the Nobel Committee’s statement. Though it may not have been intentional, the joint award evokes certain symmetry: Yousufzai, who has since moved to England to continue her education in a safer environment, is at the beginning of a life she has repeatedly said will be spent furthering her cause. Satyarthi is looking back on a career studded with achievements and dedicated to protecting children from exploitation. His work on developing international conventions for children’s rights is what enabled Yousufzai to launch her own campaign, first in her native Pakistan, and then around the world.

That the two come from rival countries and oft-clashing faiths only strengthens the message that the need for children’s education trumps both nation and creed. “The Nobel Committee regards it as an important point for a Hindu and a Muslim, an Indian and a Pakistani, to join in a common struggle for education and against extremism,” said the Peace Prize statement.

For Yousufzai, who continues to receive threats from the Pakistani Taliban who attempted to silence her demands to be educated two years ago, receiving the Nobel Peace Prize offers no better, and no louder, rebuttal.

TIME ebola

Liberia’s New Plan to Get Ebola Sufferers Into Isolation

Residents take home family and home disinfection kits distributed by Doctors Without Borders, on Oct. 4, 2014 in New Kru Town, Liberia.
Residents take home family and home disinfection kits distributed by Doctors Without Borders, on Oct. 4, 2014 in New Kru Town, Liberia. John Moore—Getty Images

The new Ebola Community Care Centers pioneered by Save the Children strike a compromise between home care and hospital-grade treatment. But will they work?

When U.S. President Barack Obama promised, on Sept. 16, to help Liberia set up 17 Ebola treatment centers to help stem the outbreak, the sense of relief was palpable in the west African country. That was the kind of robust international response it needed to stop Ebola in its tracks. Getting patients afflicted with the virus into isolation, where they could no longer infect friends and family, would go a long way towards cutting down Ebola’s exponential spread.

But nearly a month later those clinics aren’t up yet, and so far only one—a 25-bed unit designated solely for infected health workers—is even close to completion. Even though there are currently about 600 beds in Liberia, with another 300 expected to come on line in the next few weeks, it is nowhere near the 1,990 that the World Health Organization [WHO] estimates will be required for the current caseload.

The U.S.-built centers, which would make some 1700 treatment beds available, won’t be up and running for another two to three months, U.S. officials said this week. With 8011 infected and 3857 dead in west Africa as of Oct. 8, according to the WHO, and little hope of seeing the number of new cases each week go down any time soon, no one can afford to wait. Which is why both international and Liberian health officials are looking for alternatives. “One of the biggest challenges we are having is getting people out of their homes and into the treatment centers,” says Frank Mahoney, Liberia team leader for the Centers for Disease Control and Prevention’s Ebola response. “We have been working furiously trying to stand up treatment centers, but [new cases] have been outpacing our ability to stand them up.”

As a stopgap measure, USAID and some international NGOs are looking at ways to protect caregivers at home. But one organization, with support from both the Liberian government and U.S. officials, is proposing a radical compromise that gets suspected patients out of the home for care, without requiring beds in the yet-to-be-completed official Ebola Treatment Units [ETU]. They are called Ebola Community Care [ECC] centers, hyper-local clinics run by community volunteers and staffed not by trained health workers, but by the very people who would otherwise be taking care of patients in the home: family members.

To a certain extent, stopping Ebola is a question of simple math. If you can get the transmission rate to below one, meaning each infected person spreads the illness to less than one person, on average, the virus will die out. If the numbers are more than 2.5, that means the epidemic is “out of control,” according to Carolyn Miles, President of Save the Children, an international humanitarian aid agency working on Ebola in both Liberia and Sierra Leone. In Liberia, the transmission rate is somewhere between 1.75 and 2.5, dangerously close to becoming unstoppable. One of the greatest contributors to the high transmission rate is patients staying at home, where they can infect multiple family members. “From a transmission standpoint, it is essential to get people out of their homes,” says Miles. Ebola Community Care centers, she says, give people a place to go while waiting for the specialized treatment units to be set up.

One of the key factors delaying the ETUs is the necessity for a highly-trained staff of physicians, assistants, nurses, pharmacists and sanitation teams working 24/7. Finding, hiring and training that staff is at least as difficult, if not more so, as getting the physical beds in place. But Save the Children’s response cuts down the staff requirements by building temporary holding centers in every community affected by Ebola.

In these centers, patients suspected of having Ebola can wait for testing without fear of infecting others, while those with confirmed infections can wait in isolation wards until a bed in an official treatment center opens up. One caretaker, who will be trained by an on-site supervisor in basic care and self-protection measures, will accompany each patient. The caretakers will be provided with disposable gloves, aprons, gowns and masks, as well as disinfecting solutions for keeping themselves and their charges clean. “Only one family member per patient is allowed into the ECC,” says Miles. “That alone will get transmission to below one.”

