West Africa Recovers From the Shadow of Ebola
By Theodore Ezike
In late 2013, a boy came home with a mysterious ailment. He had hemorrhagic fever, black stool, and severe vomiting. He died two days later, but the disease spread throughout the small village where he lived.
The boy’s disease was not identified as the Ebola virus disease until March 2014, three months after the initial outbreak. By then, 60 people had died and the virus had spread to Sierra Leone and Liberia. By August, over 1,000 individuals had died, and the number doubled the next month, devastating Liberia, Guinea, and Sierra Leone.
This outbreak now had international attention. United States President Barack Obama quickly pledged 3,000 troops to help contain the virus. The Centers for Disease Control mobilized its Emergency Operations Center. The United Nations approved resolutions to create the Mission for Ebola Emergency Response (UNMEER). States and organizations coordinated with each other and the governments of Guinea, Liberia, and Sierra Leone to contain and eliminate the virus. West Africa was not declared Ebola free until May of 2016, almost two years after initial report. According to the WHO Ebola situation report Over 28000 people were reported infected, with 11300 people dying from the Disease. Most were from Guinea, Liberia, and Sierra Leone.
Not since the outbreak of severe acute respiratory syndrome, or SARS, in China a decade earlier have the stakes been so high in global health. Like Ebola, SARS laid bare the failings of regional health care infrastructure. Dr. Yanzhong Huang, a professor of global health at the School of Diplomacy, wrote in a 2003 paper on China’s response to SARS that the Chinese government had learned that “un-even development between the urban and rural areas, and imbalance between economic development and social progress were bound to stumble and fall.”
Because of this, the Chinese Ministry of Health expanded its budget for public health and earmarked 6.8 billion yuan (approximately $850 million) for the construction of a three-tiered network of disease control and prevention, according to the Chinese news website Sina. But many West African countries, consistently among the least developed nations, are not as fortunate to have China’s vast financial resources.
In Sierra Leone, only 9 percent of domestic revenue on average was allocated to health, sanitation, water and education services from 2010 to 2015, according to Dr. Fredline A. M’Cormack-Hale, a professor at the School of Diplomacy who recently spent a sabbatical year in the country. She was not surprised that Ebola had spread the way it did, due to the initial lack of urgency, compounded by a weak health care system.
A crucial problem was that there were not enough health care workers to meet the need, even before Ebola was declared an epidemic. According to the World Health Organization, Africa needs 140 percent more health care workers to meet the international health targets set in the United Nations’ development goals. Training capacity is also inefficient — not only are there not enough doctors, but these countries also are not producing enough health care workers at a rate that will replace those who resign or die. Death of health care workers was a serious issue during the height of the crisis. About 830 contracted the virus, 488 of whom would later die of it.
The facilities in these countries are also lacking. According to Dr. Joanne Liu, the president of Médecins Sans Frontières (known as Doctor Without Borders, or MSF), the largest health center in the region had only 40 beds.
But the state of health care infrastructure in the countries most affected by Ebola has shown change. According to Dr. M’Cormack-Hale, Sierra Leone, Guinea, and Liberia are undertaking aggressive fund-raising efforts for the post-Ebola reconstruction. Specifically, in Sierra Leone, the government has implemented a presidential delivery team with key priorities to get Sierra Leone back on track, broken down into two phases: six to nine months, and 10 to 24 months. Within the 10 to 24 month phase, there are seven priorities — health, education, social protection, private sector recovery, energy, water, and government — that are supposed to yield results by June 2017. The end goal is the “resilient zero,” as Dr. M’Cormack-Hale put it, which means zero cases of Ebola.
A problem that many West African countries face is the retention of talent in the health care profession. A 2013 report by the United Nations Department of Economic and Social Affairs found that one out of nine Africans with a university degree move to developed Western nations. In Liberia, before the Ebola outbreak, there was only one doctor for every 90,000 people.
Dr. Assefaw Bariagaber, an expert in African migration teaching at the School of Diplomacy, said the most obvious answer to West Africa’s hemorrhaging of well-educated citizens would be to pay health care workers more. Walter Gwenigale, the Liberian health minister, echoed Dr. Bariagaber’s sentiment when he told the BBC that “to encourage doctors to take assignments up-country, their pay would be increased to about $1,000 – that’s five times the current average salary.”
But Sierra Leone, Liberia, and Guinea rank as some of the lowest countries in terms of GDP growth in 2016 by the International Monetary Fund — 156, 163, and 175 respectively. Ebola will have a devastating impact on the economies of these countries. West Africa will lose around $3.6 billion in 2017, according to the United Nations Development Program, due to reduced trade and the closing of borders during the epidemic. The UNDP expects fewer airline flights and lower tourism numbers due to the stigma that Ebola has placed on the region.
Unsurprisingly, there has been a significant increase in poverty, even in West African areas not greatly affected by Ebola. Cote d’Ivoire recorded an increase of 0.5 percent in its poverty rate, while Senegal recorded an increase of 1.8 percent in 2014.
Taking advantage of existing local networks would be a cost-effective measure. During the Ebola crisis, village leaders and traditional healers, who are prominent in West African society, played an important role in disseminating information and communicating good practices when dealing with the virus. International organizations like UNICEF during the Ebola crisis engaged with traditional healers like Pa Kombrabai Kabbia from the Port Loko district of Sierra Leone. When people came to consult him about Ebola, he would redirect them to the local medical center for treatment.
During her time in Sierra Leone, Dr. M’Cormack-Hale was part of a team that conducted post-Ebola assessments. Her team found that over 80 percent of respondents could explain how one can become infected with Ebola and what to do about it, indicating that the collaboration between international organizations and community leaders had at least some success.
Besides engaging local leaders, the creation of an early warning system and the development of modern and resilient health care infrastructure are still an indispensable foundation that requires substantial funding. Most of the funding for post-Ebola reconstruction has come from outside West Africa, and Dr. M’Cormack-Hale fears that an overreliance on donor funds may jeopardize the sustainability of the recovery agenda. She cited post-conflict Sierra Leone’s reliance on international aid as precedent.
While post-Ebola recovery has been slow, and Sierra Leone was declared Ebola-free only this June, there are signs of a return to normalcy. Businesses are opening again and commerce is resuming in Guinea. Tourism is returning to the white sand beaches of Sierra Leone. Schools are reopening in Liberia. The process will definitely be slow, but the skeleton of a functional public health system is there. What is needed now is patience and trust that West African leaders will adhere to their own public health agendas without any misappropriation of funds.