Freetown, Sierra Leone, 2015. Image: Simon Davis/DFID, CC BY 2.0.
During the day, the streets of the Kissi district of eastern Freetown are perpetually crowded with pedestrians, as if a concert or soccer game has just finished. On either side of the road, in every available space, there are makeshift stalls selling mangos, grilled chicken feet, SIM cards, and second-hand clothes. There is a ceaseless soundtrack of trucks, animals, people and radios. The air is heavy with pollution from ancient taxis, and rubbish is heaped in rancid piles.
It is hard to imagine these streets empty and silent. Yet, for three days at a time, during the Ebola crisis of 2014-16, they were deserted. On several occasions, every one of Sierra Leone’s six million citizens was ordered to stay home, while 28,500 trained community workers and volunteers went door-to-door. They warned people to abandon their dangerous burial practices, thought to spread the disease, and they identified new cases. While the nation is no longer in a state of emergency, normality has not been fully restored.
There has been almost no coverage of the dismal legacy left by Ebola, or of how west Africa’s public health systems could cope in the event of another epidemic. Of those Sierra Leoneans who contracted it, 27% died. Many of those who recovered will endure problems with their hearing and vision for the rest of their lives. Moreover, they are stigmatised in a culture where superstition is widespread.
Four years after the outbreak, the disease has appeared in Congo, two thousand miles away. At the time of writing, nineteen people have died in the country’s Équateur province. Once more, international emergency response agencies are on alert, and the Western media is paying attention.
Sierra Leone government officials interviewed for this article are confident that their public health campaign has been effective, and that people will not be hesitant to seek medical advice for afflicted relatives, as some were four years ago. They say that the moment DRC reported the re-emergence of Ebola, Sierra Leone began a renewed “sensitization” effort. But, by the new president’s own admission, the country has an adult illiteracy rate of 60%, and a massively underfunded health system. How well will it cope?
Volunteers in Kailahun, in eastern Sierra Leone, 2013. Image: EC/ECHO/Cyprien Fabre, CC BY-NC-ND 2.0.
In the aftermath of the outbreak, many have found themselves ostracised from their communities. Foday, 28, had to move away from his home district when his girlfriend, who he has a daughter with, died of Ebola; his family and neighbours shunned him because of what had happened to her. He is still struggling to find a job, despite his qualifications, because the shadow of Ebola hangs over him. Yet Foday is determined to help others. He is among a group of social workers, police and government officials being trained by Network for Africa, the NGO I started, to counsel traumatised survivors of Ebola and the country’s long-running civil war (1991-2002).
His colleague, Amadu, comments: “There isn’t a family in this country that wasn’t affected in one way or another by Ebola and the civil war.” His gap-toothed smile falters for a moment. “Actually, my dad died of malaria when he was 45. He worked so hard all his life, and I guess he didn’t have much resistance. He was gone within a few days.”
Also attending the counselling training is Marie, an official from the ministry of social welfare. Each day during the Ebola crisis, she collected children from the hospital green zone, where survivors were moved once they were well enough to leave the red treatment zone. The epidemic made orphans of thousands of children. Marie would trace any surviving relatives, assessing how likely it was the child would prosper with their extended family. In too many cases, she said, distant relatives regarded surviving children as either potential domestic slaves, or as possessed by evil spirits. Marie said it is still not unusual to find Ebola orphans hawking bottles of water on the streets of Freetown, having been sold to traffickers, or handed over to strangers who promised to provide education and lodging for the children.
The epidemic left the health system, such as it was, shattered. Before Ebola struck, there were only 136 doctors and 1,017 nurses serving six million people in an area the size of Scotland or South Carolina. It is thought that 488 health professionals died during the crisis. Emergency aid agencies left behind equipment, new clinics and more efficient systems. However, tackling harmful superstitions will require more than capacity building programmes and increased official accountability and transparency, to use the current aid industry jargon. Moreover, Sierra Leone’s other, less sensational, health challenges have not gone away.
Sierra Leone’s other, less sensational, health challenges have not gone away
Throughout the epidemic, there was often more international media coverage of the prospect of Ebola coming to the privileged white world, than of the horrors being faced by west Africans. The news mirrored our skewed view of Africa. Even at the worst points of the epidemic, more people in Sierra Leone were dying of malaria, TB, diarrhoea or pneumonia. For instance, there were 4,326 malaria deaths in 2013 alone, a typical year in Sierra Leone, according to the World Health Organisation (WHO), whereas 3,955 died of Ebola during the entire epidemic. The US Centers for Disease Control believes deaths from malaria actually rose during the crisis because people were afraid to go to health clinics for fear of contracting Ebola. Staff were also drawn away from ordinary duties leaving vulnerable people even more susceptible.
However, this “normal” death toll from tropical ailments, ravaging children younger than five in particular, is less newsworthy and dramatic than a spectacular haemorrhagic fever; just as war-torn Congo’s millions of displaced people get less attention than its new cases of Ebola. Why? Because there is less chance that we Westerners will be directly affected by either of those crisis. In addition, being reminded that devastating illnesses like malaria are easily and cheaply preventable might prompt some guilt and discomfort on our part.
Four years after the outbreak, international health agencies have understandably moved on to new emergencies elsewhere. Yet, what is clearly required is a long-term commitment to improving public health facilities and educating the population. A desperately poor country like Sierra Leone, its economy battered by the epidemic and the dwindling supply of minerals it exports, cannot achieve this by itself.
A draft World Health Organization report, leaked to the Associated Press, admitted that they had underestimated the difficulties caused by superstitious beliefs around Ebola. Development officials in the wealthy white world may resist acknowledging the power that belief in evil spirits still has in many countries receiving their aid; perhaps they are concerned that their taxpayers might be less sympathetic or tolerant. But our ubiquitous “sensitisation training” will fail if we ignore the fact that many people think Ebola (or disability for that matter) is a consequence of angry ancestors or an enemy’s curse. The further one travels from Freetown, to villages off the beaten track, the greater the need for sustained public health education and schooling in critical thinking.
Yusuf Kabba, of the Sierra Leone Association of Ebola Survivors, told the Christian Science Monitor that although massive resources poured in during the 2014-16 epidemic, most of them were taken away again afterwards. There are more ambulances now, but he believes the health system is still poorly equipped to handle the burden of a further outbreak. It is questionable whether the country can return to the war-footing necessary of its own accord.
Sierra Leone has recently elected a new government, committed to stamping out corruption, while building a sense of national identity and civic responsibility. A new communal rubbish collection day is wildly popular, and it is hard to find anyone expressing cynicism about the future direction of the country. President Bio promises to provide school uniforms and books, which may increase the number of children attending and staying in education. In the meantime, Sierra Leone’s people cannot be faulted for their resilience, resourcefulness and grace under pressure.