Ebola has killed thousands, caused hundreds of millions of dollars in economic devastation and set off a global panic. But aid officials are hoping it also may help to address long-festering shortcomings in West Africa's health care systems.
Liberia, Sierra Leone and Guinea all suffer a dearth of doctors, a lack of supplies and training, and a concentration of clinics in cities rather than in the rural areas where many people still live. Those same problems have thwarted global attempts to eliminate quieter killers, like malaria and tuberculosis, in poor countries.
But talk in the international community is about moving from crisis management to long-term change — building systems that not only contain Ebola now but improve overall health in the long term.
When U.S. Agency for International Development chief Dr. Rajiv Shah called for a crisis response that "builds real resilience into the health systems," he was talking about more health care workers, stronger supply chains and permanent clinics. As aid begins to look past the crisis, the big question is whether gains to health infrastructure can last.
There are some signs of hope. In the past, aid workers struggled to reach rural areas in Liberia and Sierra Leone, but the epidemic mobilized the resources necessary to bring modern health care to some of the most remote parts of these countries, aid workers say.
Nongovernmental organizations like Oxfam have helped build community care centers, replete with clean water, toilets and electricity, in regions without hospitals. Now they're starting to think, "What can we do with those community care centers in the future?" says Shannon Scribner, humanitarian policy manager at Oxfam America.
Another reason Ebola has been so deadly in West Africa is the region's lack of health care workers. In the three nations where the virus has struck hardest, doctor-to-patient rates are stunningly low — as is the case in much of sub-Saharan Africa.
But community health workers — local providers of basic and sometimes lifesaving medical care — are starting to fill the gap. The Ebola response has leaned heavily on these workers, with foreign militaries training hundreds of people in basic health care and Ebola response by the week.
Shah expects the outcome will be "thousands of trained community health workers that should be able to power a community-based health response in West Africa for years to come."
To be sure, such statements have been made before during deadly catastrophes: Think of "build back better" after 2010's devastating earthquake in Haiti. While an emergency drives dollars for temporary clinics, equipment and even foreign armies — as seen in West Africa — aid tends to dry up once the crisis wanes. Coming up with practical ways to sustain investments won't be easy without political will from West Africa's governments and foreign donors alike.
"The vision of systemic change is the right way to characterize the opportunity, but in some ways it's incredibly optimistic," says Vicky Hausman, leader of the health practice at Dalberg, a global development consulting firm.
Sustaining an infrastructure of community health workers takes a plan — and money. Many of those newly trained workers are "still volunteer or quasi-volunteer," according to Hausman, and donors are often hesitant to pay their salaries once the crisis has receded.
NGOs have funded community health worker programs in Bangladesh, says Ariel Pablos-Méndez, USAID's assistant administrator for the Bureau of Global Health, but local government funding is usually more important in the long term.
One model that West African countries might adopt is that of the Ethiopian government, which directly employs tens of thousands of community health workers. Some international organizations credit that policy with major health gains, including helping shrink mortality rates for children under 5 by two-thirds since 1990.
With infection rates ticking down in Liberia and hope growing that Ebola will be contained in the coming months, international health officials are starting to look ahead.
The World Health Organization, the African Development Bank, the West African Health Organisation and the World Bank are convening a summit next week to look at how to "pivot from the acute response to reactivate services" and get these countries off crisis footing without falling back into the status quo, says Pablos-Méndez.
"I think everybody realizes that the weaknesses to these health systems made these countries vulnerable," he says.