Ebola's Long Shadow

The Wall Street Journal
By Betsey McKay
June 04, 2015

(Click here to view the original article.)

HARPER, Liberia—J.J. Dossen Memorial Hospital, on the southeastern tip of this nation recently declared free of Ebola, has three doctors and spotty electricity. Sixteen of its 46 nurses left during the Ebola crisis. When two motorcycle accident victims needed X-rays, the hospital dispatched them in its only ambulance on a bumpy eight-hour ride to the nearest facility with a machine.

The deadly disease may have receded, but it is still exacting a heavy toll. Run-down, poorly staffed and equipped health facilities allowed Ebola to explode. Since it was identified in early 2014, the epidemic has claimed the lives of 507 health-care workers in three West African countries, all of which already were short of medical professionals. The health-care system was so overwhelmed with Ebola victims that many other patients couldn’t receive care for malaria, heart disease or pregnancy complications. That bill is coming due. “There are more people who are going to die from Ebola, but not have Ebola,” says Paul Farmer, a Harvard professor and co-founder of the Boston-based charity Partners in Health.

Now, as the virus ebbs, the governments of Liberia, Sierra Leone, and Guinea—racked for years by civil wars, coups, and unrest—are joining forces to heal from the crisis. Working with foreign donors, they see an opportunity to remake health care in one of the poorest corners of the world, where more than 27,181 people have been sickened with Ebola and more than 11,162 have died. Better health systems will save more lives here and prevent future outbreaks that could spread around the world, they say.

But the decaying state of J.J. Dossen and dozens of other facilities like it illustrate the monumental task ahead.

Dr. Farmer is immersed in the challenge. Eventually, he hopes to see a gleaming new hospital in Liberia where patients are treated for Ebola or other diseases by specialists using state-of-the-art equipment. A Harvard Medical School professor, physician and anthropologist, Dr. Farmer envisions nothing less than “a world-class teaching hospital.”

High hopes

Across the globe, hopes run high for such a turnaround. The U.S. government, Unicef, World Health Organization and others have efforts under way. But among the various nonprofits working to boost health care in the region, Boston-based Partners in Health has one of the most comprehensive plans. Dr. Farmer insists that the only way to ensure that West Africa sees lasting improvements is to collaborate directly with government and community groups that can in turn strengthen local institutions.

To that end, Partners in Health is working with Liberia and Sierra Leone to upgrade or build new facilities. The health systems of those two countries, and neighboring Guinea, were among the weakest in the world—even before the worst Ebola epidemic in history struck. The nonprofit, funded by private donors, governments, and development agencies, is relying on its deep experience in bringing better care to the poor and disenfranchised. In earthquake-battered Haiti, for example, it built a 300-bed, solar-powered public teaching hospital at the request of the government in 2013. In Rwanda, scarred by genocide in the 1990s, it built a medical facility in a rural area. But shiny new medical centers take years to build. Meanwhile, Partners in Health is putting out smaller fires. Among other things, it is fixing the plumbing, electricity and a leaky roof over an inpatient ward at J.J. Dossen, a 14-hour drive from the capital city of Monrovia. The charity is also restocking medicines and helping nursing students from the local university prepare for licensing exams that were postponed during Ebola.

As a part of a government effort to upgrade several teaching hospitals by 2021, Partners in Health is also crafting plans to modernize the hospital, which serves a regional population of 350,000. It is bringing in clinicians to train staff, and working with nearby William V.S. Tubman University to create new teaching methods.

The reinforcements are crucial. After months of Ebola-related quarantines and canceled school days, the number of pregnant girls here is on the rise. At the same time, Ebola survivors are struggling with aftereffects ranging from blindness to depression. Measles and whooping cough outbreaks also sprouted, because the Ebola crisis cut off many childhood vaccination programs. According to local obstetricians and clinicians, more women are dying in childbirth in Sierra Leone and Liberia, which already had soaring maternal mortality rates.

