LEARNING FROM THE EBOLA CRISIS

By Charles W. Brumskine

I would like to commend Hon. Tolbert Nyenswah, Assistant Health Minister for Preventive Services at the Ministry of Health and Social Welfare, for the professional manner in which he has served the nation during this Ebola virus crisis. And I concur with his statement of Monday, November 3, 2014, warning Liberians against complacency, which could have the propensity to overturn the apparent gain in the nation’s fight against the Ebola virus disease. Learning from the health crisis over the last eight months in particular, and the last eight years in general, the Government should begin a public health campaign in earnest, to save the people from the reemergence of the spread of the deadly Ebola virus and other infectious diseases.

At this point in the Ebola crisis it might be a good time to do some reflection in an effort to draw lessons for the future. Why, for example, have more than 2,500 (official statistics) of our loved ones, relatives, and friends died from the Ebola virus disease in Liberia, while only nine died in Nigeria and one in Senegal? Liberia has a population of about 4 million; Nigeria’s population is about 174 million, while Senegal’s is about 14 million. Notwithstanding, about 57% of all the Ebola virus-related deaths from the current outbreak are in Liberia. On August 14, 2014, Blair Glencorse and Brooks Harmon wrote that the “… Ebola outbreak isn't just a health care problem. It's also about a crisis of governance.” Their article, “The Cure for Ebola Is Accountability,” further stated that, “There is a clear link between this governance failure and the current health crisis. In places where governments are so rarely willing or able to act in the interests of their citizens, we can begin to understand why the disease continues to spread.”

Today, no country wants to see a Liberian passport holder or an entry stamp from Liberia in any passport coming through their airports. Politicians around the world want to ban all travel to our homeland and quarantine anyone who would dare travel from Liberia, because we are all supposedly infected with the deadly Ebola virus disease.

Why is Liberia’s Ebola virus-related death to population ratio so high? Was it because of the condition of Liberia’s healthcare system prior to the Ebola outbreak? Was it because the Government made no attempt initially to contain the virus? Was the Government’s Ebola control message wrong and too late, or was it simply a matter of the people’s lack of trust in the Government? Was it because of our cultural practices? Or, was it because the Government was waiting for the international community to step in to help, providing some of the basic services that the Government should have been in the position to make available to its people at the onset of the outbreak?

An easy and less controversial response to such questions could be, “All of the above.” But whether or not one assigns a specific reason for what has obtained in Liberia since March, when Liberia experienced that first case of Ebola, the bottom line is that the loss of lives, pain, and suffering that the mishandling of the Ebola crisis has caused the people is the result of a colossal failure of leadership. The impact on our country of the mismanagement of the Ebola virus outbreak — on the economy, set back in the health sector, and the loss of class room hours for yet another generation of young Liberians, just to mention a few, are yet to be determined.

But while it may be too late to pontificate on what President Sirleaf and her government could and should have done, it is not too early to consider how to prevent Ebola from becoming endemic or how we might prevent the spread of other deadly diseases that might arise in the future. A good place to begin is for the Liberian Government to now catalogue lessons to be learned from this Ebola national nightmare.  So, what can the Government learn?  Here are a few areas for consideration:

Broader Definition of Health. First, Liberia must embrace a broader definition of health. Government programs must focus on the true causes of ill health such as poverty, poor nutrition, inadequate housing, and unsafe drinking water, among other things. This approach to health results in global as well as individual outcomes.

Before the Ebola virus outbreak, about 43 percent of mortality in Liberia was attributable to malaria, typhoid, and dysentery, which are easily preventable and/or treatable for pennies on the dollar. Preventive health measures, safe drinking water, and improved sanitation are less costly and more effective measures for maintaining a safe and healthy population than their curative counterparts.  Furthermore, instead of waiting for handouts from our friends in the international community, the Government should place emphasis on improving preventive measures as well as educating the people through the community health posts about preventive measures that they can take.

The Government can also learn the true meaning of the rule of law. While avoiding illegal arrests, detentions, and floggings are a part of the lessons to be learned, the Public Health Law of Liberia has ample provisions relating to public health emergencies. The Public Health Law mandates that whenever any part of the Republic appears to be threatened by any formidable epidemic, endemic or communicable disease, the Minister of Health should declare such part an infected area and should make rules to safeguard the public health, which may include preventing any person from leaving and re-entering infected areas. And any person who has been exposed to the infection of and may be in the incubation stage of any communicable disease, and is not being accommodated in a manner to adequately guard against the spread of the disease, that person may be removed to a place of isolation and there detained until s/he is free from infection or able to be discharged without danger to the public health. But the Government decided to ignore the law, and sat around helplessly until the deadly virus had spread throughout the nation. When the Government declared its State of Emergency, five months after the first Ebola virus case, many had already died, and the disease was widespread.

