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'''Did we learn the right lessons from Ebola?''' 

''The biggest modern public health emergency is now under control in West Africa. But there is a lot more to do to mend the health systems. Hazel Healy meets the people who are rebuilding Sierra Leone.''
 
''Nurse Nafisatu Jabbi worked in the Ebola outbreak in a remote community clinic. She is the only person who survived from her team of four women. Now she works for free while she waits for a government job. © Hazel Healy'' 

On the last day of Sierra Leone’s ‘Ebola-free countdown’ in March 2016, there was news of a new case of Ebola in Guinea. And scientists and government officials had a meeting in the capital Freetown to talk about what they had learned from the epidemic.  

‘The WHO [World Health Organization] can stop saying that we are “free of Ebola”, said Professor Radcliffe Lisk (vice-president of the West African College of Physicians). ‘It is useless to say this because of what happened in Guinea yesterday. You can only be free of an epidemic.’ Everyone agreed.

Sierra Leone had more than 14,000 infections and nearly 4,000 dead. They agree that this terrible epidemic must not happen again. 

Sierra Leone is now on high alert. The virus stays in the bodies of survivors and can be sexually transmitted. They still test dead bodies. But how do we keep West Africa safe from this – and other epidemics – in the future?

We need to look at what happened. 

'''A bad response'''

Sierra Leoneans know a lot about deadly disease: life expectancy is 46 - one of the lowest in the world and one in ten children die before they are five. But the Ebola virus was different, because of the 60-per-cent mortality rate and the way that it killed. The disease spread by love – through people who looked after the sick. It killed whole families together, especially at the beginning. 

Deaths were terrible. Families were separated, social meetings were banned and people went hungry, alone in their homes and neighbourhoods. To try to stop Ebola, trade and agriculture stopped. 

We’ve known about Ebola since 1976, but the previous 26 outbreaks – mostly in Congo and Uganda – were controlled in three months. Many different groups are studying why they could not control it in Sierra Leone, Liberia and Guinea this time. They agree there was not enough leadership from the WHO, and say national governments were too slow to do anything. (The WHO says it could not do better because of deep budget cuts.)

The Sierra Leonean government now agrees that it was not prepared, even though they ‘knew it was coming’. In March 2014, when the first cases started, Ebola had been slowly spreading through neighbouring Guinea and Liberia since the beginning of the year. Sierra Leone’s Ministry of Health only had 136 doctors for 6.2 million people, very few hospitals and little equipment and ability to plan, so they didn’t have much chance. 

But they didn’t say this. They had many meetings for four months. They ignored warnings from ''Médicins Sans Frontières'' – the first NGO to help. After five more months, and nearly 1,000 deaths, the WHO said Ebola was an international health emergency. Then came money and resources to help control the virus. 

'''Fear'

In 2014, Ebola spread through West Africa. It was the longest, biggest outbreak in history, killing more than all past Ebola outbreaks together. 

At the beginning, public health messages were confused. Some people said there was no cure for Ebola. So people did not trust the health system and went to traditional healers. The sick escaped from clinics to try to survive in the bush.
 
Shek Ahmed Bobor-Kamera (emergency programme officer with Christian Aid) explains: ‘The messages were really bad. They did not look at culture and tradition and how people respond to situations like this. In our tradition, if one of my people dies, I have to stay with them until the end. The message was: “Don’t touch the sick! There’s no cure!” This is my mother, my child. I have to leave my child to die? When they took them, you didn’t see them again – they never came back to report on that person’s progress.’ 

Shek Ahmed also says the start of the Ebola response was only about medical solutions. They did not involve important local people – faith leaders, traditional healers, mammy queens and paramount chiefs, who were the best people to communicate with people at risk - until far too late. But this helped later. 

‘They accepted the message from us: “Ebola will leave us, if you do this,”’ as Moses Escanu, a teacher, part of a local Ebola task force in Binkolo, Bombali District, explains.

He was part of an army of volunteers, supported by Health Poverty Action, who made people follow some strict rules. They stopped people moving around and hiding sick people refusing an Ebola test or looking after strangers in their house. 

These ‘bylaws’ started in Kenema and were so effective that the government spread them to the whole country. 

‘It was impossible to bring in enough doctors and nurses,’ says Mike McDonald  (Global Health Response and Resilience Initiative). ‘You had to stop Ebola spreading – mathematically, to stop the epidemic. Communities did that themselves.’

'''The internationals arrive'''

The global humanitarian response, halfway through the crisis, was very impressive. 

Countries from across the world from Togo to Liechtenstein all helped, with international banks and institutions. The US gave $2.1 billion and Britain gave $687 million, and by October 2015, they had $4.6 billion in grants and loans (according to the Office of the UN Special Envoy on Ebola).
 


