In 2018 Kulah Quaqua began her usual day waking up early, heading to her job as a nurse at a community health clinic with the Gbarpolu County Health team, tending to patients, and trying to squeeze in bites of food between shifts. She would grab a quick plate of rice or cassava, soaked in rich stews loaded with oil and meat, often washed down with a sugary soda. It was a comfort in her busy life -- heavy, filling, and energizing.
With three young children Kulah had little time for check-ups and even less time for exercise. Most nights, after consuming a heavy meal, she would crawl into bed, exhausted. She was a picture of modern life for women in Liberia: consumed by work and care giving, without time to think about the long-term effects of her lifestyle.
But then something began to feel wrong. Kulah lost weight rapidly, felt weak and drowsy, and had an unquenchable thirst. Her body was giving her unmistakable signs, but Kulah pushed them aside. It wasn't until a colleague pulled her aside and told her she looked unwell and needed to go to hospital, that she acted.
Kulah was diagnosed with what's called "Type 2" diabetes, a chronic condition where the body doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels. Insulin is a natural hormone that turns food into energy and manages your blood sugar level. This type of diabetes can have a genetic component but is mostly caused by lifestyle factors.
Kulah might have been expected to know better. As a nurse she might have known about diabetes - one of the fastest growing diseases afflicting Liberians. But in 2018, she says, neither she nor her colleagues had any information about how their food and lifestyle choices were connected to the disease.
Kulah is one of what is likely to be billions of people around the world battling the rise in what's known by the umbrella term "non-communicable diseases". Unlike Ebola or Covid, they are not passed from person to person. They are mostly caused by lifestyle: unhealthy diet, a lack of exercise and sleep, and exposure to stress and pollution.
Hypertension, diabetes, cardiovascular disease, chronic respiratory disease, mental health disorders and cancer are among them. NCDs are Liberia's "next epidemic," according to Dr. Clement Peter, the outgoing World Health Organization Country Representative. The true numbers in Liberia are unknown - no one is collecting the data - but Dr. Peter says they're likely alarmingly high.
A 2016 study estimated preventable disease and injury accounted for nearly 40 percent of Liberia's total disease burden and more than 43 percent of deaths. Experts say the numbers have likely grown far higher today.
The tragedy, say experts, is that while there can be a genetic factor, almost all can be prevented. But in Liberia people face two big problems: lack of information about the diseases and the lifestyle changes that can save their lives. And, once, they do have information, it is difficult and expensive to access the fresh fruit and vegetables that will help keep them safe.
The vast majority of people are going undiagnosed, struggling with symptoms that can lead to blindness, amputation, low energy, and eventually, death. Those who are diagnosed live on a rollercoaster trying to manage their illnesses and pay for expensive medicines.
Liberian health care system has been slow to recognize the dangers of NCD
When Kulah was first diagnosed she went to all of Liberia's leading hospitals seeking help. She was met with a medical maze that left her confused and frustrated. She took expensive medications to control her blood sugar, but she was still feeling sick. Four years after her diagnosis she developed asthma, an illness that is more prevalent in diabetics.
By then Kulah weighed just 84 pounds and was waking up gasping for air. She worried she might die. She collected her savings and travelled to Kigali in Rwanda, a nation gaining a reputation for good, affordable medical care.
In Rwanda doctors found Kulah was malnourished, with dangerously low-blood sugar. They immediately switched her to a diet rich in fresh fruits and vegetables. She was encouraged to drink water and avoid sugary drinks and alcohol. She also got daily exercise and 7-8 hours sleep.
Kulah finally learned the key to better health. Doctors taught her that the single most important treatment for her was not medicine, but diet. Medication could not control her symptoms. She needed to change her lifestyle.
Kulah began to feel better. She regained strength. She no longer woke up gasping for air. She was thrilled that her new diet and lifestyle would protect her children who were also at higher risk for contracting diabetes because of their diet. But when Kulah returned to Liberia she soon understood the challenge she was going to face to stay healthy. The fresh, raw fruits and vegetables she ate in Kigali were harder to find in Monrovia.
"A carrot here is very expensive," says Kulah. "Getting fruit to eat - especially a family with many children - we cannot afford it. Every morning, I get up I am afraid. I wonder if my sugar is normal. I wonder what I will eat today."
Kulah lost her job in 2024. Her husband battles high blood pressure - another NCD - and she was the family breadwinner. They are now struggling to survive and stay healthy.
"In Liberia, whatever you can afford, that's what you can eat," says Kulah. "So, you're eating depends on your pocket. How many persons can afford an apple just for themselves?"
