Can a Post-Crisis Country Survive in the Time of Ebola? Issues Arising with Liberia’s Post-war Recovery

The Wait for Health: A Pre-Ebola Health Clinic. Photo by Chris Herwig, herwigphoto.com. Used with permission.

The Wait for Health: A Pre-Ebola Health Clinic. Photo by Chris Herwig, herwigphoto.com. Used with permission.

Overview

We suspect that the first case of the current outbreak of Ebola Virus Disease (EVD) began with the illness of a two-year old child who died at the end of December 2013. This occurred in Guéckédou prefecture, Guinea, located in the sub-region adjoining Liberia and Sierra Leone. This area is well known for its porous borders and peoples who share ethnic and tribal identities, and it has been a cauldron for the brutal conflict that enveloped the area for well over 15 years.

We may never see the face or know the name of “Patient S1.” That infant’s death and the thousands of others since the EVD outbreak provoked the near collapse of the health systems in these three countries. It is a catastrophe that demands more than an emergency response from the world. Now at stake are health systems, their scope, quality, and impact— and more broadly, governance, policy choices, and progress. At a more fundamental level, the EVD outbreak requires nothing less than a wholesale reordering of our priorities and the way in which we respond to crisis and to the emerging threats, including infectious diseases — especially in areas emerging from violent conflict.

This article will consider some of these issues in broad, drawing on my personal experience and association with Liberia’s progress over the past nine years. Following a review of progress and challenges, it will provide a perspective on the lessons and priorities for doing development differently in post-Ebola Liberia and the neighboring countries. One point is clear: building on the creative energies of the Liberian people, the international system needs to learn to act in a proactive manner, rather than wait until a global crisis arises.

Some Starting Points

First, to be absolutely clear, there can be no doubt of the paramount need to support the all-out effort to stop the spread of EVD now. Although the initial response was unfortunately marked with far too much hesitation, there is now a robust Security Council approved mission, the UN Mission for Ebola Emergency Response (UNMEER). Now is the time for UNMEER, with all concerned national authorities, bilateral and other partners, including philanthropies and the private sector, to act in concert with one single goal. Donors need to provide immediate and generous support now, not next year when it will be too late.

Second, it will be important to look carefully at why the epidemic flourished and what factors allowed it to do so. This outbreak must serve as a wake-up call to the international community, for certainly this situation is and will not be an isolated incident. We are witnessing the dawn of a much more complicated world to come: one which is regularly challenged by upheavals that may at first sight appear local, but because of the nature of globalization, can have a dramatic impact upon populations living far away.

Finally, the unleashing of Ebola in the 21st century is not a case of science fiction coming true. It is instead the result of a series of failures: failures to invest in a timely manner in the right infrastructure; failures to build accountable systems; failures to concentrate on resilience; and failures to put an end to the taxing, time-consuming bureaucracy which saps the ability of people to focus on what matters most —making a difference in the lives of people, especially the poorest.

Liberia: A Story of Hope and Work

I arrived in Liberia in November 2005 to serve as the deputy special representative of the UN secretary-general (DSRSG) in the peacekeeping mission, UN Mission in Liberia (UNMIL), which had been established under a Security Council mandate to support a successful peace process.

Within the first days, I had the thrill of witnessing a former UN colleague, Ellen Johnson-Sirleaf, win the run-off presidential election to become Africa’s first democratically elected female president. In the mid 1990s, she had held senior positions within the United Nations Development Programme (UNDP), and prior to that, the World Bank.

In her inaugural address on January 6, 2006, President Sirleaf called on her fellow compatriots to “break with the past,” declaring: “The future belongs to us because we have taken charge of it. We have the resources. We have the resourcefulness. Now, we have the right government. And we have good friends who want to work with us.”

Each year since then, the international community has invested over US$1.5 billion to support the government of Liberia’s five-pillar strategy of security, economic revitalization, basic services, infrastructure, and good governance. The international community embraced this strategy and its aim to direct assistance to support tangible development gains for rural Liberians.

My primary task as the DSRSG for UNMIL was to coordinate the provision of life-saving humanitarian aid as well as the longer-range development assistance of the United Nations and international partners. Working closely with the Special Representative, I had the vast logistical, technical, and military resources of UNMIL at my disposal. I could also call on the UN agencies which were collectively known as the UN Country Team, a number of which—including UNDP, the UN Refugee Agency, UNICEF, and the World Food Programme— had been working in Liberia for many years.

My job was to harness and integrate the different strengths and activities of the peacekeeping mission and the UN Country Team in a “one UN” effort to provide relief assistance, strengthen the capacity of Liberian institutions to govern and deliver basic services (e.g., security, justice, policing, and social services like health and education), revive economic activity (particularly in rural areas), and, ultimately, to foster national healing and reconciliation.

