This week the United Nations Security Council called the Ebola outbreak in West Africa “a threat to international peace and security” and passed an emergency resolution, the first regarding health since the AIDS epidemic. It asked for $1 billion in aid to be directed toward the outbreak. According to the World Health Organization, there are currently 5,843 cases and 2,803 deaths attributed to the epidemic, which appears to be accelerating rapidly. On Tuesday the Centers for Disease Control and Prevention projected that Liberia and Sierra Leone could have 1.4 million cases by January if the epidemic is left unchecked.
In the case of Liberia, where the majority of cases have been — 3,022 cases, with 1,578 deaths — the epidemic has paralyzed and terrorized both patients and caregivers. This, in combination with high numbers of health care workers afflicted, has, understandably, destabilized the health system, with reports of facilities closing, decreased utilization of health services and even a measles outbreak where vaccinations have been halted.
Why has Liberia’s health care system been unable to contain Ebola? Imagine throwing a gallon of gasoline on a forest baked dry from a 14-year drought and then setting it ablaze: This is Ebola in Liberia. An inferno burns out of control in a chronically vulnerable health system that is ill equipped to tackle this acute crisis, with little assistance thus far from the international community.
Before the first case of Ebola crossed into Liberia from Guinea in early 2014, Liberia was one of the most challenging places in the world to receive quality health care. Fourteen years of brutal civil war had devastated the nation’s health care infrastructure, causing 90 percent of its health care workforce to flee and 80 percent of its health facilities to shut down. At the time of the peace accord in 2003, there were just 50 doctors serving a population of 4 million, leading to some of the worst maternal and child health statistics in the world; 1 in 8 women there die from childbirth complications.
Over the last decade Liberia’s Ministry of Health and Social Welfare has made laudable strides with available resources, but only so much can be expected in 10 years for a nation emerging from civil conflict and requiring (to this day) the presence of U.N. peacekeepers. It still ranks 175th out of 187 on the world development index, with neighboring Guinea and Sierra Leone coming in at 179th and 183rd, respectively.
What should be done? Liberian President Ellen Johnson Sirleaf, during a meeting with international partners, said it best: “Many people are coming to help us deal with Ebola, and that is fine. But they will disappear. The real issue is our health care system.”
Despite a devastatingly slow start, the international community is finally speeding up its aid. In a country whose yearly per-person expenditure on health is a meager $102 (compared with the United States’ $8,000), this infusion of funding is the best chance to bolster one of the poorest health systems in the world. What’s unfortunate is that the rest of the world will pay the price of a tightfisted response.
Ensuring that these resources are used to address both the current crisis and the critical weaknesses of the current health system is essential to effectively quell the epidemic and set the course for long-term capacity gains, which will prevent future outbreaks and save thousands of lives from preventable diseases in the years to come.
There are four key areas that proposed expenditures for Ebola response should take into consideration to avoid wasting an enormous opportunity.
First, integration with the government is critical. All programs and funding need the full support of Liberia’s Ministry of Health and Social Welfare and must be coordinated with the country’s Ebola response while falling in line with the long-term national health strategy. Shame on us if outside every health center in Liberia we simply erect a shiny tent with a sign that reads “Ebola,” staffed by droves of international volunteers who leave once the crisis is over. Rather, every proposed response program must prioritize building up the infrastructure of the health system as a whole. Installing yet another vertical program in an African country to address a specific problem leaves the adjacent medical facilities and surrounding community no better off than before, jeopardizing the success of the response and leaving systemic issues largely untouched.
Second, community health systems must be strengthened. Effective Ebola response requires a continuum of care to break the circle of transmission. This starts with identification and screening of cases in the community, which in turn must trust that loved ones will be in good hands until they, hopefully, come back. For example, building community response platforms for Ebola are at the core of the newly announced collaborative project between Partners in Health and Last Mile Health. For the last seven years, Last Mile Health has been working with the government to create strong rural health delivery systems in hard-to-reach areas of Liberia. This model connects highly functional, well-equipped, well-trained and appropriately compensated cadres of community health care workers with local facilities to provide high quality, comprehensive care to some of the most vulnerable populations in Liberia. Since these workers live in the communities they serve, they gain the trust of the people, which is vital when fighting Ebola and in the long run will improve overall health delivery. This is especially true in rural areas, where new outbreaks are most likely to emerge (which was the case in this epidemic).
Third, Liberia needs an improved logistics and supply chain infrastructure — and the technical know-how to build and maintain it. It is imperative to consolidate and integrate countrywide response logistics systems as much as possible with the current health system. For example, if the U.S. military gets involved, as has been suggested, its experience in logistics could be transformative for the response. But it should also be held responsible for improving information technology systems and training and mentoring Liberian staff.
Finally, health infrastructure, in the form of physical structures, equipment and laboratory capacity, is crucial to the country’s long-term ability to provide uninterrupted care even as it serves the immediate needs of the acute response. Increased capacity will help regain communities’ confidence in the health care system now and into the future.
Ebola is one of the greatest crises of our time, and it is still accelerating. The world will be judged in the coming years on how it responds. To date, we should be judged harshly, and many have suffered unnecessarily. Yet there is still great opportunity to rapidly improve the immediate and long-term conditions of the Liberian people.
Note from the author: This article is dedicated to the memories of my colleagues Dr. Samuel Brisbane and Dr. Abraham BorBor, chief and deputy chief medical doctors at JFK Hospital in Monrovia, Liberia. They died last month from Ebola after contracting the virus while taking care of patients. In working with them at JFK Hospital in 2010 through 2011, they became my friends, and I will forever admire their enduring commitment to their patients and to training the next generation of Liberia’s physicians. Liberia sorely misses them.