On Saturday, the World Health Organization declared Liberia to be Ebola-free, recognizing that there had been no new cases since the end of March. While its neighbors Sierra Leone and Guinea still wrestle with this virologic demon, this is a moment for reflection and cautious optimism in Liberia. The world must ensure that what happened in Liberia never happens again — there, or anywhere.
Only eight months ago, the most tragic scenes were still unfolding in Liberia, one of the three countries hardest hit by the outbreak. Newly built treatment centers sat empty while bodies of the dead, and nearly dead, lay in the streets. Health care workers, lacking necessary equipment to provide safe treatment, were dying at even faster rates than patients. Heath workers in Monrovia, the capital, went on a brief strike in October, demanding higher wages for their perilous work. People fled city centers and rice fields alike, bringing commerce to a halt and threatening the country’s food security.
It was in every way the worst-case scenario for an unprepared and chronically under-resourced health system. And individual lives — while the greatest of all losses — were not the only victims of the disease. Before the outbreak, Liberia had been steadily recovering from 14 years of brutal, back-to-back civil wars, ending in 2003. Since then, Liberia had been making progress toward the United Nations Millennium Development Goals in health. It was the first African country to achieve one of the top goals — reducing child mortality by two-thirds from 1990 levels — in part by doubling rates of childhood immunization. The country also made progress toward other Millennium Development Goals, particularly those focused on reducing deaths from H.I.V., malaria, tuberculosis and pregnancy or childbirth.
But when Ebola struck, the country did not have even the most rudimentary surveillance mechanisms, or enough health care workers. The fragmented health system quickly collapsed.
Certainly, Liberia was not the only place where the epidemic severely challenged the health system. From Sierra Leone to Texas, the public health response was inadequate and uncoordinated.
One of every three dollars invested in development progress is lost when a crisis hits. In this new reality, all facets of the global health system, from local health teams to global organizations, must work in a coordinated way to build a system that doesn’t break under pressure.
A resilient health system combines active surveillance mechanisms, robust health care delivery system and a vigorous response to disease. When the first signs of contagion appear, a system should be able to act quickly to stop it in its tracks — all without compromising its core functions.
Resilience is well understood in fields like biology and engineering. Resilient systems share several characteristics. One is awareness, which in the case of health systems means, first and foremost, strong disease surveillance. A second characteristic is the ability to adapt to changing conditions. We saw this in Nigeria: When Ebola first surfaced, leaders redeployed polio eradication teams to focus on Ebola. With polio “season” over, G.P.S. tracking and contact-tracing were deployed to monitor Ebola, while traditional, religious and community leaders were on the front line raising awareness.
A third characteristic is diversity: the ability to address a broad range of challenges. A good primary care system can help do so and is most feasible in countries that have prioritized universal health coverage, because they are more likely to have health workers, facilities and other capacities that span the country, and services that are affordable and accessible — which can make the difference between life and death at the earliest stages of an outbreak.
Finally, resilient systems are integrated: information is shared across different levels of government. For example, New York City, which in this century alone has experienced a terrorist attack, a blackout, and Superstorm Sandy, prepared for Ebola far in advance of an actual case. With each crisis, the city has enhanced its resilience. So when a volunteer doctor returning from West Africa checked himself in, city leaders quickly mobilized, freely sharing information with the public to explain their Ebola management plan, providing guidance as well as assurances of public safety. This integration allowed for the single case to be successfully treated.
When a resilient system is in place, cities and countries alike are prepared to yield what we call a “resilience dividend” — benefits that are independent of crises. Building trust with the public, enhancing access to quality care, and investing in public health are all wise investments at any time, helping to increase productivity and growth.
Liberia faces new threats in Ebola’s aftermath, including a rise in malnutrition and outbreaks of highly contagious yet preventable diseases, such as whooping cough and measles. It would be easy to slip back into old patterns and treat these challenges as individual problems. But with its ambitious Post-Ebola Health Investment Plan, the Liberian government is focusing on recruiting and training health workers, particularly at the local level; building up infrastructure; and investing in labs needed to quickly detect and identify dangerous diseases as soon as they emerge. Last month, the World Bank announced an additional $650 million toward rebuilding in Liberia, Sierra Leone and Guinea. The United Nations secretary-general, Ban Ki-moon, will hold a conference in July to get countries to pledge even more.
One lesson from Ebola is clear: in a resilient health system, the whole is greater than the sum of its parts. Liberia not only reminds us of the necessity to create such a system, but also can help to show the path forward.
Judith Rodin is the president of the Rockefeller Foundation and author of The Resilience Dividend: Being Strong in a World Where Things Go Wrong. Bernice Dahn is the minister-designate of health for Liberia.