“Our health infrastructure was not designed to cope with the kind of outbreak that we had,” acknowledges Bernice Dahn, Liberia’s minister of health. While the country had a system in place to keep tabs on more common diseases, like malaria, Ebola wasn’t one of them, she says.

Before the Ebola epidemic, many West African hospitals didn’t train health workers how to prevent the spread of infectious diseases, says Benjamin Park, senior adviser for international health-care quality at the U.S. Centers for Disease Control and Prevention. Now, facilities are appointing staff specifically for that purpose. The CDC is helping Ebola-affected countries strengthen disease surveillance and laboratory capacity, among other initiatives.

Finding the staff and resources to manage all these issues is no small problem. Liberia has just one medical school, and 117 doctors in its public health-care system. Redemption Hospital, one of the largest facilities in the capital of Monrovia and an epicenter of that city’s Ebola outbreak, lost its head surgeon, as well as 11 other doctors and nurses, to the virus.

“We need human resources,” says Dominic Rennie, administrator of the hospital, which he says is now treating a steady stream of patients with malaria, acute respiratory infections, and tuberculosis.

Doctors hard to attract

And yet in this troubled climate, some health professionals say attracting the next generation is difficult. Odell Kumeh’s medical studies were interrupted by Liberia’s 14-year civil war and its ripple effects. After she earned her degree, over an eight-year period, she made the equivalent of $85 a month. Today, she has a salary of $1,647 a month as the county health officer for Maryland County, which J.J. Dossen serves. “It’s not attractive to be a doctor,” says Dr. Kumeh. “At the end of the day, you get little money.”

Complicating matters further, millions of dollars in current foreign aid are still designated for emergency purposes only, such as building makeshift triage units for Ebola screening. “There’s a need to transition the funding to support routine health-care services and to strengthen the health systems,” says Dr. Dahn.

Liberia, Guinea and Sierra Leone estimate they will need $1.47 billion over the next 2½ years to expand and modernize their health-care systems. The funds are part of $8 billion over 10 years that the countries are seeking for post-Ebola recovery.

But most funding will have to come from foreign donors, say the countries, which are reeling from economic losses due to Ebola. The World Bank and other big donors have pledged roughly $1 billion so far for Ebola recovery, including building stronger health systems; the United Nations is convening a special meeting in July to attempt to raise more.

To remake hospitals like J.J. Dossen, Partners in Health has imported to West Africa veterans of its operations in Haiti and Rwanda, a country that it touts as a model for channeling the majority of its international aid through government institutions, and for sharply reducing rates of premature death since 2000.

By contrast, less than 1% of humanitarian aid to Haiti in the first three years after the 2010 earthquake was invested in national systems, according to the United Nations.

“We can’t afford to let this happen again,” says Dr. Farmer. “The question is, how many years does it take?”

Meeting recently with A.P. Koroma, medical superintendent of Princess Christian Maternity Hospital in Freetown, Sierra Leone, Dr. Farmer explains how Rwanda trained specialists in obstetrics and gynecology. Then he grabs a laptop and shows the doctor images of the public-teaching hospital that Partners in Health built in Mirebalais, Haiti. “This is what it looks like,” he says, pointing to the screen. Dr. Koroma listens intently. He is one of his country’s few obstetricians. Yet he has many other responsibilities. On his to-do list: procure fuel for ambulances and electrical generators, solve waste disposal problems and find more staff. “I should not be like a hospital manager,” he says.

As the two talk about the future, the reality of the day encroaches: The lights in his office flicker; the electricity goes off. By now, Dr. Farmer is inured to setbacks of this kind—and those much bigger. He says he is under no illusions about the difficulties that lay ahead in West Africa, having worked through coups in Haiti, fallout from the collapse of the Soviet Union, and in Peru, “where our first project was pipe bombed.”

“I have no experience of not having a rough time in 30 years of doing this,” he says. “None. Never once.”

