In 2018, Kulah Quaqua heads to her job as a nurse at a community health clinic with the Gbarpolu County Health team, looking after patients and squeezing food bites during shifts. She grabbed a quick plate of rice or cassava soaked in a rich stew filled with oil and meat, and was often washed away with sweet soda. It was comfort in her busy life – heavy, stuffed, and cheerful.
With three young children, Kulah had little time for medical checkups and even less time for exercise. After consuming a heavy meal most nights, she was exhausted and craved into the bed. She was a photograph of modern life for women in Liberia. It was consumed by work and care, and there was no time to think about the long-term impact of her lifestyle.
But then I began to feel that something was wrong. Kura lost weight rapidly, felt weak and drowsy, and had no thirst. Her body was giving her unmistakable signs, but Kura pushed them aside. Her co-workers pull her aside and told her she was feeling unwell and needed to go to the hospital because she acted.
Kulah was diagnosed with what is known as “type 2” diabetes. This diabetes is a chronic condition in which the body does not produce enough insulin or is unable to use the insulin it produces effectively, leading to high blood sugar levels. Insulin is a natural hormone that converts food into energy and controls blood sugar levels. This type of diabetes can have a genetic component, but is primarily caused by lifestyle factors.
Kura might have been expected to know better. As a nurse, she may have known about diabetes – one of the fastest growing illnesses that torment Liberians. But in 2018, neither she nor her colleagues had any information about how their food and lifestyle choices were related to illness, she says.
Kulah is one of the most likely billions of people around the world fighting the rise in what is known as the umbrella term “non-communicable disease.” Unlike Ebola and Covid, they are not passed from person to person. They are primarily caused by lifestyle: unhealthy diet, lack of exercise and sleep, exposure to stress and contamination.
These include hypertension, diabetes, cardiovascular disease, chronic respiratory disease, mental disorders, and cancer. The NCD is the “next fad” in Liberia, according to Dr. Clement Peter, the head of the World Health Organization country. The true numbers for Liberia are unknown – no one is collecting data – but Dr. Peter says they are surprisingly high.
A 2016 study estimated that preventable diseases and injuries accounted for almost 40% of Liberia’s total disease burden and more than 43% of deaths. Experts say this number is likely to be much higher today.
The tragedy, experts say, is that although there may be genetic factors, almost everything can be prevented. However, in Liberia, people face two major problems. It’s a lack of information about illness and a life-saving lifestyle change. And once they have information, it is difficult and expensive to access fresh fruits and vegetables that will help keep them safe.
The majority of people are undiagnosed and suffer from symptoms that can lead to blindness, amputation, low energy and ultimately death. Those diagnosed will be diagnosed live on a roller coaster trying to manage their illness and pay for expensive medications.
Liberia’s health care system was slow to recognize the risks of NCD
When Kura was first diagnosed, she went to all of Liberia’s major hospitals for help. She meets a medical maze that left her confused and frustrated. She took expensive medications to control her blood sugar, but she still felt sick. Four years after her diagnosis, she developed asthma. This is a more common disease in diabetic patients.
By then, Kura had weighed only 84 pounds and had been awake with gasping for the air. She worried that she might die. She collected her savings and traveled to Kigali, Rwanda.
In Rwanda, doctors have discovered that Kura is dangerously hypoglycemia and malnourished. They quickly switched her to a diet rich in fresh fruits and vegetables. She was encouraged to drink water and avoid sweet drinks and alcohol. She also gained daily exercise and 7-8 hours of sleep.
Kura finally learned the key to improving her health. The doctor taught her that the most important treatment for her is diet, not medicine. The medications were unable to control her symptoms. She had to change her lifestyle.
Kura began to feel better. She regained her strength. She no longer gasped because of the air. She was excited that her new diet and lifestyle would protect children at high risk of developing diabetes due to their diet. However, when Kra returned to Liberia, she quickly realized the challenges she faced to stay healthy. The fresh, raw fruits and vegetables she had in Kigali were difficult to find in Monrovia.
“The carrots here are very expensive,” says Kura. “Feeding fruits – especially families with many children – we can’t afford it. Every morning, I’m scared. I wonder if my sugar is normal. I wonder what I’ll eat today?”
Kulah lost his job in 2024. Her husband fought another NCD, high blood pressure, and she was a family’s earner. They are now struggling to survive and stay healthy.
“In Liberia, whatever you can afford, that’s what you can eat,” says Kura. “So you’re dependent on your pocket. How many people can afford an apple just for yourself?”
