Health care workers in February at the Logan Town clinic in Monrovia, Liberia. On Saturday, Liberia is expected to be declared free of Ebola by the World Health Organization. Credit Daniel Berehulak for The New York Times
MONROVIA, Liberia — When a taxi dropped off a man dying of Ebola one evening in June 2014, the Logan Town clinic was defenseless.
Workers had no protective suits — only a few pairs of faded gloves and a shaky grasp of infection control. They examined the patient by candlelight and washed their hands in buckets.
That single case set off a chain of contagion that killed six of the clinic’s 29 employees and at least nine of their relatives, including one of the country’s top basketball players, as Liberia became the center of the deadliest Ebola epidemic in history.
Ten months after that fateful evening, the Logan Town clinic is now equipped with a triage room and hand-washing station near the entrance, an isolation room, a large generator and a water pump that feeds the taps.
“From the improvements, and how we examine the patients now, Ebola will not come back,” said Bessie Johnson, 32, a nurse. “It won’t happen again.”
On Saturday, Liberia is expected to be declared free of Ebola by the World Health Organization, having gone 42 days since its last victim was buried, or twice the maximum incubation period of the virus.
It will be a seminal moment for a country that was once so overwhelmed by the epidemic that bodies littered the streets and hospitals shut down, leaving the sick helpless, often seeking treatment in vain.
“I am thrilled by the significant progress made by the people of Liberia,” said Tolbert Nyenswah, a deputy health minister. But, he warned, “we still need to keep up vigilance.”
The weak health systems in Liberia, Sierra Leone and Guinea, the three nations hit hardest by the disease, did more than just crumple in the face of Ebola’s onslaught last year. They played a central role in spreading the disease.
Clinics routinely misdiagnosed the disease and discharged Ebola patients with pills for common illnesses. Infected health care workers passed the virus to their colleagues, families and communities.
Local and international health officials are now focusing on extinguishing the waning Ebola epidemic in Guinea and Sierra Leone. But they have a bigger goal as well: shoring up beleaguered health systems that were inadequate long before Ebola struck.
In the decade leading up to the epidemic, the three nations made significant health gains, especially in reducing child mortality. In Liberia, immunization rates for childhood vaccines and life expectancy had risen significantly. Health programs were one of the biggest recipients of aid from the United States, the European Union and other donors.
But long-running conflicts, poverty, mismanagement and corruption left the three nations with some of Africa’s weakest networks of health care centers and workers.
Only 51 doctors were working in Liberia, a nation of 4.5 million people, at the time of the outbreak, the W.H.O. says. Even the biggest hospitals here in Monrovia, the capital, lacked running water, electricity and basic supplies like gloves.
Ebola has killed more than 500 health care workers in the three countries, worsening an acute shortage of medically trained personnel.
During the height of the epidemic last year, more than half of Liberia’s health facilities ceased operating. Those that stayed open offered only limited services, often refusing to treat patients without proof that they were free of Ebola.
Many pregnant women were refused admission to maternity wards when workers fearful of being infected avoided delivering babies. Immunization rates for measles and other childhood diseases fell.
Many of the sick, afraid of being infected or classified as Ebola patients, stayed clear of hospitals. Unable to find treatment for malaria, diarrhea, typhoid and other common illnesses, many people are believed to have died for other reasons during the epidemic because the health system collapsed.
Dr. Bernice Dahn, who was recently picked by Ms. Johnson Sirleaf to be Liberia’s new health minister, said that most of Liberia’s health facilities had reopened and were providing basic services.
The government, Dr. Dahn said, will focus on raising the quality of its health work force, on emphasizing disease prevention and control and on adding triage and isolation facilities.
Physical improvements have already been made to many hospitals and clinics, where infection control training has taken place.
But there is a lot more to do, and finding the money will not be easy.
Last month, Liberia put forward an Ebola recovery plan that included its ambitions of building a “more resilient” health system — along with better schools, sanitation, and access to clean water — at a cost of hundreds of millions of dollars.