Plan to Delegate. Next, the Government should also learn from this terrible period of our national life to delegate the responsibility for health and sanitation service delivery to local government, requiring the state to build capacity at county and district levels, and to allocate more resources to this purpose. The current “decentralization strategy” of the Ministry of Health and Social Welfare is merely an outplacement of service, because the Minister retains control of every local activity. 

If the resources cannot be generated domestically or mobilized to rehabilitate and upgrade community health posts, the Government should invest in mobile clinics—purchase vans or twin-cab pickups, equip each with medical equipment, and staff each with a physician assistant, a nurse and a lab technician. The mobile clinics will be charged with providing public health education about Ebola, HIV/AIDS and other diseases, and basic medical care to combat curable ailments such as malaria, diarrhea diseases; dressings for wounds, monitoring rural pregnant women and young children for anemia, performing antenatal examinations, monitoring and referral of pregnant women with antenatal problems, and providing basic health, sanitation and nutrition education.

Of course, Liberia needs to train more health workers and pay better salaries and benefits in order to retain healthcare professionals and to attract others to the profession. On health and social welfare, prior to the Ebola outbreak, the Government spent approximately $15.10, per annum, for each Liberian (per capita). Of the $55.9 million proposed for the health sector in the 2012/2013 budget, more than half--$29.3 million or 52% went to staff salaries, fuel, vehicles, and general and special allowances. While the nation begs for help, the Government has spent about US$64 million for foreign travel and reimbursements since 2006.

Better allocation and proper management of public funds would allow increase spending on health, education, and social development services, infrastructure and basic services for the Liberian people. More efficient use of the existing and increased allocation of public funds will reduce the overall disease burden, allowing healthy families to spend more time at school and/or doing what they need to do to survive. Certainly, the use of resources in a transparent and accountable manner would have prevented the rapid spread of the Ebola virus disease.

Government blames the Civil War that ended eleven years ago for Liberia not having gloves, surgical masks, gowns, and other personal protection equipment in the hospitals, which has resulted in the death of doctors, nurses, and other health workers, who attended patients with the Ebola virus disease. The Civil War is blamed for Liberia having one doctor for about every 86,275 persons in the country. The Civil War is blamed for fourteen of Liberia’s fifteen counties not having an ambulance that would have safely transported Ebola infected patients. But the Civil War can no more be blamed for Liberia’s current woes, than the fall of Adam and Eve can be blamed for the Civil War. Neither can be said to be the proximate cause of the other; the intervening and superseding circumstances are evident.

Develop Robust Disease Surveillance System. Finally, the Liberian Government should recognize the critical need for a more robust disease surveillance system and empower the County Health Teams (CHT) and Community Health Workers (CHW) to be effective first responders. Any future disease outbreak, and there might be others, can then be locally managed with support from central government to ensure it does not become as widespread as the Ebola contagion. 

Liberia has many national problems begging for solution, but from the perspective of national leadership, here are three common postures:

1. Firstly, our national leaders live in a state of perpetual denial;
2. Secondly, our national leaders have adopted the posture that admitting missteps is a sign of weakness; and,
3. Thirdly, every utterance that is in opposition to a Government’s policy or action is viewed as either partisan or an outright unpatriotic betrayal of the state—in the mind of those holding government positions or otherwise benefiting from unholy grafts, there is nothing nationalistic or patriotic about an opposing point of view. The preference for a common position, “so says one, so says all,” obviates the need for tolerance of alternative views!

As a result, democracy continues to elude Liberia, as our nation stumbles through recurrent crises; we move from one botched opportunity to another, awaiting the next crisis.

The Government has learned not to be proactive; its modus operandi is to expect and await assistance from and depend on the benevolence of the international community. And when the assistance of the international community is forthcoming, the Government does not seem to have a national agenda. And Liberia’s national leaders rarely take responsibility for their actions or the lack thereof.  Malfeasance, misfeasance, and nonfeasance may abound, but how often do our national leaders stop to say, “I am sorry” or at least, “I regret the mishaps”? Instead, it is always someone else’s fault. Would someone be sanctioned for the terrible handling of the Ebola virus crisis? Most likely not!

But instead of using the Civil War, anything it can imagine, and everyone else, as an excuse for its non-performance, the Government could learn a lesson or two from Paul Kagame and the Rwanda recovery story. Of course, it is all about national leadership with a vision for the country, and a passion for improving the lives of the Liberian people!