liberia-ebolaAt the height of the Ebola crisis in September 2014, Dr. Tom Frieden, the Director of the Centers for Disease Control and Prevention gave a dire warning to the world: “The level of outbreak is beyond anything we’ve seen—or even imagined.” In Liberia, one of the three West African countries hardest hit by the outbreak, the Ebola virus exposed the effects of drastically underdeveloped infrastructure, a sluggish response from the international community, and a society that had never fully recovered from back-to-back civil wars. Ebola infected and ultimately killed nearly 5,000 in Liberia, and more than 11,000 across West Africa, with an average mortality rate of 70%. Now that Liberia has been declared ‘Ebola-free’, it is imperative that the country’s leadership and the rest of West Africa analyze and understand the successes and failures of their Ebola response in order to better prepare for future epidemics.

The degrading effects of epidemics on civil society cannot be understated. A wide-scale health epidemic such as Ebola can leave societal scars that are just as deep as the effects of a civil war, or a natural disaster. These effects are wide reaching and diverse, from degradation of public services, particularly those related to health, large-scale increases in mental health problems, and lack of information or misinformation about the epidemic which can lead to a breakdown in social cohesion. All of these effects have been seen in Liberia, thus making the job of rebuilding and improving Liberian public services and infrastructure much more complex and nuanced.

Mental health services and support have always been acutely lacking throughout West Africa, and in Liberia, which did not have any official mental health policy until 2009, the problem has become particularly critical. The mental trauma that affected so many Liberians as they watched their friends and family members succumb to the gruesome effects of the Ebola virus has left many with PTSD and other mental disorders. This has only deepened the mental health crisis in the country—the 14 year long civil war left nearly half the population with signs of PTSD and depression. With only 166 trained mental health clinicians, most of them nurses with just just six months of training on psycho-social treatment, they face a nearly impossible task. These healthcare workers have to deal with extraordinarily high caseloads, a lack of institutionalized support, and the challenges that come with the extreme stigmatization of mental illness in their communities. While Liberia has focused on improving its emergency and primary care services, mental health issues continue to be stigmatized and ignored. It is unclear how much spending the Liberian Ministry of Health allocates to mental health, but its National Mental Health Policy was approved in 2009 with absolutely no funding. The WHO has not been able to ascertain the country’s mental health budget. Current estimates put mental health spending at less than 1% of the overall healthcare budget. In a country that has been so deeply traumatized by war and disease, this is a major problem that Liberian leadership cannot continue to ignore.

The Ebola outbreak underscored the importance of sharing information and connectivity between the government and its front line health workers. To that end Liberia’s Ministry of Health and Social Welfare implemented mHero, a two-way SMS communication tool that allows the ministry to collect and disseminate information to its healthcare employees on the front lines. The ministry implemented the program specifically to help coordinate the Ebola response effort, but noted in its Investment Plan for Building a Resilient Health System that it would be expanding mHero to fulfill a variety of health information and communications needs.

While these communications issues are being solved among health workers, the government has not found a way to reliably disseminate health information to the wider public and combat misinformation. In a post-Ebola context, there is rampant misinformation and fear of Ebola victims who have recovered from the virus. Those who had Ebola, but are no longer symptomatic, cannot spread the disease and are no longer contagious. Regardless, many Liberians who have returned home from treatment centers are shunned by their communities, have their water shut off for fear of contamination, and are even evicted from their homes.

There are many reasons why it is hard for the government to spread information and combat misinformation – after years of civil war, mistrust in the government is high, and telecommunications systems are weak. However, with an explosion in cell-phone ownership among Liberians, and popular radio DJs who served as a valuable source of information about Ebola during the outbreak, there are many avenues the Liberian health ministry can exploit to disseminate not only accurate, but realistic information. Hh Zaizay, the executive director of the premier civil servant training program in the country recalled that in Monrovia, the capital of Liberia, and home to more than 1 million people, they “had two ambulances to respond to health emergencies. And when the government announced: do not touch the dead, do not touch the sick…call, and an ambulance will come, the question was: where are the ambulances? We have only two.” Health information should aim to keep people safe, but must also be realistic and practical.

Finally, the Liberian healthcare system must further build its capacity so that future epidemics do not impede basic primary care functions. While the initial wave of Ebola in March 2014 could be handled by the existing health infrastructure, once the virus began spreading through dense population centers such as Monrovia, the existing health infrastructures quickly hit their capacity. Liberia’s health systems ceased even the most basic of primary and emergency care, so that those resources could be diverted to fight Ebola. Hospitals and clinics closed as supplies ran out and staff were reassigned to Ebola treatment centers, or more tragically, were infected by the virus themselves.

Many experts have noted that the largest death toll as a result of the Ebola outbreak is likely not the virus itself, but rather all of the other diseases that were no longer being treated because they had been superseded by the Ebola response. Dr. Paul Farmer, co-founder of Partners in Health and a renowned professor at Harvard College, noted that “many of the region’s recent health gains, including a sharp decline in child mortality, have already been reversed,” because general hospital care was no longer available. “Most of Ebola’s victims may well be dying from other causes: women in childbirth, children from diarrhoea, people in road accidents or from trauma of other sorts.” Dr. Jimmy Whitworth, the head of population health at the UK-based health foundation the Wellcome Trust, cites malaria as another cause of death that might exceed Ebola because Liberia’s general health system became merely an Ebola treatment system, “there will be lots of excess malaria deaths occurring because of this, and they will simply go undocumented and unremarked because patients aren’t getting into health systems. I’d expect there would be far more [excess] people dying from malaria than from Ebola.”

HIV/AIDS is another area in which treatment ground to a halt as a result of the Ebola outbreak. The National AIDS Control Program of Liberia, which had to cease its HIV treatment program for two months during the outbreak, has not been able to contact more than 2,000 HIV patients that were on its rosters. Program manager Sonpon Blamo Sieh reported that before the Ebola outbreak “we had a total of 8,865 patients, can you imagine? So we lost almost pretty close to two thousand-plus patients then during the Ebola [epidemic] because people were not accessing services,” It remains unclear if these patients have died, or went elsewhere for treatment.

Now that Liberia has defeated the Ebola virus, and general health services that were shuttered by the Ebola response have been restarted, Liberia faces a long road ahead. Little has been done to even begin addressing the mental health crisis in the country. While communication among healthcare workers is being improved, there must be a clear plan to communicate vital health information to the public, particularly during crises. Most fundamentally, Liberia must build capacity in its health system. Basic health services must be able to continue operating even during extraordinary events, because Ebola will certainly not be the last pandemic to affect West Africa.