Sierra Leone: What Next?

The country’s economy has been crippled, hospitals, health centres and schools were closed down and only now—slowly, cautiously and with great respect—is an attempt being made to reopen some of themWhen you arrive in Sierra Leone, the first thing that strikes you is how social customs have changed. You notice the difference the minute you arrive— everyone keeps their distance. You notice it first with people working at the airport, but everyone has learned the lesson, even the children in the street. They still call out to you —‘Opoto, Opoto’— but now it is different; they stay a metre and a half away and greet you only with waving hands. The change really hits home when you first meet your friends and colleagues of many years and they too greet you from a distance: no effusive hugs, not even a handshake, just a discreet nod or the wave of hands in the air. At most, the bravest people almost brush you with an elbow, a suggestion of a touch. Of course, you do get many kind words and thanks for coming to their country. Their expression is lively, but their eyes reveal the suffering. Only of those closest to you do you dare ask questions; they have suffered, they have lost friends and family and they have often wondered when their turn would come. 

Schools in Sierra Leone have reopened for the first time in over nine months, but teenage girls who are pregnant are forbidden to attend.Many people in Sierra Leone associated Ebola with witchcraft or saw the disease as a punishment for some wrongdoing. I know people who are convinced that the first patients who came to our hospital with Ebola were infected because they had taken part in a robbery. One consequence of these beliefs was that most people did not take any precautions, or at least not the necessary precautions, and this aggravated the spread of the disease. Another factor was that, because of deeply held beliefs, many people continued to take part in the funeral ceremonies of those who had died from the virus and they touched the bodies without fear, quickly becoming infected themselves. It was necessary to prohibit certain funeral rites, to create specialised equipment to ensure safe burials, and to take samples every time someone died to confirm the cause of death. All this has been very difficult for the society as a whole and a shock for some people. As is the case elsewhere in Africa, it is very traumatic for Sierra Leoneans to be deprived of the opportunity to observe their burial rituals, and Ebola prevents them from mourning the deceased in the normal way.

Human relationships have changed, like so many other things. The country’s economy has been crippled, hospitals, health centres and schools were closed down and only now—slowly, cautiously and with great respect—is an attempt being made to reopen some of them. It is also essential to convince the population that the health services are safe and that it is absolutely essential that they use them. 

Home births have increased significantly since the start of the epidemic, and since the hospital has reopened the consequences of this have become more evidentIn Masimara, in Port Loki District, community leaders, traditional midwives, social workers, health workers and especially the people have agreed and have accepted a mobile unit. The team has a van that travels from village to village on dirt tracks—almost not even tracks—to bring food to families, re-establish vaccination programmes, identify pregnant women and pregnancies that have not come to term, and to find people who are seriously ill. The team receives help from trained local volunteers. Very sad stories emerge in the course of these outreach interventions, like that of Genet, a 13-year old girl. By the time a volunteer notified the mobile unit, Genet had been in labour at home for over two days. She had lost almost all her amniotic fluid and was exhausted and developing a fever. We brought her to the hospital as fast as the road would allow and did everything we could to save both mother and baby. Before she was wheeled into the maternity ward, Genet took my hand and gazed up at me, terrified, her look expressing both fear and surprise. She appeared to have no idea what was happening to her. Barely on the threshold of adolescence, this girl was leaving her childhood behind and was discovering the pain and terror of womanhood. It was impossible to get the newborn baby to breathe on his own and he made no movements; only the beating of his heart encouraged us to continue with the resuscitation, which none of us expected to be successful. Genet survived. She recovered and we are treating her anemia. She can have other children, although I hope that will not happen for a few years and that first she can finish school. This month, schools in Sierra Leone have reopened for the first time in over nine months, but teenage girls who are pregnant are forbidden to attend.

Home births have increased significantly since the start of the epidemic, and since the hospital has reopened the consequences of this have become more evident. Almost every day sees the arrival of a mother, or a couple, with a child born a few days or weeks earlier; these newborn babies have serious blood infections, late onset sepsis, and it is extremely hard to save their lives. No current data is available on maternal and neonatal mortality, but we know that these deaths have increased during the crisis, and not as a direct result of Ebola.

When the hospital reopened, we found ourselves once again providing care for children with malaria, anemia, malnutrition, respiratory infections, diarrhoea and other conditionsWhen the hospital reopened, we found ourselves once again providing care for children with malaria, anemia, malnutrition, respiratory infections, diarrhoea and other conditions.  We have even had one child admitted with measles. Routine vaccination programmes were stopped about a year ago. The diagnostic measures undertaken on admission are limited to preventing transmission of the Ebola virus: the aim of triage is strictly to identify suspected cases of the hemorrhagic disease and to refer them directly to the International Ebola Centre. Even so, the screening system is not foolproof and we have to work as if all our patients could have Ebola: hands are washed with chlorinated water, shoes dipped in a basin of chlorinated water. We wear personal protective equipment: gown, double gloves, headpiece, facemask and, with those classified as "wet patients" (patients who are vomiting or bleeding or have diarrhoea), a transparent face shield. Laboratory testing is also affected because the staff cannot handle biological fluids owing to the risk they pose; the hospital has had to close twice and has been quarantined twice. This restriction means that we can only use rapid tests that involve no health risks. These are performed by placing a drop of blood on a test strip and reading the result with a meter. They include tests for malaria, glucose and haemoglobin, nothing more.  

At the hospital, we are still seeing patients with malaria who have a high parasite load in the blood. Some of them have been treated by traditional healers, and the signs and symptoms of malaria are confused with others produced by the poisons they have ingested, which cause hemorrhagic gastritis and other more serious conditions. Malaria is a devastating disease, particularly in children, and if diagnosis is delayed, the outcome is often fatal. For many years, Sierra Leone has been affected by political struggle and military conflicts that have had a hugely negative impact on the health of the population and the development of the country’s health services. As a result, the implementation in this country of measures that have been effective against malaria elsewhere was delayed for many years and, after a slow start, was interrupted by the closure of the health facilities. Consequently, an increase is expected in malaria transmission and mortality.

The people of Sierra Leone have reacted and changes have gradually been made that have had a huge impact. The people still express their emotions by singing, a tradition that is helping them to recover their lost joy, but if you look into their eyes, the sadness and loneliness shine through. Through suffering, they have adapted and have responded to the epidemic. Now we, the international community, must respond to the huge challenge ahead and help them, not just to stop the Ebola epidemic but also to rebuild the country’s health system and strengthen it, creating one that is capable of forecasting and controlling infections, including malaria. This is a responsibility we all share.

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[Victoria Fumadó is the Technical Director of the África Viva foundation and an Associate Researcher in ISGlobal’s Maternal, Child and Reproductive Health Initiative. She is also head of the Infectious and Imported Diseases Unit of the Paediatric Department at Sant Joan de Déu university hospital in Barcelona.]