Liberia Is Ebola Free. We Can Do More.

We take pause today to celebrate the end of this outbreak and the progress that has been made. However, another celebration will be had in a decade's time, when the vestige of this ordeal is an expansive health system that is resilient enough to address threats to the country's health in an expedient and effective manner.
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On May 9, 2015 the World Health Organization declared Liberia free of Ebola. However, the work of building a robust health system that will prevent future outbreaks goes on.

The end of Ebola in Liberia can be seen in the everyday occurrences we once took for granted. It can be seen in the resurrection of the Liberian handshake -- a traditional clasp of the hands, punctuated by a shared snap of the fingers -- a greeting that originated as a celebration of freedom from slavery. It can be seen in school children dressed in their uniforms, holding hands as they walk to classes that are once again safe to attend. It can be seen in people dancing to the vibrant, rhythmic West African music that spills out from clubs, cars and cellphones.

As doctors working in Liberia, the most poignant illustration of the end of Ebola that we have seen is in the restoration of health services that were lost during the crisis. When Ebola struck Liberia, hospitals and clinics became hot zones and there was nowhere for patients with illnesses other than Ebola to turn for healthcare. Women died giving birth and children lost their lives to preventable illnesses like diarrhea and malaria. This loss will be felt in Liberia for a long time to come, but today we are seeing a renewed effort to rebuild and strengthen Liberia's health system.

A recent example of the reviving health system is the story of Charles Doe, a 10-year-old boy from a rural village in Southeastern Liberia. Charles lived in Gloteete, two-hours away from the nearest health facility by motorbike. Two weeks ago, a community health worker named Zonnoh met Charles in his village and noticed a large mass on his left jaw. Charles' parents had sought medical help when the mass first appeared last December but were turned away from a nearby hospital, so they went to a local traditional healer instead. The mass continued to grow, making it difficult for Charles to open his mouth or eat. Zonnoh immediately recognized the gravity of his condition and activated a coordinated effort by various NGOs and a Liberian-run health facility to transport Charles via ambulance across three counties to Monrovia so that he could receive chemotherapy. Initially, the challenge seemed insurmountable, as similar cases were unable to get care only two weeks prior.

Charles' journey to treatment shows how far Liberia has come in recent months. At the height of the outbreak, hospitals and clinics were closed due to lack of personal protective equipment for health professionals to treat patients safely. People's fear of catching Ebola in hospitals prevented them from seeking care. Transport of sick patients across county line checkpoints was rare and posed a challenge even for those who did not have symptoms of Ebola. Finally, many remote villages that depended on volunteer community health workers were left vulnerable during the outbreak when they were advised to stop delivering care to ensure their own safety. These obstacles crippled an already weak referral system and made coordination of care for cases like Charles' impossible.

Though Charles' story provides a ray hope for a country emerging from an Ebola outbreak, it also exemplifies ongoing challenges. Despite receiving treatment in Monrovia, Charles did not live. His death, only days before Liberia was declared Ebola-free, reminds us of the cost of delayed care and the persistent limitations of weak health systems.

By now the statistics from the Ebola outbreak in Liberia are well known: 10,322 cases, 4,608 deaths, and thousands orphaned. As we strive to honor each of those affected and work to support the survivors, we must also recognize what is lost when we deal in numbers alone. Lost are the untolled people who died from routine and treatable conditions unrelated to Ebola because the health system collapsed: women who had no access to maternal care and children who were not treated for malaria. These cases, and cases like Charles', embolden our efforts to rebuild and strengthen the health system and ensure that every Liberian has access to a Community Health Worker like Zonnoh. Such a system, designed to serve even the most remote villages, would have helped prevent this outbreak.

Blind spots in rural healthcare lead to hotspots of epidemic disease. This epidemic began because patient zero, a two-year-old boy named Emile, lived in a remote village in Guinea with poor access to healthcare. If there had been professionally trained and supported Community Health Workers stationed in remote villages throughout Guinea, Liberia and Sierra Leone when the first patients grew sick, they could have sounded the alarm before a small outbreak became a global crisis. Instead, it took months before the global community took notice and mobilized. We may have stopped the hotspots, but the blind spots -- remote villages with little or no access to healthcare -- still exist.

We take pause today to celebrate the end of this outbreak and the progress that has been made. However, another celebration will be had in a decade's time, when the vestige of this ordeal is an expansive health system that is resilient enough to address threats to the country's health -- both urban and rural -- in an expedient and effective manner. This legacy of a better health system will honor all those whose lives and potential were lost.

Ami Waters, MD UCSF Global Health Fellow
E. John Ly, MD Last Mile Health, Medical Director

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