THINK AGAIN: Why did Liberia beat Ebola before Guinea or Sierra Leone?

Liberia's response to the Ebola outbreak was far from perfect, but it showed that medical emergencies must also be seen as crises of governance.

On 9 May, the World Health Organisation (WHO) made a remarkable announcement. After 14 months and 4 573 deaths, Liberia was formally declared to be free from Ebola.

The announcement came after Liberia successfully – albeit nervously – waited 42 days without any new cases.

‘Interruption of transmission is a monumental achievement for a country that reported the highest number of deaths in the largest, longest and most complex outbreak since Ebola first emerged in 1976. At the peak of transmission, which occurred during August and September 2014, the country was reporting from 300 to 400 new cases every week,’ said the WHO in a statement.

Although she marked the occasion, Liberian President Ellen Johnson Sirleaf’s celebrations were muted. She’s well aware that while the virus may have been defeated – for now – her country will be dealing with the consequences of the outbreak for many years to come. ‘The pain and grief will take a generation to heal,’ she said.

So too will the damage caused to Liberia’s economy, which slowed dramatically during the outbreak and shows no signs of recovering anytime soon; and the devastation caused to an already-weak public health system. (It’s important to remember that in the rush to contain Ebola, other diseases such as malaria and tuberculosis were largely ignored, leading to thousands of additional deaths).

These are failures of governance, for which each country has been made to pay dearly

As Liberia begins to contemplate its difficult post-Ebola future, Guinea and neighbouring Sierra Leone are still in the midst of the epidemic. In the latest available statistics, both countries reported nine new cases in the week that ended 3 May. Encouragingly, this is the lowest weekly total so far this year – but eradicating the virus is still a long way off.

This begs the question: what did Liberia do differently? Why is Liberia – once the hardest hit – now Ebola-free, while Guinea and Sierra Leone are still struggling? The WHO identifies four factors that contributed to Liberia’s successful response. First is the decisive leadership shown by Sirleaf, who was relatively quick to identify the scale of the threat posed by Ebola and made the response a priority for her government.

Second is the effective community engagement practised by health officials, involving traditional structures in monitoring and reporting and responding to community concerns (for instance, replacing solid walls at treatment centres with see-through walls to dispel malicious rumours).

Third is the support from the international community, including financial, logistical and human resources. Fourth is the coordination of the international and national response, with a special mention for the Presidential Advisory Committee on Ebola established by Sirleaf.

The Liberian government was transparent about Ebola from the beginning and accepted its limitations

It is telling, however, that the WHO reserves some of its highest praise for Sirleaf. ‘Her swift and sometimes tough decisions, frequent public communications, and presence at outbreak sites were expressions of this leadership,’ it said. (It’s worth noting that, Nobel Peace Prize aside, international praise for Sirleaf hasn’t always been so generous, and her family has been implicated in several major corruption scandals.)

The link between Ebola and governance is, by now, well understood. In countries with good governance, the virus struggles to flourish in the face of good communications, a functioning health system and effective monitoring and quarantine procedures.

On the other hand, poor governance facilitates transmission. In Guinea, Liberia and Sierra Leone, the response to Ebola was initially hampered by an official reluctance to acknowledge the problem; entirely inadequate medical resources to deal with it; and by a fundamental lack of trust between citizens and governments which meant, all too often, that sound government advice fell on deaf ears. These are failures of governance, for which each country has paid dearly.

As health workers in Sierra Leone ran out of basic medical equipment in late 2014, a container filled with protective suits, face masks, gloves, stretchers and mattresses languished at the Freetown port, delayed indefinitely by obscure customs regulations. This example, which is one of many, serves as a potent symbol of these failures.

Liberia received a disproportionate amount of international assistance compared with Guinea and Sierra Leone

Liberia’s government, however, was the first to take Ebola seriously and mobilise accordingly. While its response was far from perfect, it was quicker and more efficient than that of its counterparts in Guinea or Sierra Leone. ‘The Liberian government was transparent about Ebola from the beginning and accepted its limitations on how to handle the outbreak… There were also more institutional obstacles and denial in the two other countries at the beginning of the outbreak, but both countries will eventually get to zero cases if the response system remains focused,’ said Doctors Without Borders (MSF) in a set of discussion points distributed to staff.

Professor Wolfgang Preiser, Head of Medical Virology at the University of Stellenbosch, told the Institute for Security Studies that good governance is indispensable in containing any disease. He pointed to South Africa’s markedly more effective response to HIV/Aids under the leadership of Health Minister Aaron Motsoaledi as an example of how one able, committed individual at the very top can transform a response – and save thousands of lives in the process.

Preiser also pointed to another surprising factor in Liberia’s successful containment of Ebola: its colonial history. Liberia was never formally colonised; instead, it was settled by freed North American slaves, and there have been close ties between the United States (US) and Liberia ever since.

It was no surprise, therefore, when the US government finally did decide to step in – with medical resources in the form of highly trained personnel from the Centre for Disease Control and human resources in the form of 2 800 soldiers – it intervened first in Liberia. ‘I wonder if it’s not the magnitude and quality of the US intervention in Liberia [that made the difference],’ said Preiser. His hypothesis is supported by the fact that, according to MSF, Liberia received a disproportionate amount of international assistance compared with Guinea and Sierra Leone.

The Ebola epidemic in West Africa has been one the most severe medical emergencies so far this century. But Liberia’s experience shows us that medical emergencies are also governance crises – and can only be solved by good healthcare and even better governance. Let’s hope that Guinea and Sierra Leone have already learnt this lesson too.

Simon Allison, ISS Consultant

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