In the first of a series of two posts Haja Wurie (ReBUILD Consortium and College of Medicine and Allied Health Sciences, Sierra Leone) explains how Ebola has affected the already overstretched, post-conflict health system in Sierra Leone. The outbreak poses a myriad of challenges for health systems in fragile contexts. In her second post she discusses the socio-economic impacts of Ebola and provides some recommendations on ways forward.
Sierra Leone is a post-conflict country still recovering from the effects of war and this has definitely contributed to the spread of the Ebola virus. The eleven year conflict crumbled the health sector and fuelled social conflict and mistrust between the people and the government. Thus, a weak health system, together with poor governance, and complicated bureaucracy delayed the response to the outbreak. In addition, infrastructure, infection control practices, water and sanitation, electricity, communication, health promotion and education are all weak. There are inadequate numbers of health workers who are not fully trained to handle an outbreak of this nature.
Efforts made in the post-conflict era to strengthen the health system and work towards providing equitable access to health care for all have suffered a major setback.
The crucial role of trust
This outbreak highlighted and further exacerbated the lack of trust between service users and health service providers. Service users in the remote parts of Sierra Leone were more accustomed to seeking health services from traditional healers instead of health facilities, particularly in the early phase of the outbreak. This was also true for a few cases in Freetown. Gaps in the health system have led to both health workers and service users abandoning health facilities, due to fear of contracting the virus and high levels of mistrust. Health workers were ill equipped to deal with Ebola patients and with their colleagues succumbing to the disease they are afraid to go to work. In the early phase of the outbreak, victims of the virus and their families avoided going to health facilities, as most believed that they will be injected with the virus at the health facilities.
There are also reports of suspected Ebola cases being isolated in the same room due to lack of infrastructure, which increases the chance of the virus spreading. Lax quarantine measures were also in place in the early phase of the outbreak, a period in my opinion where effective contract tracing and quarantine measures should have been in place. There was a report a few weeks ago of a father taking a sick child to the Ola Children’s hospital in Freetown and failing to disclose that the child had been in contact with someone with Ebola during the screening process at the hospital. The sick child was admitted to a normal ward in the hospital (it is quite common for more than one child to share a sick bed in Sierra Leone – again due to lack of infrastructure and resources) and treated for a number of days for malaria before the child was finally tested for Ebola and was found to be positive. As a result of this incident, the only children’s hospital in Freetown was temporarily closed and the ‘moderately’ sick children were immediately discharged and given medication whilst the very sick children are being treated by Campar Amur (a German organisation supporting the hospital). People were quick to blame the father for taking his child to the hospital knowing the child had been at risk of contracting Ebola. But if contact tracing and quarantine measures were effective, the father would have never had the chance to leave his house and take the child to the hospital.
Knock on effects on other services
Mistrust in health services has had a negative impact on other health outcomes, for example child and maternal services. Families are reluctant to have their children vaccinated and women will not opt for the contraceptive injection due to fear of ‘being injected with the virus’. Most people who suspect that they 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 non-Ebola related ailments are being overlooked. This has resulted in an increase in non-Ebola related deaths due to more men, women and children dying at home from preventable illnesses. Ongoing public health programmes by international development partners have been put on hold, as most operate in the infected regions. In addition 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. Overall this has had a negative impact on health outcomes and reduced access to health care services.
Photo courtesy of Medici con l’Africa Cuamm