How can we prepare for Coronavirus? Learn from Liberia’s experience with Ebola

It was bound to happen: the Covid-19 strain of the coronavirus has come to sub-Saharan Africa. On February 25 an Italian businessman in Nigeria became the region’s first confirmed coronavirus patient, followed by a case in Senegal this week, as well as two cases in South Africa. At the time of publication, the latest World Health Organisation (WHO) figures included three more cases in Senegal, as well as one in Togo.

If the new coronavirus can strain China’s ability to respond, it will pose even greater risks in sub-Saharan Africa, where health systems are significantly more fragile. Public spending on healthcare in Africa is among the lowest in the world. Low national budgets and inconsistent support from donor countries has left Africa facing a $66-billion gap in annual healthcare spending. In Kenya, Nigeria, and Zimbabwe, and elsewhere across the region, healthcare workers routinely strike over low pay, arrears, and lack of supplies as mundane as gauze and gloves. Africa’s health systems also have a significant dearth of medical professionals, with one doctor for every 5 000 people (versus 14 doctors per 5 000 people in the UK, for instance). This leads to healthcare systems which, at their best, struggle to provide regular healthcare.

Governments across Africa that already heavily depend on financial assistance from donors to care for their citizens will be hardest hit, as traditional providers of foreign aid such as Europe, Japan and the US focus first on their own efforts to contain the coronavirus epidemic. But finding domestic resources to pay for the response will be difficult. As Africa’s largest trading partner, slowing Chinese demand is already depressing African economies, especially resource-dependent ones such as Nigeria’s, which depends on oil for more than half of government revenues and has watched global prices fall 13% this year.

As it happens, East Africa is also in the throes of an infestation of desert locusts of Biblical proportions: Some 13 million people face severe food insecurity in the region as a result of the insect’s vast damage to farmland and pastures. Some experts estimate there could be a 400-fold increase in locusts between mid-February and June.

Healthcare is already under pressure

In the eastern Democratic Republic of the Congo (DRC), the second-largest Ebola outbreak ever remains classified by the WHO as a “public health emergency of international concern.” At least 3 300 people have been infected and more than 2 250 people have died in a crisis that continues to strain the already-fragile health system of Africa’s fourth-largest country. 

That outbreak is second only to the 2014 West African outbreak, which infected 28,616 people  and killed 11 310 in Guinea, Liberia and Sierra Leone. Even today, parts of West Africa have not fully recovered economically.

We, the authors, have seen this up close. We were at the centre of the Liberian government’s response. We had based our worst-case scenario on previous Ebola epidemics, which had largely occurred in isolated rural communities. But overpopulated urban areas proved a much more explosive setting. 

Since Ebola’s symptoms mimicked those of common diseases, caregivers and healthcare professionals did not take commensurate preventive measures, which resulted in exponential infection rates. A lack of protective equipment and proper training also aggravated the spread, and before long our healthcare system began to break down. Treatment centres were filled beyond capacity, and bodies were left in the streets outside. That the government seemed unprepared for an outbreak this scale left the public feeling even more confused and fearful.

At first, some people thought that Ebola was a hoax concocted by a government that hoped to attract international aid and then siphon it away. There was little the government itself could do to dispel that impression, however wrong — and the misinformation undermined the government’s attempts to deliver public health messages. And so we began to enlist other actors — alternative repositories of trust with more credibility than government officials — in our disease response and outreach: religious and traditional leaders. 

Despite government warnings, Muslims in the north and other parts of the country had continued ritual preparation of their dead, spreading the infection, until the Chief Imam of Liberia went on radio to call for the faithful to stop the practice. Similarly, the Liberian Council of Churches advised its members to refrain from laying on hands when they prayed for healing for the sick.


Although medical treatment and traditional public health measures played an important role, the precipitous drop in infections came through behavioural change by the general public. And that only happened once community engagement and trust were made a central part of the response. 

Only a few African countries have experienced major disease outbreaks. And even experience with one epidemic doesn’t mean being prepared to detect, prevent and respond to the next one.

Preparation is crucial

For one, countries should anticipate, and prepare for, not just a major strain on resources, but a scenario of near-total breakdown to the system’s capacity to deliver healthcare. We learned the value of separating epidemic treatment from the usual health system. Each population centre should designate specific sites where suspected cases will be isolated to ensure that the other parts of the health system continue to function. In places without facilities for isolation, tent hospitals (such the Ebola Treatment Units we used in Liberia) should be built.

Early, frequent and transparent community engagement is the key to responding to any major outbreak. Governments across Africa should begin outreach before the first case is confirmed, partly because all over the continent, as in much of the world, trust in governments, institutions and experts has declined. This can hamper crisis response, as it did in Liberia, or as distrust of the central government in DRC has made it difficult to deploy experimental Ebola vaccines.

Finally, every African country must stress test its epidemic response systems. For example, in May 2018, the medical unit of the Sierra Leonean Armed Forces conducted a two-day simulation as a test of preparedness for another Ebola outbreak. It’s important that the first test of a system is not in the middle of an outbreak.  

So far Nigeria has handled its single case admirably with textbook detection, isolation, treatment and contact tracing. It is unclear how the system would respond to many more cases, but Nigeria also ably handled its few Ebola cases during the 2014 outbreak and is better prepared to respond than many other countries. Our hope is that Nigeria’s preparedness will be emulated by its counterparts across sub-Saharan Africa.

W Gyude Moore, a senior adviser to then president Ellen Johnson Sirleaf of Liberia during the Ebola outbreak of 2014 to 2015, is a visiting fellow at the Center for Global Development in Washington DC. Tolbert Nyenswah, formerly the Ebola incident manager for the Liberian government, is a senior research associate in the department of international health at the Johns Hopkins Bloomberg School of Public Health in the United States

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