Ebola: What We Need to Know About Liberia
Much of the world community, and many of you reading this health column, should be applauded for the generous outpouring on interest, concern, support, and well wishes, in response to the growing Ebola crisis.
While the terrifying spread of Ebola has captured the world’s attention, it also has produced a lesser-known crisis: the near-collapse of the already fragile health-care system in Liberia, a development that may be as dangerous – for now – as the virus for the average Liberian.
Unfortunately, clear understandings of the real social and economic conditions of Liberia are unknown to those who are now concerned, and compelled to act.
We know, all too well, about the ongoing death and sickness brought on by the ever-growing spread of the Ebola virus. But, very little about the country itself, and why it has the distinction of being the epicenter of Ebola.
Contrary to common belief, Liberia was not really founded by freed slaves. Of the nearly 100 settlers first dispatched in 1820 to West Africa’s shores, not a one had been a slave. They were free black men, women, and children, largely from New York and Pennsylvania. The first of the thousands that followed them were mostly free, too.
In 1816, some of US President George Washington’s most powerful movers and shakers gathered at a popular watering hole to found the American Colonization Society: Its mission was to transplant the country’s 200,000-plus free blacks to West Africa. Today, we would call it ethnic cleansing. To meeting chairman Henry Clay, who as U.S. speaker of the House was the second-most-powerful politician in the country, it was enlightened benevolence: “Can there be a nobler cause than that which, whilst it proposed to rid our country of a useless and pernicious, if not dangerous portion of its population, contemplates the spreading of the arts of civilized life, and the possible redemption from ignorance and barbarism of a benighted quarter of the globe?” (That is, Africa.)
Liberia, one of the world’s least developed nations, has poor Internet and telecommunications, and only around 50 doctors for a population of over 4 million. Traditional funerals, where family members bathe and dress highly contagious corpses, have expedited Ebola’s spread to 9 of the country’s 15 counties.
Reaching the sick in isolated villages there is critical because the county’s main Foya health center is full. U.S. charity Samaritan’s Purse ran the site until it pulled out after two of its health workers contracted the virus in Monrovia.
Medical charity Doctor’s Without Borders, which has now stepped in, says 137 patients are packed into the 40-bed site.
The outbreak has crippled Liberia’s economy. Its neighbors have sealed their borders and shipping has all but ceased, causing food and gas prices to skyrocket. Schools and businesses have closed down, and the country’s already meager health care system has been taxed to the breaking point. Meanwhile, as panic grips the country, crime has risen steadily and some reports suggest that Liberia’s security forces are among the perpetrators.
When the epidemic struck Liberia, a number of hospitals closed, often because their staffs had fled in fear. Adding to the problem, Ebola’s symptoms mimic other, still common diseases, but treating anything that resembles Ebola necessitates protective gear that’s not always available outside the quarantine centers. That means that many people who are suffering non-Ebola illnesses are going untreated.
Western experts said that people in Liberia are dying of preventable or treatable conditions such as malaria, diarrhea, pneumonia and the effects of high blood pressure and diabetes, such as strokes. Where services do exist, Ebola has complicated the effort to provide them by stoking fear among health-care workers, who sometimes turn away sick people or women in labor if they can’t determine whether the patient is infected. And some people, health-care workers said, will not seek care, fearful that they will become infected with Ebola at a clinic or hospital.
Liberia’s 14-year civil war, which ended in 2003, destroyed communities and their ability to meet their own health needs. People were left with poor living conditions, little access to education and jobs, and facing multiple diseases, some of which are preventable.
Before it spread to Monrovia, Ebola struck in Lofa County, Liberia’s rice-producing center. Many farmers avoided their fields, severely hurting domestic food production. Food imports (the country imports about two-thirds of its grain supply) have also been hampered because of the crisis. Borders with neighboring countries have been closed, and shipping companies have avoided the nation’s ports. All of that has led to the biggest increases in food prices since the nation’s civil war, which ended in 2003. In a country where 84 percent of everyone lived on less than $1.25 per day in 2011, this shock has become its own crisis. 45 % of Liberian children under age five chronically or acutely malnourished. 
