Remote regions of sub-Saharan Africa are among the world's hotspots for new diseases. But Liberia is using an innovative approach to identify outbreaks before they become a problem.

When Cynthia Luogon and her young son became feverish and started vomiting one night, she feared the worst. It was 2014, and an epidemic of Ebola – the highly contagious haemorrhagic fever that can cause uncontrollable internal bleeding – was spreading like wildfire across West Africa.

Without phone signal or access to a vehicle, several of Luogon’s neighbours in the remote Liberian village of Gipo – just nine miles (15km) from the border with neighbouring Guinea – were forced to carry the pair in a hammock for over an hour to the nearest health facility. "I thought I was going to die," she says.

Luogon, now 35 and with nine children, was initially suspected of having Ebola, but later diagnosed with cholera. She eventually recovered after being treated. "We were lucky," she says. "But plenty others passed away in those days."

Nearly a third of Liberia’s population lives in rural areas similar to Gipo, which health experts say have the potential to be hotspots for emerging infectious diseases that could in turn break out into major epidemics or, in the worst case, pandemics. Traditional healthcare provision systems often aren't a viable way to address this threat in many countries across sub-Saharan Africa, due to limited national budgets and often inadequate infrastructure.

But Liberia has found remarkable early success via another approach: recruiting members of rural communities to act as the crucial first line of defence against infectious diseases – helping to spot them before they become a wider problem.

Throughout the 21st Century, many infectious diseases have emerged or re-emerged across sub-Saharan Africa.

Rural areas in the region are often a particularly vulnerable to disease outbreaks, says Florence Fenollar, an infectious disease specialist at the University Hospital Institute of Mediterranean Infection in Marseille, France. Limited public health systems, poverty and social inequality, violent conflict, and close contact between humans and wildlife are among the reasons for this, she adds.

"Africa has both the greatest infectious disease burden and the weakest public health infrastructure in the world," says Fenollar. "This combination means the region must be observed carefully."

Some of the infectious diseases seen in sub-Saharan Africa in recent years, such as Rickettsia felis, a variety of cat-flea typhus, and the bacteria which causes Whipple's disease, are newly discovered. Others are historically well known, such as cholera and the bubonic plague. Still others, such as Ebola and Zika, are previously known diseases from elsewhere but have seen their first large outbreaks in the area.

The risk of failing to properly implement defences in the region has been underlined by the low supply of COVID-19 vaccines in Africa, which the World Health Organization has warned could lead to further variants. Liberia itself is currently battling with Covid-19, but must also be prepared for the potential resurgence of Ebola, as occurred in neighbouring Guinea last year. There is also the ever-present threat of an entirely new disease appearing that could lead to a serious outbreak.

But Liberia's community health workers offer a compelling solution to this threat, with thousands of them now on constant lookout for infectious disease in the furthest remote reaches of Liberia. They are part of a radical scheme in the West African nation that has provided disease surveillance and healthcare to rural populations since 2016.

These workers are paid, trained healthcare providers who come from and are based in remote villages that traditional healthcare systems often can’t reach. Crucially, the workers also provide a new aspect of pandemic preparedness: rapid warning.

"If you’re building trust with the health workers and the communities, then this is a very effective way for the government to be kept abreast of goings on," says Robert Yates, director of the global health programme at Chatham House.

Sumor Lomax Flomo, a coordinator at the National Public Health Institute of Liberia (NPHIL), which carries out surveillance for 21 diseases including yellow fever and tuberculosis, describes a recent example where a community health worker identified two cases of measles in Liberia’s north-central Lofa County.

"That quick work prevented a serious outbreak," he says. "If they have proper support, they can prevent, detect and respond to public health threats."

The health workers are familiar with and trusted by their patients, he adds. This means their work can also be critical in potentially tricky issues such as vaccination hesitancy – an important factor in an age of rumour and disinformation.

There are now some 4,000 community health workers across Liberia's 15 counties, according to data shared by Liberia’s Ministry of Health. Each worker, who must be nominated by fellow villagers and then pass a literacy test, receives months of training, covering topics such as malaria diagnosis, first aid and maternal health. They then engage with members of their community, helping to respond to any concerns, registering the details of households in the area, and aiding the launch of a community committee to discuss health issues.

Since the scheme’s nationwide launch in 2016, there have been considerable signs of progress. Around 80% of Liberia’s one million rural residents now have access to care, according to the Ministry of Health, with 7.1 million household visits carried out to date. That is resulting in faster care, according to data (which is not publicly available) provided by the Liberian government which shows the proportion of malaria cases treated in less than 24 hours rose from 47% in 2016 to 71% in 2021. Other diseases are also being picked up by community health workers: the number of detected pneumonia cases nearly trebled to 33,800 between 2017 and 2021, with a similar rise seen in the number of seriously ill patients referred to health facilities.