The centers won’t have a medical staff on hand full time. Instead each center will be visited daily by rotating teams of doctors, nurses, sanitizers and personal protection gear suppliers, who will replenish stocks as necessary. The mobile teams will be able to visit up to four community care centers a day, reducing the need for staffing and training. One such center, with 20 beds for suspected cases and 10 in a separate isolation ward, will open later this week, in Magribi County, one of Liberia’s most afflicted areas. By the end of the month Save the Children expects to have 10 more up and running.

The risk for family caretakers is still high, given that well-trained health care practitioners working for some of the most rigorously protective treatment centers are still getting sick. But the alternative is more dangerous, says Miles. “ECCs are not as safe as an ETU, but they are safer than having an ill person at home, being cared for by multiple family members in an environment where real isolation may not be possible.”

As much as communities are warming to the idea, the new care centers still face the fear and stigma that plagues anything to do with Ebola. “A lot of people do want to care for their loved ones in a safe environment, and they know there are not enough ETUs,” says Miles. The problem, she notes, is that no one wants a center next door. But until U.S. officials can keep President Obama’s promise, these kinds of stopgap solutions might be the only chance to slow the spread of Ebola.

TIME ebola

Liberia Burns its Bodies as Ebola Fears Run Rampant

A burial team disinfects an Ebola victim while collecting him for cremation on Oct. 2, 2014 in Monrovia, Liberia.
A burial team disinfects an Ebola victim while collecting him for cremation on Oct. 2, 2014 in Monrovia, Liberia. John Moore—Getty Images

In an effort to stem Ebola’s spread, Liberia’s government has all but banned burials in favor of cremation.

In the dusty shopfront of one of downtown Monrovia’s more desolate side streets, Sam Agyra flips through a fly-specked photo album showing off his custom caskets.

Cake-like confections of pale satin, gold detailing and elaborate wooden scrollwork, his coffins have earned him a well-deserved reputation for beautiful work at a cheap price. In good times he was turning out five handcrafted pine coffins a week. Now? He doesn’t even want to talk about it. Instead he just laughs, the hysterical cackle of a man watching his business of 25 years grind to a halt. He hasn’t sold a coffin in two months, ever since the Liberian government declared, in an effort to tackle the Ebola crisis, that all of the country’s dead should be burned and not buried.

An Ebola victim is most contagious in the moments and days after death, when unprotected contact with infected bodily fluids carries an extremely high risk of transmission. Liberia’s traditional burial practices, in which mourners bathe, dress and even kiss the corpse, are widely credited with the early explosion of Ebola in the country, where over 2,000 have so far died of the disease. Overwhelmed by the increasing number of dead, and faced with community fears that the buried bodies may also transmit the disease—which, if interred properly, they won’t—Liberia’s government declared in August that all those who died of Ebola should be cremated.

With international help and advice, the government established a Dead Body Management program to pick up Ebola’s victims and dispose of them safely. But testing for Ebola is difficult and time consuming. What little testing resources do exist are reserved for the living, says assistant health minister, Tolbert Nyenswah. With hospitals closed and doctors overwhelmed, it is almost impossible to prove that the cause of death is anything but the deadly virus. “These days, if someone dies, it’s Ebola,” says Agyra. “There is no testing, no questions. Just Ebola, and they take the body away. No one has time for coffins.”

The government directive, while logical from an epidemiological aspect, has taken a toll on a society already traumatized by Ebola’s sweep. It denies communities a final farewell, and has led to standoffs with the Dead Body Management teams who must pick up the dead even as the living insist that the cause of death was measles, or stroke, or malaria — anything but Ebola. “We take every body, and burn it,” says Nelson Sayon, who works on one of the teams. Dealing with the living is one of the most difficult aspects of his job, he says, because he knows how important grieving can be. “No one gets their body back, not even the ashes, so there is nothing physical left to mourn.”

Monrovia’s mass cremations, which take place in a rural area far on the outskirts of town, happen at night, to minimize the impact on neighboring communities. For a while the bodies were simply burned in a pile; now they are placed in incinerators donated by an international NGO. There are so many that it can sometimes take all night, says Sayon.

In a country where distrust between the people and the government runs deep, the mass cremations have caused a deeper rift, says Kenneth Martu, a community organizer from the Westpoint area of Monrovia. “In west Africa we don’t cremate bodies at all. So when the government takes away our bodies, and can’t even tell us if they died of Ebola or not, it breeds resentment.” Liberians, he points out, are no strangers to mass casualties: two civil wars, from 1989 to 1996 and 1999 to 2003, saw nearly half a million die. “Even with mass graves, people can bring flowers. They know where to find the dead. But here we don’t even know where the ashes are.”

