From using Bitcoins to fundraise, to adopting new strategies to prevent malaria victims appearing to be Ebola cases, to working with new partners - aid agencies in West Africa are learning to adapt fast.
"The response to every humanitarian crisis has to be context specific," said Nigel Clarke, the director of programme development and quality for Save the Children's operations in Liberia. "That's the key standard that humanitarian agencies utilize in all crises. But this Ebola crisis is unprecedented because of all the associated risks of cross infection."
Humanitarian workers, for example, would normally want to bring people together during times of crises, to do things such as spread key messages, distribute food and other supplies, and sit down with communities in groups to discuss needs, Clarke said.
"But a lot of those things are not possible in this context and so we are having to sort of adapt as we go."
In order to help get the outbreak under control, they have now branched out and partnered with the governments of Sierra Leone, Cuba and the UK, as well as other health agencies and workers, to establish and run a treatment centre in Freetown's Kerry Town.
The new, 100-bed Ebola Treatment Unit is the first time that Save the Children has ever worked on a global health emergency in this capacity.
"We're all in a place now where we never thought we would be," said Rob MacGillivray, Save the Children's country manager in Sierra Leone. "In the past, we never considered direct case management, but eventually the outbreak overtook us and now we've had to fight this battle in a way we've never fought a humanitarian battle in the past."
New health strategies
Because the symptoms of Ebola and malaria, such as high fever and headache, can be very similar, Médecins Sans Frontières (MSF) has begun distributing anti-malarial pills to an estimated 300,000 people in the poorest parts of Monrovia, where many clinics have either been shut down due to the Ebola outbreak, or people are too scared to seek treatment at them.
MSF hopes this campaign will reduce the number of people who contract malaria, but are mistaken as suspected Ebola cases.
While preventative drug administration is not new for MSF, spokesperson Julie Damond told IRIN: "It's a complete adaptation of what we do in the sense that we would have never imagined to be obliged to do it in response to the collapse of the health system."
MSF normally distributes these pills, which both prevent and cure malaria, to children under the age of five. But for the first time, they are available to people of all ages.
The goal of the campaign is also new.
"Here, the attempt is not to reduce transmission [of malaria], but to reduce the number of cases of fever," said Estrella Lasry, a tropical medicine adviser for MSF in Liberia.
To avoid many people gathering in the same area, MSF has been delivering the treatments door-to-door early in the morning, instead of having a central distribution centre.
Fundraising - with Bitcoins, too
More than US$117 million has been pledged towards the UN Ebola Response Multi-Partner Trust Fund, according to the UN Development Programme. But many local, grassroots organizations say they are still struggling to raise funds.
In Freetown, the Sierra Leone Liberty Group (SLLG), a group of young people in Sierra Leone who promote future prosperity through entrepreneurship, have turned to Bitcoins, a type of digital currency that is transacted electronically without the use of a bank or other middleman, to fund their Ebola response activities.
Real time response
As the number of people in need of food assistance continues to grow, the World Food Programme (WFP) has been trying to keep up with fulfilling needs by responding in real time.
"In this crisis government structures are weak, so there is not much information on where people are," said Chris Huddart, WFP's emergency programme manager in Liberia. "So we have to use people on the ground to try to get estimates of numbers."
But determining who the beneficiaries are and where they are going to be is not easy.
While the Centers for Disease Control and Prevention (CDC) has a model to predict case numbers (each reported case equates to 1.5 actual cases), WFP says it is difficult to target based on predictions.
"We started by targeting 30,000 people, then it went to 200,000, then 400,000 and now 600,000 in the space of a couple of months," said WFP head in Sierra Leone Gon Myers, adding that they now deliver food by any means available, including cars, trucks and bicycles.
WFP is also branching out into new programming areas - in Guinea overseeing the building of 13 transit centres to hold probable cases, and 41 community treatment centres, for instance, as well as creating logistics tools-in-a-box to help its partners get the equipment they need to set up operations. "It is not normally in our repertoire to be building treatment centres. We're putting a lot of energy into it. This is new territory for us," said Margie Rehm, interim emergency programme manager in Guinea.
Shift in targeting criteria
WFP is using health statistics and infection rates, as opposed to food insecurity or food crisis criteria, in the three most affected countries to guide their food aid distributions.