In Haiti, it took $25 million of private donations and just under three years to build and open University Hospital, which the government now helps to fund and run. Its operating rooms, large by U.S. standards, have cameras to help veteran surgeons train those with lesser experience.

The hospital couldn’t offer all its services when it opened in 2013, because staff weren’t trained for more complex procedures. Two years later, though, it provides care to more than 700 outpatients daily, and trains medical residents in surgery, pediatrics and other specialties. Last month, surgeons successfully separated conjoined twin baby girls.

“If we can’t build a proper teaching hospital like the one in Mirebalais in Liberia, then we’ve failed,” Dr. Farmer says.

At J.J. Dossen, Partners in Health plans to modernize maternal and child care, surgery, and other services, says Cate Oswald, the charity’s partnerships and policy director for Liberia and a former program director in Haiti. Among other efforts there, it is training health workers to care for HIV and tuberculosis outpatients in their communities.

Named for an early 20th-century Liberian politician and jurist, J.J. Dossen is filled now with patients suffering from diseases rarely seen in the U.S.: a baby with malaria, a 33-year-old woman covered with lesions from Kaposi’s sarcoma, a disease brought on by AIDS, and a 15-year-old girl suffering from spinal tuberculosis.

Ebola, however, is hardly forgotten. At the entrance to the hospital, a nurse diligently quizzes arriving visitors about symptoms and takes their temperatures. Anyone with a fever is pulled aside for further questioning. Meanwhile, people come and go freely through gaping holes in a chain-link fence encircling the hospital. Partners in Health and the hospital are working on replacing the fence. The hospital is still worried about performing tests for Ebola, particularly during the rainy season; the nearest lab that can test for it is at least eight hours away, says Dr. Kumeh.

A half-hour away, down a bumpy road in the town of Pleebo, four pregnant women sit along a dark hallway at a clinic. An 18 year-old lies on a bed around the corner in labor. Habibatu Alu, a midwife, says she feared Ebola last fall, particularly because symptoms of labor and its complications often mimic those of Ebola.

“Now we have protective equipment and gloves,” she says. ”Even though the fear is there, it’s not like before.”

But the clinic lacks just about everything else, such as regular electricity or ultrasound machines.

“These women are in mortal peril,” Dr. Farmer says, bumping along a dirt road in a jeep toward a new clinic that had been partially built a few years ago before funding ran dry, and that Partners in Health is finishing. “There’s no safe place for them to deliver.”

The charity also has its work cut out for it in Port Loko, Sierra Leone, where it arrived in November to help the government run an Ebola treatment center it had set up in a trade-school building. The area was an epicenter of a surge in Ebola then, and the disease is still circulating there.

The CDC, with the World Health Organization, investigated both facilities in March after a young American clinician working for Partners in Health and a Sierra Leonean health worker contracted Ebola. They found infrastructure and safety problems at both, including lax Ebola screening measures at the hospital, dirty wards, and debris on its grounds.

The treatment center, already near empty, closed. Partners in Health is making safety improvements to the hospital and upgrading services.

Oddly enough, West Africa may have missed a chance to develop Ebola expertise two decades ago, says Tabeh Freeman, a professor of public health at Tubman University. In 1995, a young Liberian man from Pleebo developed Ebola symptoms, says Dr. Freeman, who was working for the WHO at the time and helped investigate the case. A test confirmed he had Ebola, according to a WHO report at the time. The man had been in Ivory Coast, where there had been another Ebola case, Dr. Freeman says.

Concerned, Liberia and Ivory Coast decided to set up a system along their common border to detect epidemic diseases, using $50,000 in funds from a U.N. agency, says Dr. Freeman. But Liberia’s civil war interrupted those plans and they were never restarted. “Fighting escalated and we couldn’t access Maryland County,” he says.

The consequences remain with Liberia today, he says. “If we were to have another round of Ebola or another epidemic, are we prepared to cope with that epidemic with such a weak health system?” he says. “My answer is no