"A community health worker might go to a village, and then see all of a sudden a lot of kids sick," says Yates. "They are the best way to spot outbreaks quickly and bring in the cavalry."

The community health worker model also channels sorely needed income and employment to disadvantaged communities. Early indications also suggests the model is cost effective: the day-to-day running of standard health facilities would cost twice as much per year as the community health model to deliver the similar health services, according to an evaluation by Last Mile Health, one of the Liberian government’s implementing partners for the programme.

"The community health model has proven our best shot at reaching universal health coverage," says Ruston Yarnko, director of national community health systems at Last Mile Health. "It's improved prevention and control, surveillance and identification and coordination."

Just a few years ago, the picture across rural Liberia was dramatically different.

The country’s long underfunded healthcare system was decimated by civil wars between 1989 and 2003. In 2008, just 51 doctors were serving a population of 3.7 million people, many living in rural, hard-to-reach areas.

With the arrival of Ebola, trust in health institutions plummeted: outpatient visits dropped 61% in a year, immunisation rates among children more than halved, dropping to as low as 36% and women began to give birth at home again. Ebola killed more than 11,000 across the region, 40% of all those infected.

But the epidemic also marked a turning point for Liberia’s health service, which was forced to innovate in the face of disaster. The community health model was thrust centre stage, providing, among other things, an early warning system for outbreaks.

"Before Ebola, community members were not engaged and they were not given responsibility," says Olasford Wiah, head of community health for Liberia’s Ministry of Health. "One of the lessons we learned was the power of communities."

Community health workers’ ability to rapidly identify infections was crucial in putting an end to the outbreak in 2016, the year the model was scaled nationally. They were found to be more effective at carrying out Ebola-related activities than outsiders, and their relationships with locals proved resilient over time.

"Before, it could take days for villagers to be diagnosed," says Flomo. "By then, it was often too late. Community health workers cut the time it took for diagnosis and treatment to a fraction."

Life in Gipo, whose population of 4,600 relies heavily on subsistence agriculture, has markedly improved thanks to the community health workers, who visit people’s houses to check for signs of illness and are on call for emergencies.

Amelia Paye, a former farmer, has been watching over the community of Gipo, where she was born, since 2016. "I do this to help my people, my brothers and my sisters," says the 50-year-old.

My aunt’s child died of measles before. I don’t think that would happen again – Rita Leah
Zoonotic diseases – those transferred from animals to humans – are a particular risk in rural areas like Gipo, where local populations hunt monkeys and other bushmeat for food, according to Bernice Dahn, a public health expert at the University of Liberia and former chief medical officer for the country. These diseases are particularly likely to emerge in areas where humans mix with wildlife and account for more than 65% of all emerging infectious diseases globally.

Rita Leah, 26, who lives in Gipo says she sought help from a community health worker in December when one of her children had "hot skin". Within an hour the child tested positive for malaria, thanks to a rapid diagnostic test, and by the third day of treatment they were in good health. "My aunt’s child died of measles before," says Leah. "I don’t think that would happen again."

Community-based health schemes like those being used in Liberia are increasingly seen by global health experts as both an effective way of spotting and preventing epidemics and of delivering better healthcare to rural communities around the world.

The Independent Panel for Pandemic Preparedness and Response, which was formed by the World Health Organization at the onset of COVID-19 pandemic, has called on countries to further invest in community health workers to "build resilient health and social protection systems".

"The pandemic has shown there’s too much at stake to have half-baked programs or approaches," says Daniel Palazuelos, assistant professor of medicine at the Blavatnik Institute at Harvard Medical School. "The next emerging disease will be identified by a community health worker. They are living on the frontlines."

Several countries have introduced community health worker schemes over the past 50 years. In the early 1970s, Bangladesh – then the world’s poorest and most densely populated country – began to deploy its first community health workers, which have helped to cut maternal mortality by 75% between 1990 and 2015. Ethiopia’s 40,000 full-time health extension workers and three million part-time volunteers ensure that 92% of the population has access to care. In 1988, Haiti’s "accompagnateurs" formed the world’s first programme to provide free HIV treatment in the Global South.

The hope is that, in Liberia at least, the humble community health worker could play a key role in nipping the next emerging infectious disease in the bud
When not sufficiently backed, however, the community model can flounder. Experts have warned that the failure to support Brazil’s 286,000 community workers, who, unlike Liberia’s, are low-paid and not considered to be health professionals, has put them "at risk" during the Covid-19 pandemic.

But Liberia’s community health scheme is breaking new ground. One reason is its formalisation, which includes several months of training and fixed pay of $70 (£53) a month for four hours work a day, a considerable income in a country where people earn on average just $1.70 (£1.30) a day.

