Dr Haja Wurie
In this article, Dr Haja Wurie (College of Medicine and Allied Health Sciences, Sierra Leone and the ReBUILD Consortium) explains how Ebola has affected the already overstretched, post-conflict health system in Sierra Leone.
Post-conflict Sierra Leone still suffers from the effects of war. The 11-year conflict that ended in 2002 crumbled the health sector and fuelled social conflict and distrust of government. Not only did a ‘perfect storm’ of multiple weaknesses crucially delay the response to the current Ebola outbreak, but post-conflict efforts to strengthen the health system and work towards providing equitable access to health care for all have suffered a devastating setback.
The outbreak has heightened the lack of trust between service users and health service providers. People in remote areas of the country initially turned to traditional healers rather than health facilities, particularly in the early outbreak phase. This was also true for a few cases in the capital, Freetown. Fear of contracting the virus and high levels of mistrust have led both health workers and service users to abandon health facilities. Seeing their colleagues succumbing to the disease, ill-equipped health workers were understandably fearful of going to work. Victims and their families also avoided going to health facilities, as a result of rumours that spread of the virus was taking place there.
Suspected Ebola patients were reportedly isolated in shared rooms due to lack of infrastructure, further increasing the likelihood of infection. Inadequate quarantine measures were applied in the early phase of the outbreak, when effective contact tracing and isolation should have been in place. An anecdotal report highlighted the consequences of ineffective contact tracing: A father failed to disclose that his sick child had been in contact with Ebola. The child was admitted to an overcrowded ward for several days and treated for malaria before Ebola tests were ultimately found to be positive. As a result, the only children’s hospital in Freetown was temporarily closed; moderately sick children were immediately discharged for home care, while more seriously ill children were treated by Campar Amur (a German organisation supporting the hospital).
Knock-on effects on other health services
Magnified mistrust in health services has negatively impacted other health outcomes, such as child and maternal services. Fear has made families reluctant to have their children vaccinated and women will not opt for the contraceptive injection. Many people who suspect they may have Ebola are afraid of coming forward due to fear of being quarantined. The majority of the available health workers are at the forefront of the Ebola fight meaning other conditions are being overlooked. This has led to more men, women and children dying at home from preventable and treatable illnesses. Many ongoing international public health programmes have been put on hold. And the outbreak has depleted the already sparse health workforce, with four top specialist doctors and over 40 nurses and community health workers having died of Ebola to date. Women, who are the main care-givers, have been hit the hardest by the outbreak.
In addition to health impacts, the outbreak has also disrupted many aspects people’s everyday lives. Freedom of movement is curtailed both by quarantining measures and mistrust of public transport. Education, employment and trade have all suffered, with schools and universities closed indefinitely. Ebola-related social stigma is taking a toll on social relations, affecting people’s security and livelihoods. Many regard Ebola as an invisible killer, even worse than the war. At least during the war you could hear the rebels coming and try to hide or negotiate for your life. Testing positive for Ebola is seen as an inevitable death sentence.
Poverty in the post-conflict period meant that for many, education was not a priority. Initial denial and declining literacy levels translated into slow uptake of the Ebola information.
The majority of those succumbing to Ebola are in their most productive years, contributing to reduced farming, lower productivity in the labour market. Working hours have also been compromised as many people choose not to go to work to minimize their contact with others.
Sierra Leone depends heavily on food importation, and with restricted movement across borders and import vessels halted due to the outbreak, the prices of food, commodities and imported goods have already skyrocketed. This is likely to get worse as the outbreak progresses, increasingly affecting the poorest in society as they struggle to buy food. The risk of malnutrition and starvation in the hardest hit areas makes urgent provision of food to quarantined areas a top priority.
Many of the lowest paid workers, including ‘house help’ workers, have been sent home by their employees indefinitely due to fear of the continued spread of the virus, adding to already serious unemployment, particularly in affected quarantine areas (Kenema and Kailahun districts), and the initial outbreak epicentres. In recent weeks, more districts (e.g. Port Loko, Bombali and Moyamba districts) have been quarantined as the virus continues to spread. Most inhabitants living in those areas were principally self-employed in the mining and agricultural sectors, which have now been closed. Anyone employed by foreigners fleeing from quarantined areas also have no option but to remain in their homes without any income. Knock-on effects have obliterated exports and tourism, fuelling a huge loss of revenue to the state.
Survivor stigma and social life
People who survive Ebola infection are nevertheless stigmatized in society. Many families are being disrupted and many children – frequently from poor households – are left orphaned. Health workers in quarantined districts are reporting homelessness as a result of eviction by landlords who fear the disease.
Social life is non-existent as people are afraid of congregating. Cinemas are empty despite the current football season.
Even before the war the Sierra Leone health system was under-performing, with high levels of out-of-pocket spending. Coupled with the lack of efficient and effective service delivery, this shifted health-seeking behaviour towards traditional healers and drug peddlers. This tendency was further fuelled by the destruction of the health system during war that persisted in the post-conflict phase. Now we have an unprecedented Ebola outbreak that will remove even the smallest remaining remnants of our health system.
As well as re-building the Sierra Leone health system, research is needed to identify and address the issues underlying the historically fragile health care delivery sector. This should guide the way forward. Currently, the evidence-based health systems research that does exist is internationally led, meaning national ownership is weak. This needs to change to ensure sustainability in terms of re-building and strengthening the health sector. Lessons were not learned from the 2012 cholera outbreak when over 300 people lost their lives, revealing a degree of complacency in addressing the issues that facilitate a rapid health response to a disease outbreak.
In the midst of the current tragedy, Ebola provides an opportunity to take stock of what needs to change in the health system in Sierra Leone. This should include the following.
- Evidence-based health systems research and strengthening should be an utmost priority using lessons learned from this outbreak, and with involvement from the local population.
- Health workers should be fully empowered, equipped and motivated to work effectively and efficiently.
- Health care services should be accessible to all. The government should find a way to incorporating traditional healers in this process, while emphasizing the primacy of health facilities.
- Health facilities should be fully equipped (drugs, equipment and logistics, ambulances, etc.).
- Training should be provided to produce more, qualified health professionals to re-build the health workforce.
- Health education and promotion should be a priority both at central and district levels.
- An emergency response plan should be put in place for future outbreaks of this nature.
- A delayed Ebola response at the central government level led to delayed responses at the district level. The decentralization process should be critically reviewed to remove bureaucratic delays, especially in relation to the procurement of drugs, equipment etc.