As I realized during my first visit with the minister of health (whose office was unreliably lit by a single electric bulb dangling from a wire), the war had left the Liberian health sector (and many others) in shambles. The minister told me that the primary provider of health services, both during and after the war, had been international NGOs. The country’s health facilities had been completely looted and vandalized during the war, and medical supplies were simply unavailable. A country of over 4 million people had only 26 practicing doctors. In most parts of rural Liberia, health services and referral systems (including any kind of maternal or reproductive health care services and information) simply did not exist. It was clear that in the health sector, as in several other sectors, the work of strengthening institutions would be a case of rebuilding them virtually from scratch.

The Liberian government and its international partners took several key steps to rebuild these institutions. We understood from the past that the concession economy and the politics of elite capture and bribery had mutually reinforced one another, creating the dynamics that led to civil war and the deprivation, suffering, and traumatization of the Liberian people.

This led to the initial institution-building focus on building up much needed capacities and systems within government institutions, with the aim of developing the systems for accountable and transparent financial management, budgeting, and procurement. Steps were taken to put in place accountability mechanisms to reduce corruption and increase transparency, introduce a cash management system, devise a new procurement commission, and establish a general auditing commission.

Another critical task was to restore trust and public confidence between the Liberian people and the government. This needed to begin early and with quick support from Sweden and the UNDP/UN Country Team, which simultaneously began the process of decentralizing governance by supporting local development initiatives in each of the 15 administrative regions. Steps were taken to foster citizen involvement to build peace and re-establish trust between the government and the general population.

Transparency International (TI) ranked the transparency of Liberia’s government as the third best in Africa, citing the independence of the General Auditing Commission, support for the establishment of the Liberia Anti-Corruption Commission, the promotion of transparent financial management, public procurement and budget processes, and the establishment of a national law to ensure Liberia’s compliance with the Extractive Industries Transparency Initiative. The economy was also growing at an impressive rate. Trade, production, commerce, and construction expanded rapidly.

A series of government plans were issued to outline the way that the Johnson Sirleaf Administration would capitalize upon this post-conflict economic boom, starting with her 150-day Action Plan to jump-start economic recovery. This was followed by an 18-month Interim Poverty Reduction Strategy, and in 2008, the government completed its first Poverty Reduction Strategy (PRS), whose formulation drew on countywide consultations and citizen engagement.

Framed around the five pillars mentioned above, the “Lift Liberia” strategy was specifically designed to promote rapid, shared growth. Officials at all levels sought to assure the Liberian population that “growth without development,” which prior to the war had generated extreme inequality and deprivation, was gone forever. Promoting shared growth entailed the provision of quality public services (especially education and health) and the revival of small-scale agriculture and rural livelihoods supported by the expansion of infrastructure (roads, bridges, water, and sanitation) throughout the whole country.

This was music to the international community’s ears. Aid continued to pour in. As a result, investor confidence rose dramatically. Starting with the rubber plantations, the concession economy (iron ore, rubber, and timber) began attracting large-scale international investors. Private investment increased rapidly in residential and commercial property, telecommunications, and transport.

Growth Without Development: A Return of Despair?

When I left Liberia in 2009, the story was still one of hope, and there was still widespread confidence in the national leadership. In fact, the nation’s narrative of peace, stability, and recovery was heralded as a prized example of post-conflict stability, reconstruction, and development. Up until the outbreak, Liberia had experienced a sustained peace, two successful democratic elections, improved access to justice and human rights, a restoration of public services, and a reemergence of private sector activity. In conjunction were unprecedented growth rates, showcasing Liberia’s considerable strides since the August 2003 Comprehensive Peace Accord and the profound chaos and disorder the country found itself in at that time.

Since my departure, the robust transparency and accountability architecture that led to the country being ranked favorably by TI and various international watchdog groups have disintegrated as quickly as they rose. The 2010 TI Global Corruption Barometer graded Liberia as among the world’s most corrupt countries, especially in the area of citizens who need to pay bribes to public servants.

The forward march and the bright future to which the president called her compatriots at her first inauguration appear to have stalled. Instead of building on a promising foundation of public hope that greeted Liberia’s post-war government, its performance began to erode rather than continue to build trust.

It has become evident that the old, tired pursuit of “growth without development,” as well as its perennial companion, the politics of greed, have indeed begun to settle in Liberia—as is far too often the case in many resource-rich countries. While the economy continued to grow, its impact on the lives of ordinary Liberians has been limited. The original promise of broad-based engagement with citizens in order to foster countrywide development faded as government’s attention turned to the revival of the concession economy. A rail line from the port to the mines was rebuilt and the iron ore mines were reopened, while after a corruption-tainted start, large-scale timber concessions were granted and the rubber plantations were rehabilitated and expanded. With the discovery of oil along the Gulf of Guinea (especially in Ghana), Liberian officials began contemplating and preparing for the emergence of a petroleum industry.

