A little reflection about sustainability

A couple of weeks in and I’m thinking a lot about the way that the international community has responded to the Ebola outbreak, and what that will mean for the future of Sierra Leone. It’s widely acknowledged that the international response was slow to respond to the crisis, leaving a country that was ill-equipped to deal with this kind of situation to manage alone. The stories from the early days are horrendous. Families left with dead bodies in their homes for days in 35 degree heat as there were not enough retrieval teams to collect them to bury them safely. Ebola Treatment Centres (ETCs) having to turn people away and back into their communities as they had no more beds. Entire families wiped out as people’s loved ones became dangerous viral hazards within their homes, when stroking your dying child’s hair becomes a death sentence.
But then, thankfully and gratefully received, the international community did respond and in a big way, with very significant amounts of money and manpower. Large treatment centres were erected throughout the country with world class laboratories, an Ebola ambulance service was made functional, and thousands of people nationally and internationally volunteered to work in Ebola Treatment Centres in the gruelling heat and heart-breaking conditions. Finally people started getting what was needed.

Now we are a stage when case numbers are decreasing, many treatment centres are standing nearly empty, and there are plans to begin to close them, one by one. We are at a stage currently when, bizarrely, Ebola is one of the only conditions that you can guarantee getting treatment for. The resources have been committed and the facilities are there. Meanwhile, what happens if you have a different diagnosis? What if it’s malaria, or typhoid, or tuberculosis? What if it’s a complication of childbirth? It can be much harder to access care for these problems – many people are too afraid to go to hospital at all at the moment, and if they do they may have to await a negative Ebola test before being able to access care.
Many clinics and hospitals have closed at some point during the outbreak, with very understandable and real concerns about the health of their staff. This has led to a surprising example of inequity – you can now perhaps receive better care for Ebola than for other, less feared, conditions. Some ETCs in particular are providing quite advanced care and using tests that are for the most part not available in the rest of Sierra Leone, such as blood electrolyte levels (a very routine and basic test that is performed very frequently in high income settings).

Yes, absolutely, this kind of massive vertical programme was needed to deal with Ebola. Without it I cannot bear to think about what kind of situation may have arisen. But the question to my mind is what happens next – what is the next stage?
A couple of days ago I had the opportunity to be shown around Princess Christian Maternity Hospital, which is one of the hospitals I will be focussing on while I am here. I have a certain amount of experience in Sierra Leonean health care settings now, having worked in Kambia for 5 months last year, so while I don’t think I was feeling complacent, I didn’t expect to be shocked by the conditions that I saw; but I was. It was evident that support is still needed to enable the staff to access running water and supply a fresh and clean set of linen and mosquito nets for each patient, and dispose of their waste safely.
None of this is different or worse from what I’ve seen before, so I was a bit surprised at my reaction. But I think it stemmed from two things – firstly, this hospital is much bigger than Kambia Government Hospital, so all the challenges seem bigger and harder to surmount in some ways. But secondly, and more importantly, because it is astonishing to me that now, even now, in the context of the biggest outbreak of Ebola ever seen that has infected over 400 health workers in Sierra Leone alone, and despite the millions and millions of dollars that are flowing into the country to tackle this, even now most health workers cannot even wash their hands between patients. To me that is extraordinary and it’s unacceptable. It is brought home even more by the “in loving memory” posters stuck on the hospital walls in tribute to colleagues, some of whom have been lost to Ebola in the line of duty.

It is an absolute testament to the courage and resilience of the healthcare workers here that they are still working at all. I’m not sure that I would, knowing that I was putting myself in danger every day, and being unable to protect myself as soap and water are not always available. This is not just about Ebola, although that of course is important and mustn’t be forgotten, it is about all the other infections that exist and that are inevitably passed around between patients and staff when people are not able to protect themselves.
In some ways the emergency stage is the easy stage. There is no time for lengthy consultation and compromise, it is accepted that international agencies have the right and indeed the duty to act swiftly and almost unilaterally. That is not to diminish the efforts that have gone in to trying to control this outbreak, they have certainly been life-saving, and the work from individuals has been relentless and difficult. But the next stage, surely, is to help support a health system that, weak from the outset, has been utterly ravaged by this crisis – health care workers have lost their lives, routine vaccinations have not been given, HIV medications have been hard to come by, and hospital staff are too afraid to come to work. It is to strengthen the health system so that this can never happen in the same way again. And that will not be by imposing grand solutions from on high, but by working painstakingly and meticulously at engaging every level, from Ministry to hospital cleaner, in every aspect of the healthcare system, listening to the people who work there and making a solution that is owned by the people to whom it matters most. There, the hard work really begins.