There are exceptions to the cremation directive. If a family can get a signed death certificate from the Ministry of Health stating that the cause of death was not Ebola, they can take the body to a funeral parlor for embalming and eventual burial. There are even dispensations for those who do die of Ebola; under certain circumstances the dead can be buried in a cemetery, if the Dead Body Management team conducts the preliminary steps of laying the body six feet deep and soaking the next four feet of earth with chlorine solution.

But those dispensations are impossible to get without connections. One recent Saturday, a funeral cortege down one of Monrovia’s main thoroughfares drew questioning comments and glares of resentment from bystanders. “Haven’t seen that in a while,” exclaimed one woman. “Must be related to a minister,” muttered a man.

Considering Liberia’s mounting death toll, it is an irony not lost on coffin-maker Agyra that an enterprise that ordinarily profits from death should be struggling. “You hear of 50, 80, 100 people dying a day here, and the coffin business has never been so bad,” he groans. “This Ebola business. It’s bad for people, and it’s bad for me.”

TIME ebola

People Are Prank Calling Liberia’s Ebola Hotline

While others ring to report a dead body or a sick family member

In a recently converted warehouse in downtown Monrovia, Liberia’s capital city, some 30 Liberian university students are manning a bank of phones. Armed with pens, clipboards and multiple bottles of hand sanitizer, they pick up the constantly ringing receivers in quick succession. “Good afternoon. You have reached the Ebola call center. How may I help you?” It’s the national Liberian Ebola hotline, a toll-free number for residents from all over the country worried about a sick neighbor, a suspicious death in the family or troubling symptoms. It serves a vital link between a public terrified of Ebola and the government who can provide help — but pranksters often get in the way.

The call center opened in early August to address the rapidly escalating number of Ebola cases in the country. Ebola spreads through contact with infected bodily fluids, and transmission most often happens in the home, where family members take care of the ill without adequate protection. To stop that chain of transmission, it is vital to get the sick out of home care and into specially designated centers where they can be treated by trained health care workers in isolation. A call to the hotline, the government promised, would result in the dispatch of an ambulance to take the sick person to a treatment center, or, in the case of someone who died, a dead body management team to pick up the corpse, which is still contagious for days after death, for safe disposal.

But no one was prepared for the volume of response. From the very beginning, the center was receiving thousands of calls a day. The government had neither the ambulances to pick up the ill, nor the space to treat them. Instead of a solution, the hotline became a source of frustration. And the callers took it out on the agents at the other end of the line.

“A lot of people think that we are the doctors, that we are the ambulance drivers, or the dead body teams,” says call center manager Tina Kpan. “All we do is transmit the information, but the public doesn’t understand that, and they take their anger out on us.”

The number of calls has declined to around 1,000 a day, says Kpan, who sports short, spiky dreads and dangling gold earrings. But it’s not exactly cause for hope. “Instead of getting one call for one sick person, we are getting reports of five or six sick people at a time,” Kpan says. The phone center’s statistician says that he is averaging 100 calls a day reporting dead bodies. Some of them are duplicate calls, he says, but the numbers are still growing.

Even if the agents aren’t on the front lines of the fight against Ebola, they still feel the pain. “I am sorry for your loss,” whispered one agent into the phone as she took down details of a recently deceased 34-year-old mother from her 12-year-old daughter. The agent briefly rested her forehead in her hands upon hanging up.“You put yourself in that persons’ shoes, and sometimes you feel like its you that it has happened to,” she says. “Its very frustrating. Sometimes they just die.” On her shirt is stapled a small square of paper marked with her temperature coming into work that morning: 36.1 Celsius.

Not all the calls are about the sick and dying. Some, in a way, are worse: the prank callers. Agents say that 90% of the calls are legitimate, but Kpan pulls out a thick folder filled with the recorded phone numbers of people who called simply to harass the center’s workers. Some make lewd jokes or attempt to pick up the female staffers. Others invite the agents out to eat “bush meat,” the monkey and bat flesh consumed in rural areas in a practice that may have spread Ebola into the human population. Kpan has instructed her agents to record the calls, as she plans to broadcast them on the radio in an attempt to name and shame. One prank caller had the misfortune of calling just as she was making the rounds of the phone banks. Kpan grabbed the phone from the agent.

“You listen here,” she shouted into the mouthpiece. “We are here to pick up calls for sick people, and you are occupying the line. And then the public complains that we are not picking up calls. The very next time you call this number, I will have the police pick you up.”

She slams the phone down, and asks the agent for the number. For the moment, she says, they don’t really have the right to call the police. When they do, she expects the call volume to go down. That may make the agents’ job easier. But it’s unlikely to indicate anything about the course of Ebola in Liberia.

Your browser, Internet Explorer 8 or below, is out of date. It has known security flaws and may not display all features of this and other websites.

Learn how to update your browser