Years after the West Africa Ebola virus epidemic, Liberia's health system still carries the burden of the deadly outbreak. Laura Salm-Reifferscheidt reports from Gbarnga, Liberia.
Comfort Gbainsay is huddled on a bed under a mosquito net at the CB Dunbar Maternity Hospital in Gbarnga, a small city about a 3 hours' drive from Liberia's capital Monrovia. A few days ago, she started feeling weak. She had stomach cramps and was breathing fast. At the hospital, she was diagnosed with stomach ulcers and typhoid fever. The 37-year old is 3 months' pregnant.
The ward is veiled in darkness. With a torch in one hand and a spoon in the other, Gbainsay is eating her dinner from a plastic container. There are not enough funds to run the hospital generators 24 h a day, so electricity is scheduled. This will be her third child, says Gbainsay. Her large eyes look exhausted, her voice is muted. She gave birth to her other two children at CB Dunbar, but back then, she says, she did not have to pay for any of her medication.
CB Dunbar is a government hospital and therefore drugs and services should be free. The National Health and Social Welfare Policy 2011-2021 focuses on an essential package of health services, and the country has set itself the goal of reaching universal health coverage. However, the coverage index for essential health services lies at 34, the target value being 100. Gbainsay has already spent more than LRD3000, or around US$18, on medication during her stay, a third of her monthly income as a teacher. "The drugs that were here, they gave me; the ones that were not here, they told me to go out and buy", she says. One of the prescribed medicines is out of stock at all pharmacies in Gbarnga and she had to send her husband to Monrovia to buy it.
"Everything is becoming very difficult because of, I don't know, the economic condition or because of the new president", she says. "Over the past year, things that we easily used to do just can't be done easily nowadays. If you don't have money, things don't work for you."
The new president Gbainsay is referring to is ex-footballer George Weah, "The [gross domestic product] of Liberia was growing very fast... Then Ebola struck. It went below 0·5%. Liberia has not recovered economically to support those things it is supposed to support." who was sworn in as head of state in January, 2018. Voters had high expectations and hoped he would reign in corruption, kick-start the economy, alleviate poverty, and rebuild the health system after the Ebola outbreak of 2014-15, which killed 4810 people in Liberia, including almost 180 health workers. When the hemorrhagic fever struck, the health sector was on a slow path to recovery after years of brutal civil war that had ended in 2003.
However the new president has other priorities, as he highlighted in his second annual message in January, of this year. "... I have set my eyes on roads as my administration's path to delivering a better living condition for the Liberian people", he said and added that good road connectivity will, among other things, "reduce travel times to schools and hospitals". Health care was otherwise barely touched upon.
"The collateral damage to the health system, education and the economy cannot be compared to anything", says Tolbert Nyenswah referring to the Ebola outbreak.
The public health specialist was head of the incident management system during the epidemic, coordinating the national and international actors involved. "The [gross domestic product] of Liberia was growing very fast", he recounts. "Almost double digit at 8·5%. Then Ebola struck. It went below 0·5%. Liberia has not recovered economically to support those things it is supposed to support."
Nyenswah believes that Ebola was so devastating for the country because the virus caught the health system unawares. Liberia was concentrating on curing patients and not on preventing diseases in the first place. Surveillance, research, health communication, epidemic preparedness, and control were not the focus. At the beginning of the outbreak, there was no laboratory in the entire country that could test blood samples from patients with suspected Ebola. After the outbreak, "we knew there was something lacking and that we needed to build a resilient health-care system in our country", he said.
And despite the challenges on the curative side of the health system, with regard to surveillance and early detection, Liberia has taken steps forward. The National Public Health Institute of Liberia, of which Nyenswah is the Director General, was established soon after Ebola. It was modeled after the US Centers for Disease Control and Prevention and is responsible for detecting, preventing, and responding to disease outbreaks. More than ten diseases, including yellow fever, Lassa fever, Ebola, cholera, meningitis, and measles, can now be tested for in Liberia. Before the outbreak, it was only three.
"The capacity to respond is ten times better than what we were doing preEbola", Nyenswah says, adding that in the past 12 months alone, Liberia has reacted to 48 disease outbreaks. There is now a focus on a so-called One Health approach, where different sectors such as human health, animal health, and food and agriculture sectors work together to achieve better public health outcomes. It was with such cooperation, and with the help of international partners such as EcoHealth Alliance, that the Zaire strain of Ebola virus was for the first time found in a bat in Liberia, a discovery that brings scientists closer to understanding where and how the deadly virus jumps the species barrier.
Adding to this, doctors, nurses, and other health workers climbed a steep learning curve during what Liberians refer to as the Ebola war. Emmanuel Dweh, a surveillance officer in Bong County, was stretched to his limits at the height of the epidemic in 2014, tracing contacts, delivering blood samples, talking to relatives of patients, and vaccinating children in remote villages. "Now we are very organized and grateful to have gone through this training", Dweh says. "We have people who have the knowledge and ability, and an emergency operation centre is already there." Ebola is not an unknown illness to Liberians anymore, and it will not "... doctors, nurses and other health workers climbed a steep learning curve during what Liberians refer to as the Ebola war." take the country by surprise as it did back in 2014. However, Dweh worries because there is no strong patient management system to break the chain of transmission.
Nyenswah agrees: "If you look at health system strengthening and prevention, I am a little bit worried. Hospitals are out of drugs and medical supplies. Doctors don't have the equipment to work with; the public health system is under a huge stretch." He also cites shortcomings in areas such as maternal health, immunization, nutritional services, diagnostics, and imaging.
It follows, then, that health workers are struggling to help their patients.
Mabel Musa is a maternity nurse at CB Dunbar hospital. "We had a patient that needed a medication. She was in shock, but we could not get that medicine at the hospital", she recalls. "Before we wrote the prescription, the patient was dead."
The situation is so extreme that patients even have to buy surgical gloves for the medical staff who treat them. "They buy gloves, touch them, and then we wear them. So it is not even safe for us."
Hospitals all over Liberia are affected by a lack of funds. Local papers are full of stories of near shutdowns, power failures, and drug stock-outs. Phebe Hospital in Suakoko, a 20-min drive from the maternity clinic, is one of the largest referral institutions in the country. The shelves in its warehouse are near empty. Antibiotics, malaria drugs, and injectables are low in supply or simply not there. "We have a serious challenge when it comes to purchasing from our local vendors because we are heavily indebted with them", says Clifford Johnson, chief pharmacist at the hospital. According to Johnson, the hospital receives up to 400 outpatients daily and caters to around 120-150 inpatients. He laments the fact that because the hospital cannot meet their needs, patients who live in remote communities often have to resort to informal medicine peddlers and risk ending up with counterfeit or substandard drugs.
Although Ebola ravaged the country, nurse Musa says that some things were actually better during the outbreak. The 33-year-old was at the forefront of the fight against Ebola, working as an ambulance nurse, picking up patients from remote villages and transporting them to an Ebola Treatment Unit. She wonders where all those ambulances have gone today. "Sometimes you see people dying because the ambulance is delayed. Sometimes there is no fuel. During Ebola, ambulances were there... "
Yet despite the current situation, Musa remains positive. She says before Ebola she thought of herself as just a nurse who would give injections and go about her daily routines, but the Ebola experience opened up her mind. "I have bigger dreams now. I want to move forward. It has given me this push to work hard."
Now colleagues who are more senior, doctors, and government health officials listen to her and respect her experience and opinion. She was even offered a job in the Democratic Republic of the Congo to fight Ebola there. But she remains in Liberia to put all her strength into helping her own people.