How can a woman survive Ebola and then die in childbirth? Easily, if you live in a low-income country where there are big gaps in skilled birth attendants, clinics are far away, and you generally think people who go to hospital never come out. Compound that with the continued stigma associated with Ebola, the death of a woman such as Salome Karwah from childbirth complications is not a surprise, but should be a source of deep shame to the global health community.
The news of the death of Salome Karwah is deeply tragic for her family and friends. It is deeply tragic for global health. Karwah's life shows how global health rests on the bravery of individuals when combatting outbreaks such as Ebola yet cannot attend to their basic needs. Karwah was there when the global health community needed her in the fight against Ebola, but the weak health system in Liberia and the much-promised post-Ebola recovery plan for the health sector were not there when she needed them.
My life at the moment is full of friends' babies. My Facebook feed is a constant stream of the latest baby and exhausted but delighted Mum in their hospital bed. Sometimes when I look at these pictures I think about how many of my friends would not be alive if they lived in a developing country, where 99% of the 830 women who die every day from childbirth live. That 830 women die everyday from preventable reasons and while giving life is beyond tragedy. If maternal mortality was infectious it would be a pandemic. Why does nothing happen?
The good news in this grim tale is that things have improved. The World Health Organisation reports maternal mortality declined by 43% since 1990 to 2015, with things speeding up to a 3% decline from 2000 in response to efforts to combat maternal mortality through the United Nations Millennium Development Goals. The UN and Bill and Melinda Gates have been very vocal about this issue, and in the case of the Gates Foundation, invested resources to reduce maternal mortality even more and at a quicker pace.
The bigger problem is the wider system of global health governance that is supposed to address global health challenges around the world. Not all global health challenges are created equal and the issues that get attention and money are predominantly those seen as a risk to the world, particularly people living in developing countries. This is why the global response to Ebola stepped up once there was a confirmed case outside of West Africa, partly why HIV/AIDS occupies more attention than diarrhoea, and why the World Health Organisation wants to establish a Health Emergencies Programme. Women continue to die in childbirth in developing countries because they pose no threat to the developed world.
Because global health governance is skewed towards mitigating risks to people living in developed countries, vital challenges of global health such as health systems strengthening - training nurses and midwives, building clinics and hospitals, procurement etc - goes under-funded. Everyone working in global health knows the key to realising most global health targets is to strengthen health systems but no-one knows how to convince states and philanthropists of how to invest in this. Financing specific diseases interventions is easier to account for by showing results and performance indicators. Health systems are trickier to measure and often involve complex political engagements with health ministries.
Finally, global health governance neglects the needs of women. Women were conspicuously invisible in the Ebola response. HIV/AIDS prevalence and care is extremely gendered. Women still die in childbirth from preventable causes. Women in developing countries shoulder a huge burden of care that fill the gaps left by weak health systems and non-existent welfare. Global health institutions have shown commitments to women and health and to combating maternal mortality. However, such commitments are commonly undermined by institutional side-lining of gender experts, highly patriarchal countries in which such plans are operationalized, and the disregard of questions of gender in health emergencies as not a pressing issue.
When Karwah was dealing with Ebola she was a potential risk to the world, her pregnancy was only seen as a risk to herself. She was fortunate to make it into a clinic, however stigma meant she became another devastating stereotype of a person who goes in alive but comes out dead. How an individual who was showed both bravery, protection and care to others in providing health could die from childbirth complications should bring shame to all of the global health community. Her death should shake global health governance to its core.