The final day of Sierra Leone’s most recent ‘Ebola-free countdown’ in March 2016 coincided with news of a fresh incidence of the killer disease in neighbouring Guinea. A mix of scientists and government officials were picking over the lessons learned from the epidemic at a symposium in the capital Freetown.
‘The WHO [World Health Organization] can stop announcing that we are “free of Ebola”, said Professor Radcliffe Lisk, vice-president of the West African College of Physicians. ‘It is absolutely futile and irrelevant, considering what happened in Guinea yesterday. You can only be free of an epidemic.’
‘We should talk of when, not if,’ agreed Tina Davies from Sierra Leone’s ministry of welfare. A row of grim faces on the platform suggested that everyone knows they are in this for the long haul.
Sierra Leone has learnt the hard way – after over 14,000 infections and nearly 4,000 dead. There is resolve: ‘Let us understand one thing,’ says Stephen Ngoujah from Sierra Leone’s National Ebola Response Co-ordination (NERC). ‘The scope and magnitude of this epidemic will not happen again.’
For now, Sierra Leone is on high alert. The virus is known to linger on in the bodies of survivors and can be sexually transmitted. Dead bodies are still being swabbed, a skeletal response infrastructure is still in place. But how do we keep West Africa safe from this – and other epidemics – in the future?
The answers have less to do with medicine than you might think. The first place to look for them is in the nature of the response to the outbreak, which allowed things to spiral out of hand.
A botched response
Sierra Leoneans are no strangers to deadly disease: life expectancy, at just 46, is one of the lowest in the world and one in ten children do not live past five. But the Ebola virus was different, in part due to its terrifying 60-per-cent mortality rate and the way that it killed. This was a disease spread by love – through those who cared for the sick. It wiped out entire families in one fell swoop, especially in the early days.
Deaths were undignified, often delirious. Households were cut off from one another, all social gatherings banned and people went hungry, quarantined in their homes and neighbourhoods. No-one escaped the economic impact of the stringent measures put in place to stop it – restrictions on movement that brought trade and agriculture to a standstill.
‘It’s not easy to forget my colleagues. The ones who lost their lives weren’t even being paid’
We’ve known about Ebola since 1976, but the previous 26 outbreaks – mostly in Congo and Uganda – were brought under control within three months. The failure to contain it successfully in Sierra Leone, Liberia and Guinea this time has prompted a slew of soul-searching – and at times anguished – reports from medical and multilateral institutions and NGOs. They concur on a chronic lack of leadership from the WHO, and accuse national governments of being painfully slow to act. (The WHO, in turn, blames its inertia on deep budget cuts.)
The Sierra Leonean government now openly admits that it was not prepared. Even though, in the words of Stephen Ngoujah, they ‘knew it was coming’. In March 2014, when the first cases crept in, Ebola had been slowly spreading through neighbouring Guinea and Liberia since the beginning of the year. With just 136 doctors for 6.2 million people, a dearth of hospitals, equipment or centralized logistics, Sierra Leone’s Ministry of Health didn’t stand much of a chance.
But instead of admitting that it could not cope, four months of unproductive high-level meetings ensued. Repeated, frantic warnings from Médicins Sans Frontières – one of the first NGOs to respond – were ignored. It would be five more months, and nearly 1,000 deaths, before the WHO declared Ebola an international health emergency that would prompt the influx of funds and resources to help bring the virus under control.
In the early days of the epidemic, public health messages were confused. Perhaps the most pernicious message was that Ebola had no cure. This served to reduce trust and confidence in an already dysfunctional and long-neglected health system and encouraged Ebola sufferers to turn to the supernatural for solutions, seeking cures from traditional healers. The sick would break out of clinics, preferring to take their chances in the bush.
As Shek Ahmed Bobor-Kamera, an emergency programme officer with Christian Aid, explains: ‘The messaging was really bad. It failed to look at culture and tradition and how people respond to situations like this. In our tradition, if one of my people dies, I have to stay with them until the end. The message was: “Don’t touch the sick! There’s no cure!” This is my mother, my child. I have to abandon my child? When they took them, you didn’t see them again – they never came back to report on that person’s progress.’
