ONROVIA, Liberia — The Ebola crisis here may be over, but its impact can be seen at health clinics across the country. Running water is sporadic. Drugs are in short supply. And with the medical system still reeling, Liberia is now recording a spike in cases of tuberculosis and other treatable infections.
One in every 300 people here now has tuberculosis, making Liberia one of the countries with the highest TB burdens in the world. Before Ebola, the cure rate for the deadly bacterium stood at about 55 percent. Now, in some parts of the country, it’s closer to 28 percent.
Researchers from the Yale School of Public Health, writing this month in the journal Emerging Infectious Diseases, estimate that during the year-long Ebola outbreak, an extra 600 Liberians died from TB because the health care system was so crippled; another 1,000 died from HIV and malaria. That’s on top of the 4,800 killed at the hands of the Ebola virus itself.
A year has passed since the outbreak started tapering off, but the situation remains dire. At Liberia’s national TB hospital, on the outskirts of the capital, there is one doctor to care for 105 inpatients. Another 50 to 60 outpatients arrive every day, and the nurses — who number fewer than 25, alongside four physician assistants — cannot cope with the increased load.
Electricity is limited, the roof is bowed and leaky, and empty window frames bring in mosquitoes and rain. “Just from the physical appearance of the hospital, anyone who comes here can tell that something is wrong,” said hospital administrator Lucelia Michael.
Dr. Maxo Luma, a TB expert who works in Liberia with the nonprofit Partners In Health, described the conditions as “alarming.”
“I had one patient, a 21-year-old man, who I spent many hours convincing to come to the hospital for treatment,” Luma recalled. “Once he arrived, he looked around and said, ‘I’m not going to sleep here.’” The patient returned to his apartment, which he shared with 15 others, putting them at risk of contracting the life-threatening disease.
On a recent morning inside the hospital wing dedicated to treating highly drug-resistant strains of TB, Jack Kallah and other patients passed the time playing checkers, ludo, and other board games. Some are there for eight months, some for 12, some for 24. They take an average of 19 pills a day to combat an infection that most commonly grows in the lungs, triggering chest pain, bloody coughs, night sweats, and more.
Kallah was training to be an engineer, but his studies were interrupted by his diagnosis. For months, he underwent treatment as an outpatient from his hometown in northern Liberia. But when clinicians decided he was not responding well, they sent him to Monrovia for a six-month stint.
“The conditions here are bad, but I just have to accept it until I get better,” Kallah said. “I can’t work or study, and I’m not with my fiancée. She could visit me, but I told her to stay away from this place in case she changes her mind about me.”
Patients are referred to the national TB hospital from all over Liberia. Among those admitted recently was a teenager with severe TB infections outside her lungs. After failing to respond to treatment in the southeastern county of Maryland, she became so despondent that her parents found her in her bedroom with a rope.
Partners In Health has begun working with the Liberian Ministry of Health to improve patient outcomes in Maryland County and at the national TB hospital in Monrovia, easing access to drugs and staff. The organization is also training community health workers to identify new TB cases and renovating the county’s run-down J.J. Dossen Memorial Hospital, with plans to build a world-class teaching hospital nearby.
From Maryland to Monrovia, clinicians have their work cut out. But for responders like Luma, tackling TB is only one part of the equation.
In a country where the root causes of Ebola — dilapidated health facilities, shortages of staff and equipment, and fractured trust in the system — persist, getting primary health services up and running is key.
“Whatever is happening now with regards to health in Liberia is the result of a broken system,” Luma said. “If we truly want to address health issues in this country, it cannot be through isolated programs for, say, Ebola or tuberculosis.”
There are other neglected diseases, including leprosy and epilepsy, he noted. “All of these could be curbed by implementing an integrated health system.”