Rebuilding Health Care in the Shadow of Ebola

20 February 2017

Painted warnings about the Ebola virus are fading from walls as life slowly returns to normal across Sierra Leone, but Princess Koroma’s scars remain as vivid as her sorrow. Left nearly blind and suffering from joint pains, Princess lost 21 members of her family to the disease, including her husband and two sons. But like her country, she is determined to rebuild and go forward. “I am surviving,” the 37-year-old woman said. “I am not alone.”

Sierra Leone, a low-income country, was recovering from the effects of a civil war when the Ebola virus erupted in 2014. The disease decimated communities and devastated the country’s already fragile health infrastructure.

The epidemic in West Africa threw a harsh spotlight on the importance of strong health systems to tackle emergencies and improve global security by preventing future disease outbreaks. Countries with stronger systems like Nigeria and Senegal quickly contained Ebola. But in Guinea, Liberia and Sierra Leone, poor health services, a shortage of health care workers, lack of roads and high illiteracy combined to prevent an adequate response to the crisis, which claimed 11,300 lives. Basic health services, including treatment and prevention for HIV, TB and malaria, ground to a halt.

Ebola also terrified the world, with its speed and virulence. Sierra Leone hopes the experience of living through the epidemic can be used to prevent another outbreak, by rebuilding and strengthening its health systems. The Global Fund and partners have joined forces to help Sierra Leone train health workers, improve diagnostics and supply chains, and increase awareness through community work.

A year after Sierra Leone was declared Ebola-free, its social fabric is now healing. Handshakes are back, market stalls brim with vegetables and fruits, schools have reopened and the sound of music echoes in its streets and villages and along its wide beaches.

“Ebola was an eye-opener,” said Dr. Lynda Foray, program manager of Sierra Leone’s National Leprosy and TB Control Program. “We never used to wash our hands in Sierra Leone. Now there are hand sanitizers at every health center, and people are more aware of how diseases can spread. Simple things can make a big difference.”

Dr. Foray said other improvements introduced during the response to Ebola, such as better laboratory capacity, will help stave off future diseases. As Ebola cases multiplied, staff at her Central Public Health Reference Laboratory in Lakka received intensive training in lab diagnosis and detection techniques, as well as state-of-the-art technology. Those skills and machines have been enlisted to fight tuberculosis and HIV, and reinforce care of TB/HIV co-infection.

The Global Fund is placing a special focus on how it invests in challenging operating environments like Sierra Leone – countries or regions affected by disease outbreaks, natural disasters, armed conflicts and/or weak governance. Providing health care during an Ebola outbreak calls for flexible approaches and strong partnerships on the ground. During the peak of the crisis, the Global Fund mobilized emergency funds to support an antimalarial mass drug administration in Sierra Leone.

In partnership with WHO and UNICEF, the effort reached 2.5 million people, or 95 percent of targeted households. Malaria and Ebola have many of the same symptoms, so reducing the number of people going to hospital for malaria treatment allowed health workers to focus on Ebola, and helped lower the number of people exposed to Ebola. The effort also helped restore community trust in the health sector, which was damaged by misinformation and myths surrounding Ebola.

Between 2016 and 2018, the Global Fund will invest US$103 million to strengthen health systems and fight HIV, TB and malaria in Sierra Leone. The Global Fund provides 80 percent of funding for Sierra Leone’s fight against the diseases.

Global Fund investments aim to nearly double the number of people on antiretroviral treatment for HIV to 46 percent and reduce new infections by boosting prevention activities among female sex workers and men who have sex with men, two communities disproportionately impacted by HIV and AIDS.

Global Fund investments will also help Sierra Leone create stronger data and surveillance, and better deploy and train its 15,000 community health workers. Sierra Leone has the world’s highest levels of maternal mortality, and one of the highest rates of child mortality; better surveillance systems will help detect future outbreaks more quickly, while community health workers deliver crucial services to children and pregnant women.

Prior to the Ebola outbreak, Guinea, Liberia and Sierra Leone had a ratio of only one to two doctors per nearly 100,000 population, among the lowest in the world.

Extra health care capacity is critical. Prior to the Ebola outbreak, Guinea, Liberia and Sierra Leone had a ratio of only one to two doctors per nearly 100,000 population, among the lowest in the world. By comparison, the doctor-to-patient ratio in the European Union is 350 doctors for every 100,000 people. Sierra Leone’s meagre medical workforce was further diminished by a high number of health care workers infected. More than 221 doctors, nurses and midwives died while treating Ebola patients.

Makeshift tributes to the “fallen heroes” decorate hospitals and clinics in Sierra Leone, many showing doctors and nurses smiling in their bright blue or green gowns with handwritten signs: “Gone But Not Forgotten” and "Angie, We all love U. May your soul rest in peace.”

Because of reduced access to health services during the Ebola outbreak, an estimated additional 10,600 lives were lost to HIV, TB and malaria in Guinea, Liberia and Sierra Leone.

The Global Fund will invest US$1.5 million in Sierra Leone to introduce treatment for multidrug-resistant TB, an emerging health threat could spread, increasing the cost and complexity of fighting the disease.

“Many patients stopped coming to the clinic or interrupted treatment, raising the risk of developing multidrug-resistant TB,” said Senesie Margao, who heads the Connaughty Hospital chest clinic in Freetown. “Our nurses went to their houses to persuade them to come back to the clinic and avoid the risk of developing resistance.”

As life goes on, the walls daubed with “Ebola e du so” (“Ebola, it’s enough”) seem to be a thing of the past. But Sierra Leone faces daunting challenges.

Most rural health posts lack running water and electricity, and mothers need to walk through the bush for hours, babies strapped to their backs, to see a nurse for malaria or diarrhea. Public health experts say that while Ebola caught the attention of the global community, malaria silently killed twice as many people than Ebola in Sierra Leone in 2014. And the World Bank has estimated that the overall impact of the Ebola crisis in Sierra Leone is US$1.9 billion, a huge toll for a country listed as the eighth least-developed country in the world.

“Nobody expected the Ebola epidemic to overwhelm us the way it did,” said Brima Kargbo, Sierra Leone’s Chief Medical Officer. “But it has presented us with an opportunity to build a comprehensive and robust health system.”

Survivors like Princess are showing the way forward. After being discharged from hospital, she struggled to get by, but she is now retraining herself through a Global Fund-supported program. The program provides HIV prevention services and has given her a new sense of purpose. “They want me to become a leader,” she said with pride.

Banner: Simon Davis/DFID
Other photos: The Global Fund/Nana Kofi Acquah.