The Liberia malaria indicator survey 2009 also found that 43% of households have access to an improved sanitary facility, while significant rural/urban disparities exist. Improved sanitation is available to 63% of urban households but only 27% of rural households.
Significant percentages of Liberians have little or no education, with females being less educated than males. A total of 42% of women and 18% of men have never attended school. While 19% of men have completed secondary school or higher, only 8% of women have accomplished the same. For both women and men, urban residents are better educated than rural residents.
Access to health care is a major determinant of health. The National population and housing census, 2008 reported that 40% of all households travel 1 hour or more to the nearest health facility. This figure represents over two thirds of households in rural areas.
According to the Core Welfare Indicator Questionnaire 2007, 63.8% of Liberians live below the poverty line. In absolute terms, the proportion of population living below poverty line – those living on less than US$ 1 a day – is 1.7 million, with 48% (1.3 million people) living in extreme poverty. The level of poverty in rural area (67.7%) is higher than that in urban areas (55%).
Considerable amounts of the population suffer from mental illnesses or were mentally or physically traumatized. This was due to 14 year of intense civil conflict. For the next 14 years—aside from a brief hiatus of troubled peace in the late 1990s—Liberia was torn by a civil war so brutal it beggars the imagination: teenagers forced to kill their parents to prove allegiance to this warlord or that, once-respected elders ordered by soldiers young enough to be their grandchildren to “give me six feet,” meaning dig their own graves.
A study by the American Medical Association (AMA) in 2008 had showed that a staggering 40% of adults had shown symptoms of major depressive disorders. 44% of adults also had symptoms of PTSD, or post-traumatic stress disorder. There was only one psychiatrist in the country at the time. It is impossible for 1 psychiatrist to be able to tend to over 1 million victims. In addition, E. S. Grant Mental Health Hospital was the only hospital for patients with mental illness. The hospital only had 80 beds, which left almost all those with traumatization unattended for.
The main illness cited is fever/malaria, which accounts for more than 60 percent of the episodes of illness. Next is pain in a person’s back, limbs, or joints, accounting for 15.8 percent of episodes. Diarrhea and abdominal pain accounts for 13.5 percent of episodes, followed by cough and breathing difficulties, for 9.8 percent of episodes.
Some 41.7 percent of the population does not take any measures to prevent Malaria.
Liberia has 5,000 full-time or part-time health workers and 51 Liberian doctors to cater to a population of 3.8 million, according to the 2006 health survey. That is equivalent to about 76,000 civilians being attended to by 1 doctor. Most of the hospitals, clinics and equipment were destroyed due to its 14 years of civil conflict from 1989 all the way until 2003.
Liberians were already struggling with the everyday grind of poverty and the devastation of the recent civil war when the Ebola epidemic struck. They are reacting with a mix of fear and a sort of weary determination that this is yet another crisis to overcome. Liberia alone won’t be able to stop the outbreak from spiraling out of control. It is going to take a combined effort of governments, non-governmental organizations, multilateral organizations, and the private sector coming together to support Liberians and halt this epidemic. And once that is accomplished, it is going to take an even greater — and much more sustained effort — to restore and improve the health system of Liberia so that it doesn’t happen again.
And now this—a mass epidemic of a most terrifying disease that appears to have no end in sight. International health officials predict that, even with America’s aid, the disease is likely to infect tens of thousands of Liberians in the coming weeks and months. We cannot do enough for Liberia – our African stepchild – in its moment of need. When those pioneers from America settled Liberia and established it as Africa’s first republic; they modeled its institutions after our own. If we are true to our values and obligations, we will not abandon Liberia again once the current crisis has passed.
Think this is not a “health column”? Let me leave you with this”:
“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”
-World Health Organization-