It’s important to change your diet, says the country’s representative, retired Dr. Peter. “People have to eat fresher fruits and vegetables, not just good looking drinks, but also lean meat and oils like palm oil. We can prevent them,” he says of the non-infectious disease. “That’s the only remedy.”
Food systems to prevent malnutrition rather than NCD
With the aftermath of the civil war and the devastation of the Ebola outbreak, Liberia has focused on basic priorities. It is basic health care and the reconstruction of the agricultural system that prevents malnutrition in children, particularly in children. The construction of a food system to deal with NCD was not on the radar.
Rwanda has made extensive reforms to improve agricultural production despite the continued major challenges. NCD prevention and malnutrition were among the factors behind its reform. Liberia has come a long way, according to Jonathan Stewart, chief executive of Agro Tech, an agricultural development company that works with farmers and other stakeholders.
Almost all of Liberia’s agriculture is grown enough to eat and sell for a small profit by small “subsistence” farmers. The terrible roads in Liberia make transporting vulnerable fruits and vegetables almost impossible. Without a storage facility, there is no place to store fresh fruit for a period of time.
“Vegetables are prone to perishing,” Stewart said. “They will be spoiled within a few days. It is actually a risk to vegetable sellers. Therefore, the produce cannot feed us as a nation in terms of what we harvest or sell.”
Stewart says they must invest in roads and storage and strive to ensure farmers grow and sell to encourage fruit and vegetables to be produced sufficiently to feed people like Kura and the William government.
Dr. Peter agrees. He wants to see a nationally coordinated plan.
“Is it difficult to grow fruits? It’s not,” he says. “This is a very important partnership with the Ministry of Agriculture, and a very important partnership with other relevant ministries. NCDS is not just purely medical issues. Information campaigns can run educational campaigns through the Ministry of Information, gender (municipality), etc.
Dr. Peter urges the government to focus much more on other measures, such as awareness raising and soda and alcohol regulation. He welcomed the government’s recent tobacco ban – there was little smoke for the Liberians – but I hope that it goes further.
“The cost of soda bottles is the same as water bottles, and more people will prefer soda that doesn’t know the dangers pose to their health,” he says. “Many unemployed young people compromise on stress by drinking locally made alcohol, which is also low prices.”
Medicines are available, but they are expensive and cannot be treated only for illnesses
William Pugh, 54, was diagnosed with hypertension and diabetes in 2019, is lucky more than most people. He is enrolled in health insurance through his job as an accountant for the Ministry of Health, paying for drugs that lower blood sugar levels. But I don’t pay $25 for 50 test strips. He should check his blood sugar and stab his insulin if he is too high or too low, he should stab his finger three times a day.
William is still in bad condition. He lost weight, but he is still battling blood sugar spikes. He doesn’t want to take insulin. Instead, he relies on diet and medication to try to control his blood sugar levels. He has what is known as the “diabetic foot,” so he does not dare cut his toenails. Decreased blood circulation and nerve damage mean that ablation can lead to an uncontrolled infection that can lead to an amputation. It’s not easy.
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“Sometimes, I have to leave town for my family to fuss,” William says. “But I can’t get out there because if I leave this and leave town and work, I have to eat things that I shouldn’t have.
The Ministry of Health published its first NCD policy in 2017 and established an independent unit in the ministry. As the crisis worsened, the Ministry of Health raised funds to integrate NCD diagnosis and awareness into hospitals and clinics across the country. (We’ll look at those efforts for future stories in this series.)
Patients here at the government-run James N. Davis Jr. Memorial Hospital, Memorial Hospital in Neesoe, Montserrado County, and the diabetes clinic, are sitting on several benches waiting for blood sugar levels to be tested or treated for diabetes.
The clinic begins in 2012 with support from Australian diabetes and cares only for the number of children with type 1 diabetes. This is not caused by lifestyle. Type 2 – A type caused primarily by lifestyle – Diabetic patients under the age of 30. Adult patients pay a registration fee of $L500 ($US2). Since the program launched an awareness campaign in 2022, the number of patients has steadily increased here to a maximum of 30 a day, according to Donetta Hoff, the hospital’s diabetes focal group.
“I want the central government to know that this diabetes is a serious crisis in Liberia,” says Hoff. “We have a lot of people dying of diabetes because we can’t afford medicine.”
Part 1 of this series examined the increase in the incidence of NCD in Liberia. The series is a collaboration with a new story funded by the Swedish embassy in Liberia. The funders were not making any comments on the content of the story.
