Ebola may no longer be a “public health emergency of international concern,” but its legacy is badly damaged healthcare systems.

On March 29th, over a year and a half after the World Health Organization declared the West African Ebola outbreak a public health emergency of international concern (PHEIC), WHO’s Ebola emergency committee announced that the epidemic will no longer carry the PHEIC label.
More than 11,000 people have died from Ebola virus disease (EVD) in West Africa, out of about 28,000 reported cases.1 Those who survived now face numerous adverse health effects, including neurological problems, chronic inflammatory conditions and uveitis, an eye disorder that can lead to blindness.2 But the outbreak did much more harm than just to those infected with EVD: it caused lasting damage to healthcare infrastructure in Guinea, Li­­beria and Sierra Leone, which has already been responsible for more deaths than EVD itself.
Damage to the healthcare system began soon after the onset of the outbreak. As Ebola deaths increased in 2014, overall hospital admissions—one measure of the system’s capacity to care for patients—declined dramatically3 (Fig. 1). The strongest blow to healthcare capacity was the deaths of West African healthcare workers—physicians, nurses and caregivers who were on the front lines caring for Ebola patients. Beyond the lack of clinicians, many sick people avoided healthcare facilities for fear of contracting Ebola. Delivery of medications and vaccines was also limited due to government-mandated containment strategies, such as border closures and mandatory curfews.
What was left were healthcare systems in all three countries that could not function at very basic levels. Illnesses that once occupied health workers’ time and energy—malaria, measles, HIV, diarrheal disease, tuberculosis, pregnancy complications, respiratory infections—suddenly had fewer resources each week, and began to claim more and more lives.
Long-term effects of the breakdown in services didn’t go without warning. Starting in December 2014, predictions of the coming toll from other health conditions were published in prominent scientific journals. One mathematical model predicted that the disruption of malaria control measures would lead to 10,900 excess malaria deaths.4 The United Nations Population Fund (UNFPA) estimated that insufficient care for obstetric emergencies and other pregnancy complications would cause thousands of additional deaths from maternal mortality.5 Infant vaccination campaigns were also predicted to suffer: nearly 100,000 more measles cases would occur because of the shortfall in healthcare workers to deliver vaccines, according to one study.6
Mortality from these three estimates alone adds up to more than twice the number of deaths from EVD (Fig. 2).  It’s reasonable to assume that other leading causes of death in the region, including acute respiratory infections, diarrheal disease, tuberculosis and HIV, would have been affected similarly. Research published this month used a model to estimate that a 50 percent reduction in access to healthcare in Guinea, Liberia and Sierra Leone—a likely possibility in many areas—would have conservatively caused more than 10,600 additional deaths from malaria, HIV and tuberculosis in 2014 and 2015. 7
Though we will have to wait years before there is enough reported data to assess the accuracy of these predictions, preliminary data show that they generally proved to be correct. The effect on malaria is corroborated by WHO’s 2015 World Malaria Report, which showed a clear uptick in reported malaria deaths in Guinea and Liberia (though not Sierra Leone) in 20148 (Fig. 3).
A study published in February 2016 reported that the number of in-hospital deliveries and C-sections (a measure of healthcare access for obstetric emergencies) decreased by over 20 percent in Sierra Leone during the Ebola outbreak9 (Fig. 4).
Through the end of 2014, both measles10 (Fig. 5) and diphtheria-pertussis-tetanus (DPT)11 vaccine coverage dropped in all three countries, while coverage in neighboring countries remained constant. This decline—nearly 15 percentage points in Liberia—will have repercussions years into the future.
Not unlike a weakened immune system that is highly susceptible to infection, a weakened healthcare system is at the mercy of both everyday diseases and new epidemics. Illnesses that have been the leading causes of mortality in the region for decades got a leg up in West Africa after healthcare systems were weakened.
When trying to restore health after an attack on an immune system, it’s the boring stuff that we’ve been told to do over and over again that’s most important. To prevent illness and infection in individuals, that includes things like handwashing, hydration, good hygiene, nutrition, sufficient sleep and keeping up to date with vaccines. For populations, it’s not much different: sanitation, infection control and prevention, widespread vaccination, bednet distribution, training and equipping healthcare workers, disease surveillance and providing access to medications and treatment. Going back to basics before things happen—as unglamorous as it may be—is the plan that will save lives.
Andrea White is a Communications Associate at CDDEP.

1World Health Organization. “Ebola Situation Report – 30 March 2016.” Accessed 6 April 2016.

2Tiffany, A., P. Vetter, J. Mattia, J.A. Dayer, M. Bartsch, M. Katzura, E. Sterk, A.M. Tijerino, L. Kaiser and I. Ciglenecki. “Ebola virus disease complications as experienced by survivors in Sierra Leone.” Clinical Infectious Diseases. Mar 21, 2016. doi:
3Bolkan, H.A., D.A. Bash-Taqi, M. Samai, M. Gerdin and J. von Schreeb. “Ebola and Indirect Effects on Health Service Function in Sierra Leone.” PLOS Currents Outbreaks. Dec 19, 2014. Edition 1.
4Walker, P., M. White, J. Griffin, A. Reynolds, N. Ferguson and A. Ghani. “Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modeling analysis.” The Lancet Infectious Diseases. July 2015. 15(7): 825-832.
5A. Delamou, A., R.M. Hammonds, S. Caluwarts, B. Utz and T. Delvaux. “Ebola in Africa: beyond epidemics, reproductive health in crisis.The Lancet. Dec 13, 2014; 384(9960): 2105.
6Takahashi, S., J. Metcalf, M. Ferrari, W. Moss, S. Truelove, A. Tatem, B. Grenfell and J. Lessler. “Reduced vaccination and the risk of measles and other childhood infections post-Ebola.” Science. Mar 13, 2015; 347(6227): 1240-1242.
7Parpia, A.S., M.L. Ndeffo-Mbah, N.S. Wenzel and A.P. Galvani. “Effects of Response to 2014-2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa.” Emerging Infectious Diseases. Mar 2016; 22(3): 433-441.
8World Health Organization. World Malaria Report 2015. Geneva.
9Brolin Ribacke, K.J., A.J. van Duinen, H. Nordenstedt, J. Hoijer, R. Molnes, T.W. Froseth, A.P. Koroma, E. Darj, H.A. Bolkan and A. Ekstrom. “The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone.PLOS ONE. Feb 24, 2016; 11(2): e0150080.
10World Bank, World Development Indicators (2015).  Immunization, measles (% of children ages 12-23 months).
11World Bank, World Development Indicators (2015).  Immunization, DPT (% of children ages 12-23 months).