Shek Ahmed also says the initial emphasis of the Ebola response was too focused on medical solutions (‘it was all “treatment, treatment, treatment!”). The influential locals – faith leaders, traditional healers, mammy queens and paramount chiefs – who were best placed to communicate with people at risk were not involved in the response until far too late. Once communities were enlisted, though, evidence suggests their impact was decisive.1
‘They accepted the message from us: “Ebola will leave us, if you do this,”’ as Moses Escanu, a teacher who was part of a local Ebola task force in Binkolo, Bombali District, explains. He was part of an army of volunteers, supported by Health Poverty Action, who enforced a set of draconian bylaws that stopped movement and forbade hiding sick people, refusing an Ebola test or ‘harbouring strangers’. First thought up by paramount chiefs in Kenema, the bylaws were so effective that the government rolled them out nationally.
‘You couldn’t bring in enough doctors and nurses,’ says Mike McDonald of the Global Health Response and Resilience Initiative. ‘You had to stop the transmission – mathematically, that’s what had to happen to shut down the epidemic. Communities did that themselves.’
Enter the internationals
The global humanitarian response, when it came, midway through the crisis, was truly impressive. Countries from across the world from Togo to Liechtenstein all threw something into the pot, alongside international banks and institutions. The US and Britain were major donors, mobilizing $2.1 billion and $687 million respectively, and by October 2015, $4.6 billion had been disbursed, in grants and loans, according to the Office of the UN Special Envoy on Ebola.
Alongside 39,000 local health workers, and large numbers of surveillance and community mobilization staff, some 1,300 foreign medics took part (including 850 volunteers from other African countries and a delegation of Cubans) and over 1,000 WHO and UN logistics personnel.
It was a generous display of solidarity. But it came too late for many Sierra Leonean health workers, who were working in unprepared, overwhelmed facilities. The World Bank has reported that Ebola killed five per cent of doctors, and seven per cent of nurses and midwives.
Nafisatu Jabbi was the only survivor of her four-woman team, who ran a maternal health post in Koindu, Kailahun district, the early epicentre of the outbreak. ‘It’s not easy to forget your colleagues. The ones who lost their lives were not even being paid,’ she explains. Their situation was not atypical: in Sierra Leone’s chronically underfunded health system, trained nurses are expected to volunteer for years before earning a salary.
Her best friend Mercy was among those who died. It was early May 2014, just days before the first confirmed case. ‘We thought Mercy had cholera. I cleared up her vomit, felt her skin, took her temperature,’ she says. ‘We trained together; we were like sisters.’ Five other nurses they trained with went to visit Mercy when she was sick, and later died. Nafisatu herself never contracted Ebola. With all the other clinic staff either dead, infected or having fled, she ran the centre alone, delivering babies in the morning and staffing an Ebola holding-centre in the afternoon, while caring for Mercy’s three orphaned children. Later she would earn some hazard pay, at $80 per week.
Nafisatu’s experience raises questions around the allocation of resources. The science journalist Amy Maxmen has documented how Save The Children spent an $18.9 million grant from Britain’s overseas aid office DFID to set up an Ebola Treatment Unit (ETU). The ETU treated some 280 patients, after opening in stages in November as infections peaked. Staff salaries and living expenses spoke for $12 million of the grant. From all the millions that flowed in, Maxmen found that less than two per cent was earmarked for frontline hospital workers. This imbalance is symptomatic of a wider problem in the humanitarian industry, which tends to exclude the locals. Last year’s World Disasters Report shows that just 1.6 per cent of funding to tackle global crises went to in-country NGOs, while just three per cent went to national states.
‘I felt some foreign agencies prioritized health worker safety over patient care,’ says young military medic Boie Jalloh, specifically in relation to one medical NGO’s policy not to administer intravenous fluids for Ebola patients.2 Jalloh was 29 and less than a year out of medical school when he set up and ran an ETU in a former police training school on the edge of Freetown, where he would go on to treat over 1,000 patients.