''Ground zero: Koindu was destroyed first by Sierra Leone’s civil war and then by Ebola. This town and other villages across the border from Guinea, were the centre of Ebola at the beginning. Now the town has no market day and no work. The streets are quiet and empty. Hazel Healy'' 

1,300 foreign doctors (including 850 volunteers from other African countries and a group of Cubans) came to help 39,000 local health workers, many community staff, and more than 1,000 people from the WHO and the UN. 

It was a lot of solidarity. But it was too late for many Sierra Leonean health workers. They were working in facilities that were not prepared for so many people. The World Bank said that Ebola killed five per cent of doctors, and seven per cent of nurses and midwives.

Nafisatu Jabbi, the only survivor of her four-woman team, ran a health post for mothers in Koindu, the early centre of the outbreak. ‘It’s not easy to forget your colleagues. The ones who lost their lives were not even being paid,’ she explains. There were many others like this: in Sierra Leone, with no money in the health system, trained nurses have to volunteer for years before they get a salary.

Her best friend Mercy died. It was early May 2014, just days before the first confirmed case of Ebola. ‘We thought Mercy had cholera. I cleared up her vomit, felt her skin, took her temperature,’ she says. ‘We trained together; we were like sisters.’ Five other nurses they trained with went to visit Mercy when she was sick, and later died. Nafisatu didn’t get Ebola. All the other clinic staff died, had Ebola or ran away, so she ran the centre alone. She delivered babies in the morning and looked after an Ebola centre in the afternoon. She also looked after Mercy’s three children, who now had no parents. Later she earned some money - $80 per week.

So who decided where the money went? Save The Children used an $18.9 million grant from Britain’s overseas aid office DFID to set up an Ebola Treatment Unit (ETU). The ETU treated about 280 patients – it opened slowly in November as Ebola cases rose. $12 million of the grant paid staff salaries and living expenses. From all the millions that came in, less than two per cent was for frontline hospital workers. 

This is typical of a big problem in the humanitarian industry – local people do not usually get the money or help. Last year’s World Disasters Report shows that only 1.6 per cent of money to help with global crises went to NGOs in the relevant countries. And only three per cent went to national states.

‘I felt that some foreign agencies thought it was more important to keep the health workers safe than to look after the patients,’ says young military medic Boie Jalloh. This was about one medical NGO’s policy not to give intravenous fluids to Ebola patients. Jalloh was 29 and had left medical school one year before when he set up and ran an ETU in an old police training school outside Freetown. He treated more than 1,000 patients.

‘We needed these people. They did very well. They were very quick to open ETUs and raising the alarm,’ he says. ‘But if it happened again I would do things differently. The goal was to isolate patients, so people did not want to come because everyone died.’

'''After Ebola'''

Sierra Leone was already fragile before Ebola. It was recovering from a terrible 10-year civil war that ended in 2002. About 70 per cent of people lived below the poverty line. The economy was starting to improve, but Ebola stopped this as it stopped trading, investments were taken back and the price of iron ore (an important export) collapsed.

And now, eighteen months later, the country is only starting to recover. Sierra Leone’s main occupations - farming and small trade - both suffered. The farmers missed two growing seasons. They had to eat their seed stock of ground nuts and rice to survive. Traders had to use up their business money, so could not start trading again.  

But the survivors of Ebola – and orphans and carers - have the biggest problems. About 17,000 survivors across West Africa still have very bad health problems, serious eye conditions, very bad joint pain and loss of hearing. There is a lot of depression and post-traumatic stress disorder.
Survivors often look after children with no parents. Alhassan Kemokai caught Ebola from his mother Madame Basheratu, who worked at Kenema hospital. As she was dying, she held out her hands to her eldest son and blessed him. ‘She told me not to forget my younger sisters,’ he remembers. He survived Ebola and went home to find everything had been burnt – to stop contamination – and he had a much larger family to care for. His had planned his family to have two children, but now has 17: seven orphans plus young widows and their brothers and sisters (aged between 4 and 22).
‘We are full!’ he says of the new house that he has rented on the edge of town. The family lives on simple meals of rice and pepper with palm oil. He desperately tries to keep all the children in school. His partner, Kumba Kendema, is very tired by the washing (three to four hours a day) but she wants the children to feel they are her own. Her mother and aunt come to help cook the food.
Alhassan has a desk job with an Irish NGO and they are just surviving – many people are not so lucky. But he is not sure how long he can continue, and is thinking about an offer from a Guinean family to adopt the youngest orphan. Alhassan’s case is typical of many families –now almost at their limits because of Ebola. 
 
