After months of beating back Ebola from behind spacesuit-like protective gear, exhausted foreign aid workers in Liberia are beginning to pack up and go home. The final wave of Cuban workers in Liberia held its farewell ceremony last Monday. Only about 100 of the more than 1,500 U.S. military personnel deployed to help stem the epidemic are still in the country, and they are expected to leave by the end of April. The head of the Liberian Ebola response even managed to take a long overdue weekend off with his family. Until a new case was discovered late last week, Liberia was on track to be declared Ebola-free in April.
Yet the country is now more vulnerable to almost any health crisis than it was before the Ebola epidemic. Without swift action to fix the destruction left in Ebola’s wake, the crisis is far from over. “Perhaps the only good news from the tragic Ebola epidemic … is that it may serve as a wake up call: we must prepare for future epidemics of diseases that may spread,” Bill Gates wrote in a recent article in the New England Journal of Medicine. Even with such a wake-up call, however, there is arguably no clear blueprint for how to proceed.
Imagine if one of the countries affected by Ebola — or even another poor nation — were struck with a particularly lethal influenza or even the measles. It could potentially cause more damage than the Ebola crisis, since those viruses can be transmitted far more readily. Just as the worldwide response to Ebola was criticized for being slow, inadequately funded and poorly coordinated, the same is expected for a response to other health crises in the current system. In fact, measles is already being carefully watched as an all-too-real risk. A recent public health analysis published in Science suggested that lapses in childhood vaccines during the past year in west Africa could leave Ebola-affected countries vulnerable to measles outbreaks and death tolls on par with the Ebola epidemic itself.
The battered, rudderless health care system augments this risk. Despite the glut of international attention that put Sierra Leone, Guinea and Liberia on the map, those nations have not developed infrastructures much better positioned to respond to another infectious disease threat, and amid new Ebola cases the problems that plagued the countries pre-Ebola are creeping back into view. “The Ebola infrastructure would be difficult to use for future outbreaks because it was not permanent,” Tolbert Nyenswah, Liberia’s assistant minister of health says. “Future outbreaks would need a health care system that is resilient to Ebola or other emerging diseases we may not know about. We would need to build systems that can withstand future shocks like the ones we just went through,” he says.
Only now is it becoming increasingly apparent how dire the situation will be in the coming months and years for these Ebola-stricken countries. Ebola certainly laid bare preexisting health problems, but it also exacerbated them in profound ways. Before Ebola, salary issues and other worker demands had fueled health worker strikes in Liberia and soon the stopgap solutions that sustained the country for the past year are expected to run aground. “Issues around health worker shortages are still not resolved, so there have been promises and temporary solutions but the main issues are still there,” Mit Philips, a health policy analyst for Doctors Without Borders says. Due to myriad competing needs, some Ebola-affected countries have only invested small portions of their own funds to support health care. Guinea, for example, dedicated only about 2 percent of its GDP to health care over the last five years, according to World Bank statistics. Requirements in Guinea for patients to pay for almost all services out of pocket often prompted people to avoid formal care and hobbled efforts to catch infectious disease quickly.
Making matters worse, the number of health care workers was diminished by the epidemic itself. In Sierra Leone, 24 of the 27 medical personnel staffing the Ebola ward at Kenema Government Hospital had contracted Ebola as of late last year, and 19 had died. In Liberia, more than 300 health care staff were infected by the virus and 180 were killed, according to the World Health Organization. Many of those workers were not officially responding to Ebola — they died providing routine care, Nyenswah says.
It is not clear that foreign countries will provide the funding and technical support to overcome these hurdles. Liberia, the nation furthest along in its Ebola response, reports it will need about $1.3 billion through fiscal year 2021 to rebuild and strengthen health care. Without assistance, Nyenswah says, Liberia has a “very, very fragile health care system.” The country made its case to the European Union earlier this month and plans to formally present its request to the World Bank in April at a conference in Washington, D.C. The funding request includes a laundry list of health needs: everything from better health care monitoring and consistent drug supply chains to lofty goals like combating medical brain drain and setting up biosafety labs that could securely handle dangerous pathogens in the future.  