‘We needed these people. They did very well. They were very swift at opening ETUs and raising the alarm,’ he says. ‘But if it happened again I would do things differently. By setting the goal as isolating patients, that put people off coming because everyone died.’
Ebola has added another layer of trauma to an already fragile society. When the virus hit, Sierra Leone was still recovering from a vicious 10-year civil war that ended in 2002. Some 70 per cent of people lived below the poverty line. The epidemic wiped out a recent financial upswing, with the economy taking a double hit from the trading restrictions, withdrawn investment and blocked foreign trade provoked by Ebola, and the collapsed price of iron ore, a key export.
Eighteen months since the peak of the outbreak, the recovery has barely begun, as any Sierra Leonean will tell you. Both of the country’s main occupations of farming and petty trading suffered in equal measure. The farmers missed two growing seasons. They were forced to eat their seed stock of ground nuts and rice to survive. In a similar fashion, traders were forced to use up their assets, or ‘eat our business money’ as market trader Theresa Jusu put it, becoming unable to start up trade again.
Still, it is Ebola survivors, orphaned children and their carers who bear the greatest burden in families stretched to the limit. While less stigmatized than in the early days of the disease, some 17,000 survivors across West Africa have ongoing health problems with eye conditions, debilitating joint pain and loss of hearing. Depression and post-traumatic stress disorder are widespread.
Sierra Leoneans will also point out that Ebola has brought some changes for the better. For one thing, the country now has a fledgling mental health service, with 20 nurses operating across all districts who are able to offer counselling and support for some of the many thousands left traumatized.
Standards of hygiene and care in hospitals are also improved. ‘It used to be hard to see a packet of gloves here,’ remarks Mark Ali, the medical officer in charge of a freshly painted emergency ward at Connaught government hospital in Freetown. ‘Now things are easier.’ He is working alongside Kings Partnership Sierra Leone, a British charity that builds up health systems through long term co-development. One positive legacy of Ebola is that Kings has scaled up from a $146,000 per year operation to close to $2.9 million. That means, among other things, that Connaught now has piped oxygen (which has led to a 20-per-cent improvement in mortality rates) and a functioning triage system.
Outside, Spanish doctor Marta Lado is standing at the entrance to another Ebola legacy – Sierra Leone’s first infectious diseases isolation unit, which can now serve patients with TB, Lassa fever and cholera. Lado was working as a clinical manager for Kings when Ebola hit, and refused point blank to leave. She cared for over 1,000 patients in an improvised isolation ward at Connaught with a British nurse and a handful of local staff in very difficult conditions. ‘The way I coped with the terrible things that I witnessed is that I stayed on. Now we start to see the real value of partnership,’ she says. ‘The new unit is run entirely by the nurses. Healthcare workers have this new confidence and pride in what they do; they want to improve the hospital. And that came from Ebola. Don’t ask me how, but it did.’
‘It was a steep learning curve but we are all experts now – our clinicians are the most experienced in the world,’ says Boie Jalloh, whose outstanding role in the response won him a presidential award, which he shrugs off. ‘Thousands of others did more than me, in their quiet corners. I am just happy to be alive,’ he says. It is a point of pride to him, however, that the ETU he managed was set up and run by Sierra Leoneans. He wants to see local research capacity enhanced so it is not just international experts presenting papers on Ebola at conferences.
Another unexpected legacy is a more united country with a stronger civil society. ‘We have seen what was possible, we can build solidarity and act together,’ says Fatou Wurie, an activist who runs the Survivor Dream project. ‘We have to hold Sierra Leone to account. It’s not enough to say health or women’s rights is a government priority.’
‘Healthcare workers have this new confidence and pride in what they do – and that came from Ebola’
Meanwhile, the Budget Advocacy Network is pushing for changes in tax regimes for mining companies that would see more money available for public services, and for an IMF debt write-off. They want action on illicit capital flight to the tune of $71 million per year over the past decade. This is money that could and should have been spent on the people of Sierra Leone.3
It’s a civic confidence that will be sorely needed to keep the government on track. Much work lies ahead for a cash-strapped executive whose first challenge is to keep its promise to employ the Ebola health-worker volunteers – or risk losing that expertise and momentum. There is also the small matter of a missing $3 million from the government’s own Ebola response funds, which has yet to be resolved.4 And the authorities will need to fight IMF restrictions if they are to increase public spending.
