Ebola Recovery: The Long View

September 9, 2015

[Written February 2015] While the Ebola crisis has quietly exited mainstream media and public interest (Figure 1), over 15,000, Ebola survivors [1][2] struggle to regain a semblance of normalcy in a complex environment of pre-existing poverty and post-conflict dynamics. Each country heavily impacted by Ebola, Liberia, Sierra Leone, and Guinea has its own unique historical context which has influenced their ability respond to the Ebola crisis and plays an important role each country’s resiliency and recovery [3].


We are at a turning point in the Ebola epidemic in West Africa. With a steady downward trend of new cases (Figure 2) [4], and a current caseload of ~710 across all three countries (77% in Sierra Leone alone) , the situation is improving. The downward trend should not be interpreted to suggest that Ebola isn’t as deadly as it was before (it is), as the case fatality rate has not changed at all, remaining at an average of 60% across the three most impacted countries [5]. These data suggest it’s a time to not just continue the valiant effort of ending the epidemic but begin the process of recovery.


Recovery is a concept which at the very basic level gets us back to a baseline “normal”. However, recovery is often an afterthought – it is not on the agenda before and during an emergent event. Within most contexts, especially the developing world, “normal” isn’t good enough. Unlike a natural disaster, much of the damage in the context of Ebola Virus Disease, is not purely physical and visible in nature as we saw, for example, in the 2010 Haiti quake, 2014 Philippines tsunami, and the domestic impacts of Hurricane Katrina in 2005. That is not to say that these events did not have their own share of pre- and post- social inequities and poverty, but that we saw damage and could fix it by hauling off the rubble and making the “brick and mortar” repairs providing what amounted to an illusion of recovery. Ebola is fundamentally different.

Is disaster recovery on the agenda of Humanitarian Aid organizations and the affected governments? In a brief review of the allocation analysis from UNOCHA [6], out of a $3.2 billion budget of funded or allocated dollars for EVD, only $240,000 or 0.008% has been specifically set aside for recovery efforts. This is not to say that development and response dollars won’t be used for activities that may support recovery, but without the foresight, planning, and community involvement in how that money should be utilized, the recovery process will progress in a way that positively and productively impacts the regions which require the most assistance. Some good news – just recently the World Bank [7] pledged to contribute $650 million to the response and recovery efforts with goals of improving infrastructure, health systems, education, and agriculture. This dedicated funding stream is a step in the right direction.

Vulnerable populations are at a greater risk during this transition to recovery. According to UNICEF, more than 16,000 children lost their one or both of their parents or caregivers as a directly result of Ebola [8]. The pre-Ebola orphan population has increased by approximately 3,700 [9], under-utilization of pre- and post- natal care utilization has been noted and women and girls are subject to greater than normal violence and non-consensual sex. And with the economy devastated the underground transactions are likely to rise.

Disaster recovery planning should incorporate direct planning for the most vulnerable populations. Vulnerable populations, are often overlooked in recovery planning but require specific planning and accommodations for very specific needs. Children are vulnerable as a class but they are also powerful centers of action. If recovery planning is centered on children  community recovery will trickle up. Research has that a major predictor of community recovery is how soon children are able to return to school. Considering schools have been closed for an entire year in the country of Sierra Leone, we have yet to see how this will impact recovery and the long-term educational outcomes of this young population.

The central question to the issues presented is how do funders and disaster planners attend to and plan for the most vulnerable populations? The solution: support, fund, and bolster long-term programming by local grassroots organizations and the international organizations who had a strong in-country presence before the outbreak made the news. These organizations tend to have extensive local knowledge and experience which makes them agile, responsive, and culturally competent. They are able to navigate complex political relationships, work within social and cultural norms, which enables them to have a far greater impact. Funders and organizations on-the-ground need to focus on planning efforts which improve, above baseline, technological and social infrastructure, resilient communities, and continue to bolster local health systems.