The lofty mission to “Lift Liberia” as captured in the PRS, especially as it related to small-scale agriculture, rural infrastructure, and strengthening rural public services, has failed. Rural poverty has remained high, exacerbating the low levels of health, poor standards of education, and food insecurity. Sadly it appears that Liberia has firmly moved onto a trajectory that it has already been before: once more growing but not developing.

Ebola in a Time of Crisis

It is against this background—one of governance failures— that the EVD outbreak began. Within months, the disease dislocated the institutional fabric of Liberia, disrupting not just the health system, but also the entire system of governance. Of the 10,129 reported cases globally as of October 23, 2014, 4,665 people are in Liberia and 2,705 have died. The estimated figures will be more alarming if the epidemic is not brought under control.

Many health centers have shut down as health workers abandoned their posts for fear of contracting the virus, leaving hundreds of Liberians without access to health services. These centers have done so due to poor conditions, and provide no protective equipment and incentive to perform the life-threatening work for which they were created. They have already seen over 95 of their fellow health workers die, and hundreds of others fighting for their lives.

Consequently, there are widespread reports that people with high blood pressure and diabetes are no longer cared for. Pregnant women have been turned away from hospitals. They are left to die or lose their babies before they are born. Desperate Liberians have abandoned neighbors or relatives suspected of having EVD to die slow and painful deaths. Both Liberia’s society and culture are being challenged in many new and desperate ways. This is a different type of war now, not the civil war of the 1990s, but a war brought about in part by a health system unable to cope with the scale of the Ebola outbreak.

The Ebola epidemic is not just devastating the Liberian population. It is also severely crippling all sectors of the country’s economy: notably health, trade and commerce, and education. The World Bank recently projected major reductions in the economy over the coming years— estimating that Liberia could see significant contractions of its growth. The impact of EVD has seen the original GDP growth projections revised downwards from the initial 8.7 percent, progressively to 5.9 percent, 2.5 percent, and most recently, to 1 percent. This will have a direct impact on the country’s Human Development Index. With villages decimated by the disease and agricultural fields being abandoned, famine is becoming a reality. The prices of food have been rising due to shortages. Liberian professionals who hold foreign passports, many of whom returned with high hopes of contributing to the development of their motherland, are leaving the country. This will accentuate Liberia’s deficiencies in human resources. Schools have closed, business has declined, and international connections (via air and sea transport) have been curtailed. In rural Liberia, communities shun many who contract the virus for bringing calamity upon their neighbors. This is further undermining the fragile social fabric that had been slowly rebuilding after the war.

Medicine: An Alternative Approach. Photo by Chris Herwig, herwigphoto.com. Used with permission.

Medicine: An Alternative Approach. Photo by Chris Herwig, herwigphoto.com. Used with permission.

Lessons for Re-engaging on Recovery in Liberia

There will be plenty of calls for lessons learned from future analysis of what happened in Guinea, Sierra Leone, and Liberia during the early months from the death of S1 in December 2013. Looking even further back, the efforts and choices made by the government of Liberia, as well as other governments in the regional and international community, in strengthening institutions appear to be either inappropriate, misguided, or too superficial to support the country’s development. We need to learn from this so that we can build new and robust local, national, regional, and global architectures that can effectively respond to current and future epidemics. For me, the following lessons are worth heeding:

(1) Effective and accountable institutions remain key in post-conflict recovery and transition out of fragility.

It is already expected that climate change will shift where infectious diseases break out. We should expect both an increasing number of epidemics and mega multi-hazards. The WHO has warned that climate change will see the rise of infectious diseases. Many of these would likely originate in so called conflict-affected fragile states, so we must learn quickly to engage these states in ways that increase their resilience as the first line of defense in our emerging complex new world.

In my role as director for the former Bureau for Crisis Prevention and Recovery in UNDP, we supported the work of the g7+ (a group of self-identified fragile states) that organized themselves under what is called the New Deal for Peacebuilding and Statebuilding. The specific goal was to determine how the countries could transition out of fragility to become more resilient. At the heart of the New Deal is the building of institutions to promote inclusive politics, security, justice, revenue and jobs, and basic services. These countries recognize that until they build more resilient and participatory governance systems, their prospects for peace and sustained development are limited.

We cannot continue this firefight since the resources and the know-how are simply not available to respond in an ad-hoc manner to all of these mega-hazards. Resilient institutions are essential. According to the World Bank, these are institutions that “can sustain and enhance results overtime, can adapt to changing circumstances, anticipate new challenges, and cope with exogenous shocks.” Building such institutions requires that they be embedded in the societal, political, and geographical contexts from where they derive meaning and legitimacy.