Such systems would largely need to be built from the ground up, and there are few funds available to get started. Making matters worse, the country does not have a good sense of who is going to be available to lend a hand. A stable of experts from the U.S., Doctors Without Borders and international health and development organizations will stay behind to provide assistance in Liberia, but the all-hands-on deck mentality has passed. The three countries worst hit by Ebola each suffered from decades of civil strife that fostered weak states with massive funding gaps, and now those lackluster systems must attend to even greater health needs.
It is hard to know where they should begin. Aside from the ongoing threats of Ebola or of measles taking off in the region, health experts are also calling for support to help with overall mental health counseling and maternal health needs. The World Health Organization, the World Bank and Doctors Without Borders do not have any figures about how many medical specialists are available to respond to such needs in those locations, but they agree there are not nearly enough workers trained to conduct caeseran sections or, in some cases, safely deliver babies without contracting the virus.
Fear of Ebola has also left too many women without needed care. Scared health workers in Monrovia, Liberia’s capital, have frequently demanded a negative Ebola blood test prior to admitting pregnant women, Philips says — and if the city’s laboratory is closed for the day, a woman who is in labor or comes in with a complication may be asked to wait for the test. “Some people have died waiting for care or during referral between health facilities. They were not even showing signs of Ebola, but they are perceived as high-risk patients,” she says.
There are also unexpected health complications among Ebola survivors. Some are now suffering from vision loss or blindness, and health workers are struggling to address this burgeoning need even though little is understood about why the problem exists or how many survivors it affects. “Whether this is permanent or not we don’t know, but it’s a common problem we are seeing — people with visual problems,” says Daniel Bausch, a senior consultant on Ebola at the World Health Organization. In the months following prior Ebola outbreaks there were scattered reports of people suffering from progressive vision loss, but it was unclear if such symptoms were rare. In those cases, treatment with topical medication and steroids managed to alleviate the symptoms within a few weeks. With few ophthalmologists in the field, however, aid organizations are being forced to consider bringing in foreign specialists who could treat patients and train health workers. “It’s a huge need going forward,” says Bausch.
Eye problems are not the only pressing need. Surveillance systems that were keeping health officials posted about the spread of infectious diseases like cholera also stalled during the epidemic. Before Ebola, Doctors Without Borders was working in Guinea to track and tamp down yellow fever, meningitis and cholera, Philips says. “Now, for one year, there is almost no case being reported. No outbreaks. It’s almost impossible that it is not there anymore, but because of the health service slowdown and interrupted reporting, the health system is blind to this. We don’t know what is going on,” she says. There are also reports of active cases of measles in west Africa, says Philips, but it’s hard to track or verify them without timely surveillance systems in place. Moreover, since some of the symptoms of measles — like fever — can be confused with Ebola, people worried about potential exposure to Ebola patients or stigma are reluctant to bring their children for care.
These demands are also running up against a difficult climate for securing public health dollars. The World Health Organization’s budget for 2014–2015, $3.98 billion, was largely unchanged from the $3.96 billion budget approved for 2012-2013. And the monies for responding to health crises were actually halved — from $469 million in 2012–2013 to only $228 million. Yet the Ebola epidemic exposed just how ill-equipped the organization is to marshal massive resources in an emergency. The U.S. and the U.K. are the countries providing the greatest funding for global health today, but the lion’s share of U.S. funding goes exclusively toward fighting HIV/AIDs worldwide (in fiscal year 2012 the U.S. spent $8.9 billion on global health, with more than half of the funds dedicated to HIV/AIDs). “Ultimately, it’s just sort of human nature when a crisis is over that people will move on a little bit,” says Bausch. “The challenge with public health is that it’s not seen most of the time, so people conclude nothing needs to be done. But that’s when you need consistent investment.”