"I’ve always railed against volunteer-based programmes," says Paula Tavrow, adjunct professor at the department of community health sciences at the University of California, Los Angeles. "To have a paid workforce who is supervised and more accountable and better equipped is definitely an improvement. They become the final fingertips of the healthcare system."

Another key plank is Liberia’s commitment to employing one community health worker for every 350 villagers. "It’s one of the lowest ratios I’ve seen," says Palazuelos. "In many other countries, it’s 1 to 2000 or it’s 1 to 500."

The speed of the programme’s scale-up – going from dispersed pilots in 2012 to fully-integrated nationwide scale four years later – is also remarkable. "It shows that even extremely low-resourced countries can achieve this," adds Palazuelos.

But the programme still has its difficulties. In Nimba, Liberia’s second most populous county, community health workers report being overworked. Paye says she should be visiting five households a day in Gipo, but often it’s many more. "All day we are in the community," she says.

Drug shortages are a regular occurrence in the county, which has porous borders with Guinea and the Ivory Coast. Supply chains must be improved, workers say, but demand is heightened by influxes of migrants visiting for free treatment. "The improvement has been immense," says Ibrahim Kamara of Plan International, Nimba’s implementing partner. "But everyone wants a piece of the pie."

The model has also yet to overcome gender barriers such as societal gender norms and literacy disparities. Just 17% of Liberia’s community health workers are female, which can be problematic if female patients aren't comfortable interacting with a male health worker about pregnancy or reproductive health.

And while the priority for community health workers is the diagnosis and treatment of children under five for malaria, pneumonia and malnutrition in rural areas, Liberia’s wider population also has enormous health needs.

Yet amendments are on the way as Liberia’s scheme evolves to the end goal of universal health coverage.

In its second five-year strategy, set to come into effect later this year, reporting tools and methods are being improved – negative as well as positive malaria test results, for example, will be recorded. Training will be expanded from four to eight modules, including new areas such as administering injectable contraceptiveso tackle the low numbers of female community health workers, the minimum requirement of sixth grade education will be dropped to open up access.

"We are on the right trajectory," says Wiah. "But we want to see more being done."

Still, question marks remain over the long-term financial sustainability of the scheme, which is currently heavily reliant on funding from international donors such as US Aid and the Global Fund.

That funding could disappear at any time, particularly as governments cut foreign aid budgets. UNICEF, for example, provided technical and financial support to five Liberian counties from 2015 up until March 2021, when, according to a spokesperson, "it ran out of funds and could no longer support the programme".

A revolving drug fund (RDF) could be one solution. Here, users are required to pay fees for medication rather than receiving it for free, although those who can’t afford the fees can in theory be exempt. Implementing this system could help put an end to drug shortages. A pilot in Lofa County is currently trialling the system.

But global health experts argue that the Liberian government should take up the slack instead, arguing that introducing drug fees would see the poorest suffer. "It would be a huge mistake," says Yates. "Drug fees are inequitable and the poor get excluded – exemptions never work."

Yates points to the examples of Rwanda and Uganda, which scrapped fees, and Ethiopia, which pays for its community health workers through taxation. "I know public financing is difficult, but other countries have done it," he says. "But given Liberia’s economic situation, external funding will be needed for quite a while."

Studies show that the cost of the damage done by major outbreaks far outweigh the investment required to prevent them
Donors acknowledge the necessity of that long-term shift. A spokesperson for the Global Fund said it focuses on supporting countries in "moving away from donor financing toward domestically funded health systems" as they grow economically.

Studies show that the cost of the damage done by major outbreaks far outweigh the investment required to prevent them. The West African Ebola epidemic cost the region $6bn (£4.6bn), and the world $15bn (£11.4bn). Meanwhile, the Covid-19 pandemic is expected to cost the global economy at least $12.5 trillion (£9.6 trillion) by 2024.

The hope is that, in Liberia at least, the humble community health worker could play a key role in nipping the next emerging infectious disease in the bud. Meanwhile these workers on the health frontline keep their eyes open for anything out of the ordinary.

Under the baking afternoon sun, in Liberia's Wulu Town, Konobo, community health worker Emmanuel Poler examines a four-month-old whose mother has brought to him with swollen feet, a persistent fever, and, she says, "white eyes".

Wearing blue rubber gloves, Poler, 45, takes a pin prick of blood from the child to test for malaria, which comes out positive. Due to the severity of the symptoms, Poler refers the child to the health facility.

"They know the signs and symptoms themselves," says Poler, writing down the results in his large black notebook. "Now they come to me [for treatment]. They know that their health is in their hands. It’s in all of our hands."

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