In Liberia, food insecure areas with more than 50 cases of Ebola are being prioritized over food insecure areas with fewer Ebola cases. In Guinea, any village with at least five Ebola cases is eligible for food assistance.
"It's purely logistical," said Huddart. "[We] target areas with high incidents of [Ebola] transmission and historical food insecurity."
In Sierra Leone, WFP has suspended its usual school feeding programme (schools are closed) and food-for-work programmes, and is instead supplying food to treatment centres nationwide, targeting Ebola patients and health workers, as well as Ebola survivors who have been discharged.
Keeping distributions safe
Under "normal" circumstances, WFP staff would work with communities to create a list of vulnerable households, print out ration books and then distribute food at a centralized location. But due to a lack of time and capacity, as well as the risk of contamination, WFP is now working with elected community representatives to identify vulnerable households and then deliver food door-to-door.
"WFP has had to completely change the way that it operates due to the contact dangers that the disease poses," said Myers. "All public gatherings have been banned in Sierra Leone. [so] gathering crowds to a food distribution would pose too great a danger to people at risk of contracting Ebola."
WFP pre-packages food in its warehouses, and then either works with partners to distribute the food parcels door-to-door, or else organizes distributions in such a way that families come individually, to avoid jostling and touching.
Distributing food to slums and other densely populated areas poses particular challenges, as the risk of drawing a crowd or raising tensions is much higher.
"We try to keep it cool by identifying a distribution point on the edge of the slum and distributing ration cards ahead of time, so we know everyone who comes is entitled," Myers said.
"It's often difficult to get money into and out of African countries," said Dan McLaughlin, co-founder of SLLG. "Western Union, for example, or banks, charge big wire transfer fees and a lot of people don't have bank accounts. But anyone with a cell phone or computer can have a Bitcoin account."
While there currently is no ability to transfer Bitcoin directly into local currency, the donations, which are received instantaneously from around the world, are converted into US dollars and then used to purchase local goods. This system allows SLLG to respond much more quickly than they could with money from, say, a Kickstarter campaign or PayPal.
The Bitcoin fundraising model was used for the first time last year by a woman in Botswana, who raised $1,500 for the international NGO SOS Children's Village, which cares for orphaned and abandoned children.
SLLG has now raised around $2,500 from Bitcoin users. The money is being used to distribute food, and other supplies to quarantined households.
"The Bitcoin community has been good so far, and that's a pretty exciting thing," McLaughlin said. "It's not a tremendous amount of money, but it does make a difference on the ground, and I think this can be a big part of future fundraising campaigns in Africa."
"A lot of the focus has been on social mobilization and getting the right messages out to the people," said Shane O'Connor, a technology for development officer with UNICEF in Sierra Leone. "And one of the best ways to respond in a situation like this is to look at technologies that are there and then use them in an innovative way."
To speed up the dissemination of positive health information, UNICEF has been working with local mobile phone carriers to send mass SMS messages to subscribers. They are also taking advantage of Facebook groups to provide information and start discussions about Ebola.
"We're still going door-to-door, but we need to reach many, many more people and much more quickly," O'Connor said. "With SMS, we can get a message out to 1.5 million people, almost instantaneously."
The "blast messages" give both general information about Ebola prevention to people nationwide, as well as target specific regions. In a district where the Ebola incidence is low, for example, subscribers might receive tips for protecting themselves against the virus. In an Ebola hotspot, people might receive a message about the importance of safe burial practices.
In addition to text messages, UNICEF has also started sending out short, recorded voice messages, with similar content, both to reinforce the text messages and target the illiterate population.
UNICEF has also been working with the Ministry of Health to connect with health workers on the ground using a mobile phone application known as mHero. mHero allows the Ministry to quickly relay information to health workers across the country, giving them information about the diagnosis, treatment and prevention of Ebola and reinforce safety training measures.
At the same time, health workers can use mHero to report information from the ground in real time into existing databases, related to surveillance or contact tracing.
"So nothing quite new, per say, but we are using all these technologies in a way that hasn't been used before, and it's allowing us to react more quickly and to have information move around more widely and this will hopefully bring about a change in the curve as it stands now," O'Connor said.