Alhassan Kemokai with his partner Kumba Kendema and their youngest child Masour, who got 11 new brothers and sister after his parents took in the children of relatives who died from Ebola. Hazel Healy 
Positive changes
Sierra Leoneans also say that Ebola has brought some good changes. They now have the start of a mental health service, with 20 nurses working across all districts. They offer counselling and support for some of the many thousands with trauma. 
Hygiene and care in hospitals is better. ‘We didn’t often see gloves,’ says Mark Ali, the medical officer in charge of a newly painted emergency ward at Connaught government hospital in Freetown. ‘Now things are easier.’ He is working alongside Kings Sierra Leone Partnership, a British charity that builds up health systems by working together with them over time. After Ebola, Kings increased their operation from $146,000 per year to nearly $2.9 million. So Connaught now has piped oxygen (this led to a 20-per-cent improvement in mortality rates in the hospital) and a triage system. 
Sierra Leone now has its first infectious diseases isolation unit, for patients with TB, Lassa fever and cholera. Marta Lado was working as a clinical manager for Kings when Ebola started. She refused to leave. She looked after more than 1,000 patients in an improvised isolation ward at Connaught with a British nurse and a few local staff in very difficult conditions. ‘It was so difficult. But now we start to see the real value of partnership,’ she says. ‘The nurses run the new unit. Healthcare workers now have confidence and pride in what they do; they want to improve the hospital. And that came from Ebola. I don’t know how, but it did.’
‘We all learnt a lot, but we are all experts now – our clinicians are the most experienced in the world,’ says Boie Jalloh. He won a presidential award for his work. ‘Thousands of others did more than me. I am just happy to be alive,’ he says. He is proud that Sierra Leoneans set up and ran the ETU he managed. He wants to see local people research more so it is not only international experts presenting papers on Ebola at conferences.
Also, Sierra Leone is now a more united country with a stronger civil society. ‘We have seen what was possible, we can build solidarity and act together,’ says Fatou Wurie, an activist who runs the Survivor Dream project. ‘We have to make Sierra Leone responsible. It’s not enough to say the government need to do something about health or women’s rights.’
The Budget Advocacy Network is fighting for tax changes for mining companies. Then there would be more money for public services, and to write off the IMF debt. $71 million per year has left the country illegally over the past decade. This money could and should have been spent on the people of Sierra Leone.
They need to keep the government on track. There is a lot of work to do, for example, to employ the Ebola health-worker volunteers – or risk losing that expertise and momentum. Also, $3 million is missing from the government’s own Ebola response funds. And the authorities will need to fight IMF restrictions so they can increase public spending.
It will take a long time to rebuild the health systems. Ebola showed how easy it is for an epidemic to start. 30 per cent of people are too poor to go to a health centre. Also, the world has seen how important it is to improve weak health systems and focus on Universal Health Coverage – the dream of free healthcare, stopped by the IMF and World Bank structural adjustment policies of the 1980s and ’90s. 
Sierra Leone now has free healthcare for pregnant mothers and children under five. This started in 2010, but child and maternal mortality figures are still some of the highest in the world. More money must go to public health.
The country will need support for many years. They have spent $1.6 billion dispersed and got promises for more than $3 billion in global ‘Ebola recovery’ funds, so there is some evidence of international commitment. But it will need to be the right kind of aid that enhances capacity, and builds up national systems. Success, says Shek Ahmed, will come from support ‘that goes direct to local partners or in direct money – not on salaries for foreigners.’
 
After Ebola: Nafisatu Jabbi (centre right) at the Koindu community clinic, with a new team, including Community Health Officer Alfonsus Vandi (centre left). Hazel Healy 
Heroes at the front 
Back at Nafisatu’s clinic in Koindu, there is now a new team of maternal health workers. Nafisatu says they now have more medicines and equipment – but she is still waiting for a paid job. 
Men are working on an isolation unit and they have built new places for nurses to live. This is Phase 1 of the government’s plan to improve healthcare facilities after Ebola.
Alfonsus Vandi has just started working as Community Health Officer. ‘We’ve got some idea about how to protect ourselves,’ he says, showing a biohazard safety box. ‘Even the communities have learned!’
He is full of optimism. Staff are talking to many people, so people are coming back to the clinic. He wants the ambulance service to start again – but the driver is sick at the moment. And he says medical supplies should reflect the needs of the area. 
The success of his remote outpost will be an important test of an effective decentralized health system, and how they need the involvement of the community to keep Ebola away.  
It would be good to think the world will support Vandi. Let’s hope we have learned the right lessons from Ebola. We owe it to the victims, and the people protecting the country. 
NOW READ THE ORIGINAL: https://newint.org/features/2016/06/01/after-ebola-keynote/