The road to rebuilding health systems will be a long one. Ebola exposed the intense vulnerability of a country to epidemics when 30 per cent of people are too poor even to seek care. The international spread of Ebola has also turned the world’s attention to the value of shoring up weak health systems and has helped to bring Universal Health Coverage – the dream of free healthcare seen off by IMF and World Bank structural adjustment policies of the 1980s and ’90s – back into the frame.
Sierra Leone has taken small steps towards this with its free healthcare initiative for pregnant mothers and the under-fives, launched in 2010, but still has among the highest child and maternal mortality figures in the world. For systemic change, more funders must eschew ‘single-issue’ high-profile diseases and quick fixes, in favour of the more hum-drum business of public health.
The country will need support for some years to come. With $1.6 billion dispersed and over $3 billion pledged in global ‘Ebola recovery’ funds, there is some evidence of international commitment. But it will need to be the right kind of aid that enhances capacity, and builds up national systems. Success, says Shek Ahmed, will come from support ‘that goes direct to local partners or in direct cash transfers – not on expat salaries’.
Back up at Ebola champion Nafisatu’s station in Koindu, a new team of maternal health promoters are in post. She reports that there are more medicines and equipment available – though she is still waiting to go on to the government payroll.
Outside, men are working on an isolation unit and new nurses’ quarters have been built – both evidence of Phase 1 of the government’s plan to upgrade healthcare facilities, post-Ebola.
Ebola exposed the intense vulnerability of a country where 30 per cent of people are too poor even to seek care
An energetic Alfonsus Vandi has just taken up the job of Community Health Officer. ‘We’ve got some idea about how to protect ourselves,’ he says, pointing out a biohazard safety box. ‘Infection Prevention Control is now creating an impact. Even the communities have learned!’
He is full of optimism. He says outreach work by staff is bringing people back to the clinic. Anxious for the ambulance service – currently banjaxed by a sick driver – to come back on line, he talks about how medical supplies should reflect the needs of the area.
The success of his remote outpost will be a key test of an effective decentralized health system, and the ongoing community engagement that will be essential to keep Ebola at bay.
It would be good to think the world has got Vandi’s back. Let’s hope we have learned the right lessons from Ebola. We owe it to the victims, and the people standing guard.
Alhassan Kemokai caught Ebola from his mother Madame Basheratu, who worked at Kenema hospital. As she lay dying, she held out her hands to her eldest son and blessed him. ‘She told me not to forget my younger sisters,’ he recalls, explaining how he survived the disease and emerged to find his belongings burnt – for fear of contamination – and a much larger family to care for. His carefully planned household of two well-spaced children has expanded from four to 17, after he became the breadwinner for seven orphans plus young widows and siblings (aged between 4 and 22).
‘We are jam-packed!’ he says of the new house that he has rented on the edge of town, where the family lives on simple meals of rice and pepper with palm oil while desperately trying to keep all the children in school. He seems at once exhilarated and overwhelmed by the challenge, while his partner is exhausted by the washing (three to four hours a day) but wants the children to feel they are her own. Her mother and aunt have been bussed in to help prepare meals.
Alhassan has a desk job with an Irish NGO and they are just about surviving – many are not so lucky. But he is not sure how long he can cope, and is considering taking up an offer from a Guinean family to adopt the youngest orphan.
Many survivors end up caring for the dependents of others. Alhassan’s case is typical of many extended families – elastic at the best of times – that have been stretched to the limits by Ebola.
- Africa All-Party Parliamentary Group, February 2016. nin.tl/LessonsCommunities. ↩
- Read more on this controversy in The New York Times: nin.tl/EbolaDoctorsDividedIVTherapy ↩
- Health Poverty Action, 2015. nin.tl/HealthyRevenues ↩
- The Guardian, February 2015. nin.tl/NationalAuditorReport ↩