Creating such an institutional context means investing in education so that these countries can have the critical mass through which a supportive institutional environment can develop. While institution-building is for the long-term, this is a great opportunity to experiment with the concept of the use of the country system, national ownership, and the rebuilding of trust between government and society as well as governments and international partners. These are the core principles of the New Deal for Peacebuilding and Statebuilding.

(2) Timely, targeted, coordinated, and coherent result oriented response.

The Ebola crisis is not just a health emergency; it is a multi-dimensional social and humanitarian crisis. It requires a complex, multi-pronged response involving health, aid coordination, personal security, food security, appropriate budgetary decision-making, and responsive governance, among others. It is a whole of government challenge. While this point cannot be ducked we in the international community regularly develop “whole of government” approaches in ways that overextend the agendas of already fragile countries well beyond their capacities to respond. We often call on the government to act in a coordinated manner, but as international partners we can be disorganized and consequently fail to act in a unified or coordinated manner ourselves.

Rolling back an epidemic is not the time for long complicated layers of bureaucracies and agency-driven interests. We need targeted and efficient responses that produce results rapidly. In their immediate response, these countries need enough ambulances to quickly collect the sick and the dead. They need health workers including infectious disease control doctors on the ground in all affected parts of the countries. They need funds to pay health workers adequately for undertaking such dangerous work. Most importantly, they need the international community to accompany them by nurturing the use of their respective country systems. This includes the training programs at the local and regional level that will continuously build capacity to stay abreast with medical science, technology, and innovation.

In the medium-term, the network of health workers across the countries must be strengthened to exchange experiences and build practices on a regular basis. But much more is needed if the countries are to rebound. They need considerable support to revitalize the productivity of their agricultural sectors, and they need innovative ways to open the schools. Early recovery activities should be prioritized, including cash transfers targeting not only the directly impacted, but also the affected households; enterprise recovery must be a key component as well.

These are concrete tasks and should be carried out without being subject to the typical bogs of bureaucracy and complexity. How can this be done differently? Where is the venture-capitalist mindset behind all the Silicon Valley startups for all of West Africa? We need to adopt modern methods of training rural health workers, the young women and men who are ready to stay in the provinces and counties and who are willing to provide real services to their fellow citizens, in exchange for being paid real salaries on time.

(3) Limit coordination layers.

There are multiple actors who are returning to these countries to help. They must be coordinated and the governments must be at the center of these coordination platforms, but these should not result in multiple and burdensome transaction costs for coordination. Coordination at the center of government is one of the core functions that needs to be strengthened, particularly in countries where such systems are still not fully consolidated. There is absolutely no time for competing layers of coordination.

As director of the former Bureau for Crisis Response and Recovery in UNDP, I saw firsthand how effective a network of actors across the government can be. In fact, it is critical. As the former UN resident coordinator in Vietnam, I witnessed firsthand that nation’s response to SARS and the avian flu. The remarkable success in that country was primarily due to the cohesive response of the government, as well as its clarity of purpose and its decisiveness.

(4) From knee-jerk international mobilization to global solidarity to shared security.

We all hope the current epidemic will be brought under control as rapidly as possible. Soon we will need to face the next challenge: rebuilding the affected countries. Yes, there will be calls to build back better. But it will take much more than slogans this time. The world will be challenged to make the right investments. It cannot be business as usual nor can we allow ourselves to slip simply into old comfortable patterns of working. We should be measured as to whether we are doing the right things. Who are the best judges? The people on the ground are. Do they see an improvement in the education system, the delivery of health, and access to clean water, all of which make life livable?

It is no longer a cliché to say that our security and existence are intertwined even with that of remote villages and impoverished fragile states It is no longer a world of them and us. Whatever support we give to affected countries is not an act of a good Samaritan. It is for our very own personal safety and well-being.

In our affluent and technologically sophisticated world, complacency is not an option. We cannot glibly dismiss seemingly faraway threats as problems of the poor and remote parts of the world. As the Ebola epidemic in West Africa has revealed in just a matter of months, it is in our personal interest to address those problems at their source before they escalate. This will reduce the tragic impact of the epidemic locally and avoid having it become a global crisis.

With 2015 approaching, and its world of conferences and goals, now would be time to take decisive action that fundamentally reinvigorates the ability of the international system to work in a more effective and cohesive manner with human, physical, and financial resources upfront to support national response plans as well as those that transcend national boundaries in the way modern threats do. Whether this requires fine-tuning or a complete overhaul, now is the time for action, and hopefully for something a bit more ambitious than just making the United Nations “fit for purpose” which seems to mean simply “good enough to get the job done”.

About Author

Jordan Ryan

Jordan Ryan headed the UN Development Programme's Bureau for Crisis Prevention and Recovery from 2009 until retiring in September. He has also served as the UN Secretary-General's Deputy Special Representative in Liberia from 2005 to 2009. Ryan has worked as a lawyer in Saudi Arabia and China and was a Visiting Fellow at the Harvard Kennedy School in 2001.