Changing the diet is key, says Dr. Peter, outgoing WHO Country Representative. "People must eat more fresh fruit and vegetables and cut back on red meat and oils like palm oil as well as sugary drinks. We can prevent them," he says of noncommunicable diseases. "That is the only remedy."
A Food System Geared to Prevent Malnutrition, Not NCDs
In the aftermath of civil war and with the devastation of the Ebola outbreak, Liberia has been focused on basic priorities: rebuilding basic healthcare and an agriculture system that prevents malnutrition, especially for children. Building a food system that addresses NCDs has not been on the radar.
Rwanda has undertaken extensive reforms to improve agriculture production though major challenges persist. Prevention of NCDs, as well as malnutrition, was one of the drivers of its reforms. Liberia has a long way to go according to Mr. Jonathan Stewart, Chief Executive Officer of Agro Tech, an agriculture development firm working with farmers and other stakeholders.
Almost all farming in Liberia is done by small scale "subsistence" farmers growing enough to eat and sell for a small profit. Liberia's terrible roads make it almost impossible to transport fragile fruit and vegetables. Without storage facilities there is nowhere to store fresh fruit for periods.
"Vegetables are perishable things," Mr. Stewart says. "They get spoiled within days. It's actually a risk for vegetable sellers. So the output is not able to feed us as a country in terms of what we harvest or sell."
Mr. Stewart says that to encourage the production of fruits and vegetables enough to feed people like Kulah and William government must invest in roads and storage and work harder to encourage farmers to grow and sell them.
Dr. Peter agrees. He wants to see a nationally coordinated plan.
"Is it difficult to grow the fruits? It is not," he says. "This is where partnership with the Ministry of Agriculture is very important, and other relevant ministries is very important. NCDs is not purely a medical problem alone. An informational campaign can be done through education, through the Ministry of Information, through Gender (ministry) and so on. So this is a multi-sectoral issue that requires a collective action from the relevant ministries, in addition to the Ministry of Health."
Dr. Peter urges government to put a much bigger focus on awareness raising and other measures including regulation of soda and alcohol. He welcomed government's recent ban on tobacco - very few Liberians smoke - but would like it to go further.
"The cost of a bottle of soda is the same as a bottle of water and more people would prefer soda not knowing the danger it poses to their health," he says. "A lot of unemployed young people compromise their stress with drinking locally made alcohol which is also low-priced."
Medicine Is Available But it's Expensive and Cannot Treat the Illnesses Alone
William Pewu, 54, diagnosed with hypertension and diabetes in 2019, is luckier than most. He has health insurance through his job as an accountant at the Health Ministry which pays for the medication that brings his blood sugar levels down. But it does not pay the $25 cost for 50 test strips that he must prick his finger three times a day to check his blood sugar levels and inject insulin if they go too high or low.
William is still in bad shape. He has lost weight, but he still battles blood sugar spikes. He doesn't want to take the insulin. Instead he relies on diet and medicine to try to control his blood sugar levels. He doesn't dare cut his toenails because he has what's known as "diabetic foot". Reduced blood circulation and nerve damage means a cut can result in an uncontrollable infection that might lead to amputation. It's not easy.
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"Sometimes, I have to go out of town to hustle for my family," says William. "But again, I can't go out there, because if I leave from here to go out of town to do some work, I will have to eat the things that am not supposed to eat. So I am now depending on salary, which is not much."
The Ministry of Health published the first NCD policy in 2017 and established an independent unit in the ministry. As the crisis worsens the Ministry of Health has attracted funds to integrate NCD diagnoses and awareness into hospitals and clinics across the country. (A future story in this series will look at those efforts.)
Here at the government-run James N. Davis Jr. Memorial Hospital in Neezoe, Montserrado County, patients at the diabetes clinic sit squeezed together on a few benches waiting to have their blood sugar tested or receive treatment for diabetes.
The clinic started in 2012 with support from Diabetes Australia caring only for the small number of children with type 1 diabetes, which is not caused by lifestyle, and type 2 - the type caused primarily by lifestyle - diabetics aged under 30. But in 2022 as the number of type 2 diabetics rose it started taking adults too. Adult patients pay a $L500 ($US2) enrollment fee. There has been a steady increase in patients here to as many as 30 a day since the program started an awareness campaign in 2022, according to Ms. Donnetta Hoff, the hospital's diabetes focal person.
"I want for national government to know that this diabetes thing is a serious crisis in Liberia," says Ms. Hoff. "We got lot of people that are dying from diabetes because they can't afford to buy the medicine."
Part 1 of this series looked at the growing incidence of NCDs in Liberia. This series is a collaboration with New Narratives with funding from the Swedish Embassy in Liberia. The funder had no say in the story's content.
