The outrageous death toll of 200 people in a single day in Liberia due to the recent Ebola outbreak is recognition of something that the international community has long known and for which it must assume responsibility. The Republic of Liberia, like other states in West Africa, has been struggling to recover from the devastating effects of successive civil wars and the indirect consequences of conflict. As the Ebola crisis demonstrates, even in peace, the legacy of infrastructure and institutional destruction can be fatal. As Liberian Minister of National Defense Brownie Samukai put it: "Liberia is facing a serious threat to its national existence. The deadly Ebola virus has caused a disruption of the normal functioning of our State."
My research jointly with a team from the Harvard School of Public Health establishes that after periods of armed conflict, post-conflict societies undergo five major phenomena affecting the levels of public health and development: (1) population growth; (2) rapid urbanization and population displacement; (3) severe levels of poverty; (4) weakness and/or lack of basic infrastructure; and (5) lack of qualified professionals. In Liberia today, each of these forces is at work. To understand the Ebola crisis, we need to understand the legacy of war and its lasting impacts.
First, countries in post-conflict situation usually experience rapid population growth. According to the World Bank, Liberia's population growth increased from 2.0% in 2004 to 4.2% in 2008, but then decreased to 2.4% in 2013. The population growth can be explained in part because mortality rates, especially deaths in direct conflict, are reduced and because the birth rate tends to increase post-conflict. This growing population increases the demand for health services. If a State does not provide for these basic health needs, they intensify and become more complex and more expensive. As a result, the total health expenditure (the sum of public and private health expenditures as a ratio of total population) has been increasing in Liberia to US$65.5 million in 2012 from about US$12.0 million in 2004.
The second phenomenon is rapid urbanization. After armed conflict, rural areas suffer more from the lack of infrastructure of all kinds, generating rural exodus to urban areas. In addition, conflicts often cause displacement of populations and the break with the bonds of belonging to traditional, rural society that also accelerates the process of urbanization.
Urbanization in itself is not necessarily a social and public health problem. In fact, the shift to urban life is often conducive to dissemination of important health and personal hygiene and disease prevention concepts. But if urbanization is not minimally organized it can instead foster the conditions for epidemics or other complications of public health. In 2012, only 16.8% of Liberians had access to improved sanitation facilities.
Individual and collective widespread poverty is also a consequence of conflict. That does not mean that countries in conflict or post-conflict are poor in absolute terms. In fact, often, wars are generated by conflict over wealth and battle for control of natural resources in these countries. But during conflict and in post-conflict situations, individuals are often removed from their assets and basic means of production exacerbating the impact of poverty.
Conflicts lead to a disruption or destruction of major infrastructure such as airports, roads or other means of transporting people and products, including food distribution. Consequences include the destruction of schools, hospitals and public places such as courts or government spaces. Physical destruction is simultaneous with the destruction of the organizational and public administration. Thus, the destruction of infrastructure often causes the collapse of the health system. Medecins Sans Frontieres (MSF) has stated that Liberia's Montserrado County, which includes the capital, Monrovia, needs 1,000 hospital beds to treat Ebola patients but the medical charity can provide only 400. "The number of new cases is moving far faster than the capacity to manage them in Ebola-specific treatment centers," MSF has noted. "We know that every day there are more people that need to be taken care of than we can include in our program. At the moment, there are insufficient beds," emergency coordinator Laurence Sailly told a news conference last Tuesday.
Another important characteristic of post-conflict contexts is the shortage of professional and human resources. During conflict, professionals in all areas are frequently the primary targets of violence. That's because they are regarded as leaders or potential leaders. In addition, professionals are usually part of a middle class that sometimes has resources to escape the conflict. The shortage of professionals is also reflected in the lack of indicators and health data. Ebola is a hemorrhagic fever spread through the blood, sweat or vomit of those infected, making those working directly with the sick among the most vulnerable to the disease. In a country with just one doctor for nearly 100,000 inhabitants before the outbreak, according to the WHO, some 152 health care workers have been infected and 79 have died in Liberia since the crisis began.The international community has been mobilizing resources and considerable efforts to reduce the impact of the Ebola epidemics. This is important. But if we do not devote investments to public health systems in countries that are only beginning to return to stability after decades of war, there will be other fevers, and their consequences may be even more catastrophic. Systemic response is what is called for. Public health, understood as a tool for reducing economic and social disparities and not merely specific health interventions is essential. This investment promotes human development, reconciliation and reduction of violence because it addresses two of the most common elements laid bare in conflicts: social inequality and the struggle for power. In Liberia and throughout the region, once the emergency is contained, investing in public health systems must be a priority.