Jacob is one year and five months old, but you wouldn't know by looking at him as the shy, malnourished boy rests on his mother's shoulder in the Pipeline Community Clinic located on the outskirts of Monrovia. Starting in September, he refused his mother's breast milk for five months. The 25-year-old woman, Agnes Tweh, was worried about her son's health, but due to the Ebola outbreak that began to spread through Liberia last year, she was unable to access treatment or routine immunizations for him.
Tweh and Jacob's experience is similar to that of other Liberians in recent months, as the spread of the Ebola subsides and residents in the country make their way back to medical clinics. As the influx of patients increases, however, the U.N. children's agency, UNICEF, said it is seeing an increase in cases of malnutrition and a "sharp drop" in vaccination rates - something that could have a long lasting effect on Liberia's children, well after the Ebola outbreak burns itself out.
"[Increase in Malnutrition] is something that we would expect because of course there was a decrease in commerce and decrease in income," Sheldon Yett, UNICEF's country representative in Liberia, told VICE News, adding that vaccine rates dropped 30 percent in December 2014 compared with December 2013. "Particularly during the height of the epidemic, people couldn't go to the health centers to take their kids to go get their routine vaccinations."
After the virus made its way to the capital city in June, residents watched as their neighbors fell ill, dead bodies were carted away from homes or streets, and healthcare facilities became overrun with Ebola patients. This instilled fear in women like Tweh, scaring them away from medical clinics, even to treat their babies in need of essential newborn care. On top of the fear, many clinics shut their doors because they were not equipped to operate in the conditions of the Ebola outbreak.
"Five months he refused my breast milk... I worried about him a lot," Tweh told VICE News, explaining that she was scared about what would happen if she took Jacob to a hospital. Jacob also missed vaccinations he was supposed to receive in July.
"Because of the Ebola outbreak I was afraid," Tweh said.
Between June and December, after the disease's spread finally began to slow, healthcare centers were either closed or received very few patients, meaning many young children like Jacob did not receive medical treatment during this period. Tweh finally brought the boy into the UNICEF-supported Pipeline clinic - which remained opened throughout the outbreak, but saw a drastic drop in patients - after realizing that other children going for treatment were not contracting the hemorrhagic fever that has infected nearly 24,000 people in the last year, mostly in Liberia, Guinea, and Sierra Leone.
"I'm not afraid, I can see others coming and nothing is happening," Tweh said.
During her second visit at the clinic on March 3 - the first taking place in the middle of February - Tweh sat in a small room in the open-air clinic with her son, lined up next to a row of other mothers and babies seeking treatment for malnourishment - for which a medicical treatment called Plumpy'nut is prescribed. They are evaluated by nurses, but the procedures have changed slightly in the wake of the virus. Now, the clinic workers wear a partial form of protective gear, which includes gloves, face masks and gowns. They change gloves between each patient, wash their hands, and also use disposable tapes to measure the child's limbs, which is a key indicator of malnourishment. The babies are no longer weighed, as the equipment would be too challenging to clean between every patient, and too expensive to render disposable.
UNICEF is still compiling exact figures on the increased rate of malnourishment cases, but Yett said observations indicate they have gone up. Nurses at the clinic also said they were seeing more cases after the outbreak.
While Ebola may have only lasted a year, growing malnutrition rates as a result of the outbreak could have serious long-term effects on these childrens' lives, according to UNICEF. Yett chronic malnutrition can have a permanent effect on a child's ability to learn in school. He also noted that it was the largest single contributor to premature death.
"Some of the studies that we have seen have shown that [malnutrition] can lead to income reduction of up to 22 percent," he said. "The first 1000 days of life are the most critical of any child and that's why its really important for a young child to have proper nutrition in those years."
When it comes to vaccines, the impact of Ebola may already be materializing. In 2013, for example, Yett said around 74 percent of immunization eligible children in Liberia had received the Measles vaccine. But in 2014, these rates dropped by 15 percentage points to around 60 percent.
"In the world of vaccination that's a sharp drop," Yett said. UNICEF is working to boost vaccinations throughout the country using community support systems. Pipeline clinic is currently administering vaccines to children, and as with the new guidelines for diagnosing malnutrition, updated safety protocols are in place to ensure all of the injections are safely administered.
During the outbreak, fear of Ebola and inability to access the treatment center was likely the cause of the decline. In recent months, however, everyone from UNICEF to the Pipeline Clinic staff and various doctors from other centers are concerned that a recent Ebola trial vaccine being administered in the capital is scaring mothers away. In other scenarios, rumors that children would be injected with Ebola have also reportedly scared mom's away.
"We had vaccines trials. We've heard reports around the country about mothers not wanting to get their kids vaccinated," Yett explained.
UNICEF, Doctors Without Borders (MSF), and IRC all say cases of measles appear to be cropping up in parts of the country, which is likely due to the drop in vaccination rates and general impact on the healthcare sector. Nick Lobel-Weiss, a hospital project coordinator with IRC currently based in Liberia's Maryland county, told VICE News he has also seen illnesses that could be Whooping cough.
MSF said in a recent statement there were suspected Whooping Cough in the county as well. No aid organizations working in the area have been able to confirm the cases of measles or whooping cough, however, because Liberia does not have testing capabilities. UNICEF said the proper equipment was being sent to the country.
"Since the Ebola outbreak there's been a comprehensive destruction of health services all across the country," Lobel-Weiss said, explaining that everyone has understandably turned to fighting this frightening illness. Another factor deals with the fact that many still feel facilities are not safe.
Despite the fact that the effects of Ebola on childrens' health are already materializing, the effects can be reversed if healthcare systems are restored and trust in medical services is also rebuilt.
"With what happened in this past year - and we haven't even seen the impact of what that's like, we may not know for years - once the dust settles on this... what do we do?" Lobel-Weiss asked. "The answer is we have to get back to these core things."
A key element to fixing the broken system is involving the community at the grass roots. This was evident at Pipeline Clinic, where many of the children have been identified by nurses and community workers while wandering neighborhoods and markets, often simply in their spare time.
Just two chairs down from Jacob was a 10-month-old boy named Reverend, whose collar bone was poking out and his thin limbs dangled in the lap of his mother, Vivienne Small. In December, after months without care, a nurse from the clinic spotted the child in a market wrapped to his mother's back. The nurse asked Small to take her son off her back so she could examine him. After determining he was likely malnourished, she told the mother about the clinic and the program that would treat him.
"The Ebola it was not easy. We didn't move," Small explained. "I was thinking about him because he was sick."
Explaining why he had started coming to the center, every two weeks starting in December, she said "he was dry so I bring him to the hospital."
Yett explained that community action was crucial for getting through the recovery stage of Ebola, while also keeping the virus from spreading again.
"The most important issue is working at the community level, building up the community structures put in place," Yett said. "Empowerment allows us to bend the curve of [the Ebola outbreak]."
Follow Kayla Ruble on Twitter: @RubleKB