Given that Ebola delivered a huge economic blow to an already poor country, much of the money it needs to rebound from the epidemic will have to come from outside Liberia, the plan makes clear.
And some improvements can be fragile. During an Ebola outbreak in a neighborhood called St. Paul’s Bridge in February, the sick scattered to community clinics, and hundreds of health care workers had to be placed under quarantine. A half-dozen clinics were shut down temporarily.
Dr. Dahn said that triage was not carried out properly at the affected clinics, adding, “It’s difficult to change behavior. It requires a lot of coaching and mentoring, which need to go on.”
Even if the country is declared Ebola-free on Saturday, the threat persists. Infections continue across the porous borders with Guinea and Sierra Leone, though in much smaller numbers, and experts warn that another outbreak at some point in the region is a near certainty.
Here in Monrovia, a major goal is rebuilding the government-run Redemption Hospital, the first health center in the capital to be crippled by Ebola. Its closing in June had a domino effect on the city’s other health facilities.
Though it is the second-largest hospital in the capital, Redemption had only sporadic running water and electricity before the outbreak. Its roof leaked. Its plumbing and sewage systems did not function. Medical and regular wastes were burned together in the open. Septic tanks underground often overflowed and gave off a fetid stench.
“You feel you want to give up; I never wanted to come to this place, Redemption, again,” he said, adding that his wife managed to recover nonetheless.
Because of overcrowding, patients were often placed in any ward with an available bed; in pediatrics, two to three children often shared one bed, said Dr. Phil Afolabi, who has worked at Redemption since 2009 and is now employed by the International Rescue Committee, the aid organization based in New York that is rebuilding the hospital.
“Infection control was not a main concern at the hospital,” Dr. Afolabi said, as construction crews loudly tore out walls and floors. “So many things have actually not been in place at the hospital, and that’s been the case for a long while.”
In June, after a young woman with Ebola was admitted, eight health care workers at Redemption died in quick succession. The hospital, located in New Kru Town, one of the largest slums in the capital, was shut down.
The sick flooded the area’s private clinics, including Logan Town. The clinic serves an area of 20,000 people, according to the aid group Oxfam, which has made $7,200 in improvements to the clinic.
By the standards of Monrovia’s community clinics, Logan Town was average. Two physician assistants led the medical staff, helped by a doctor who visited twice a month.
An old generator seldom worked. Drugs and equipment were always in short supply; the staff used gloves only for deliveries and minor surgeries, and reused them until the color faded. Janitors fetched water in buckets from a neighborhood well.
“It was difficult, especially when the patients were sick and needed to use the bathroom,” said Nancy Kanneh, a nurse. “Often, we didn’t have water to wash our own hands.”
On the evening of June 25, about a week after workers at Redemption started dying, Logan Town took in a young Ebola patient named James Fallah, the caretaker of a nearby Pentecostal church, United God Is Our Light.
The security guard who had wheeled Mr. Fallah into the building held him down a few hours later when he became violent before dying. A week later, the guard came down with Ebola and passed on the virus to two of his children and one grandchild, all of whom died.
After the guard was treated at the clinic, the contagion widened to five other clinic employees. All of them died, including the chief administrator, Edwin Dour, who fatally infected his son, Kaizer, one of Liberia’s most promising basketball players. Kaizer, in turn, passed the virus on to five family members, who all died.
The clinic, which closed for three months, is now operating only during the day and seeing about half of the patients it treated before the epidemic.
“Because of the stigma, people that used to come here before are afraid to come,” said Edwin Sengar, the physician assistant who is now in charge of the clinic.
Some of the staff members had not returned, either.
“I’m afraid,” said Moses Safa, the physician assistant who was on duty the night the Ebola patient was brought in. “I’m not doing anything now. I’m just staying at home. Maybe I’ll go back after Liberia is declared Ebola-free.”