Ebola and the Health Care Crisis in Liberia

The Ebola disease seems to be out of control in Liberia. Media outlets recount the horrific litany of death, disease, and more death. The horror has given rise to the cautionary song, Ebola in Town: “Something happen/something in town/ Ebola in town. Don’t touch your friend, No kissing, no eating something, it’s dangerous”—and the remedy seem to strike at the heart of Liberia’s communal culture—“I Know the medicine/Distant hugging/I say Distant shaking/Distant kissing, Don’t touch me/ Ebola in town.”

Cherise Udell writes that “arguably, one of the best ways to (address rumors and conspiracy theories) is to treat people with the respect they deserve, whether urban or rural, educated or uneducated.” This is what is missing from the Ebola narrative in Liberia. Journalists and many others within the country react with amazement as family members demand the infected bodies of loved ones, and newspaper outlets and discussion groups recoil with revulsion when relatives retrieve the ill from containment centers to care for them at home. Centuries-old beliefs of the dead watching over the living are being burnt in crematoria along with the bodies of loved ones, giving death a finality that had not existed. Cultures with long-established practices of communal caring for the sick are suddenly adrift, their established beliefs fractured by an invisible enemy. While outsiders may think that their actions are illogical, those within these cultures cling to their surety, whatever the cost. Liberians in the diaspora view daily reports of the disease and the various reactions by their fellow citizens at home, they understand the realities from which these responses spring. The Union of Liberian Associations in the Americas (ULAA) resolution on the Ebola crisis called on Liberians everywhere to join together, “aware and realizing the difficult experiences of our national existence as a Republic . . . that all Liberians are one people indivisible and of a common destiny.”

The disease has also brought to the fore the deep inequalities within society and the deep distrust of the government. Many Liberians have been consigned to watching “democracy” from the sidelines, spectators rather than players in a game that should be inclusive. “If the forum is not fully open, then those who control access become gatekeepers. . . . When only those who have wealth can afford to enter the principal forum in which the majority of people receive their information, then those who can pay the price of admission automatically become more influential" (Al Gore, The Assault on Reason, 75). Years of being spectators have made most Liberians deeply distrustful of the messenger (the government), and if the messenger cannot be trusted, the message cannot be believed. Many Liberians see the Ebola crisis as made up by the government to receive more donor aid, to be shared amongst those high up in the government.

While perhaps nothing could have halted the Ebola virus from entering West Africa, lack of education, marginalization, and a weak health care system has provided fertile soil. The 2007 Demographic and Health Survey, which covered 2002–2006, listed an infant mortality rate of 71 deaths per 1,000 live births. Only 39 percent of children under the age of two had received their recommended immunizations and approximately 1.5 percent of the 15–49 age group tested positive for HIV by 2007. Tuberculosis rates in Liberia are 518 per 100,000, according to the World Health Organization (WHO).

The health sector falls under the Poverty Reduction Strategy (PRS) and the priority areas listed in the 2007 National Health Plan (NHP) included health service delivery, human resources, infrastructure and support systems. But written policies are not material realities; Liberia’s health care system is virtually nonexistent, short on drugs, equipment, and personnel. Most people depend on NGOs for basic services. Non-governmental organizations (NGOs) manage three-fourths of government-owned health facilities with funding from emergency donors. “We don’t want the population to associate peace with lack of services. We need NGOs to continue service delivery” (Walter T. Gwenigale M.D., Minister of Health and Social Welfare, Liberia Health Sector Partnership Forum Report, Washington D.C., 2007, MOHSW). The government dependence on the NGO sector for basic health services showed how woefully inadequate and unprepared the country is for a major health crisis, as is now being seen.

Although the percentage of government spending for health care is increasing, the system remains overwhelmed, inconsistent, and inadequate. Health care and education have always taken a back seat to other “pressing” national concerns. In the 2012–2013 Liberian budget of $672 million, the Office of the President was allocated $31 million and the legislature $34 million. The Ministry of Education, one of the most needed sectors in the country, was cut by $2.774 million, from $45.73 million to $42.96 million. In Nimba County, Liberia’s second largest in terms of population, the percentage of primary schools without access to water is 49 percent and those without toilet facilities 34 percent (Liberia Education Statistics). The Liberian-based Concerned Citizens of Nimba County noted that in the 2012–2013 budget allocation, the Zekeh Health Center, the Kwendin Health Center, the Graie Health Center, and the Toweh Town Health Center all lost their government funding, (which in past years was very meager) as did the Zekeh Memorial High school, the Kwendin Vocational Training Center, and other educational institutions in the county.

What is missing is the multidimensional aspect of the health delivery system. Health care and health delivery is currently seen as separate from the everyday sanitary needs of the country. Keeping the streets of Monrovia clean should not be a power play between the mayor and the members of the legislature; alleyways should not be used as bathrooms and drainage systems as waste baskets. Rules of cleanliness must be enforced and real punishment meted out to those who disobey. Broader development areas must be made to work together to have a functional health system. Roads must be built and those that already exist must be made accessible to towns and villages where needed medical and other health supplies can be delivered; there must be emphasis on health education in the K–12 curriculum and daily attention to personal hygiene (including functioning lavatories) in schools; and there must be committed government focus on health care and education. It is not surprising that the government seems unable to cope with a health crisis of this magnitude or that some Liberians see this as a ruse for more donor funds. The government needs to integrate health care and health care delivery into all areas of national development to ensure the health and security of the nation and it must build credibility and credible institutions to combat the deep distrust of its citizens.

Cover image: John Moore / Getty