First Ebola, then Covid-19

Four years ago, New Internationalist travelled to West Africa to hear the stories of communities in recovery from the deadly Ebola epidemic. Hazel Healy gets back in touch.

Simon Davis/DFiD
Dr Asamte Fidel, one of the local Sierra Leonean doctors working at Connaught Hospital, which was on the frontline of the Ebola epidemic when it hit in Freetown, Sierra Leone. Credit: Simon Davis/DFiD

In early April, Sierra Leone confirmed its first case of coronavirus, one of the last nations in the world to do so. A low-income country, it has limited intensive care capacity, a total of 18 ventilators and a population of six million, the vast majority of whom lack the financial means to ‘stay at home’ or observe social distance.

In this context, a full-blown outbreak would be devastating. To date, the country’s strategy has hinged on meticulous testing, contact tracing and isolating, which is aimed at keeping Covid-19 out of its under-equipped general hospitals. Borders are closed, the airport shuttered and there are short, periodic countrywide lockdowns.

Sierra Leone is still in the early stages of the pandemic. Authorities are quarantining all who test positive for coronavirus. The asymptomatic go to community care centres – a relic from the fight against Ebola – as close-quarters living rules out self-isolation for most, while those who get sick are sent first to isolation wards and then on to dedicated Covid-19 treatment centres.

This decisive action has so far kept the number of cases and fatalities low. But infections are rising steadily. As the first community transmissions – which are unconnected to known clusters of cases – start to emerge, we speak to a market trader, a junior doctor, a community activist and an aid worker about Sierra Leone’s fight against Covid-19 – and the immense challenge of combating a virus without the drugs to treat it.

Flip-flop seller

Theresa Jusu is a 31-year-old market trader from Koindu, on the border with Guinea and Liberia, one of the early epicentres of Ebola.

Since coronavirus, the government closed the cross-border markets. Those of us who live on the border make our living through trade and Sunday was our market day. People travelled far to come to the Koindu market. It was chock-a-block; people made the town look lively.

The Guineans used to sell pepper and onions, cows’ milk and textiles. You could buy greens, potato leaves, cassava leaves; I sold dry goods, clothes and flip-flops. I might sell 10 in a day.

Now people are only looking to buy food. So, I sell rice and oil instead, at the local market. I get it on credit from shopkeepers, sell it on and keep any profit. But I can go a whole morning without selling a single thing.

With what I make, I support my four children plus my younger sister and her child, who are living with me. Before, we would eat two meals a day – breakfast and dinner – now it’s down to one.

People are scared of the coronavirus in Koindu, because of the way Ebola came in and destroyed our people. But we are getting to understand that people are surviving – they are going into 14-day quarantine and then they are coming home. With Ebola, they never came back.

At least, because of Ebola, we know how to protect ourselves. At the market, there are handwashing stations, some people have sanitizer. And they were giving out African-made masks for free. I got one, but there wasn’t enough for everyone.

There have just been short lockdowns so far. If people are hungry, they start breaking into houses looking for food. And if you go out, the police will beat you. Sierra Leone doesn’t have the economy to pay people, but at least the government should give them something to eat.

Infectious diseases specialist

Marta Lado is a Spanish clinician who has worked in Sierra Leone for the past six years. Chief Medical Officer at the NGO Partners In Health, she trains hospital staff and is treating coronavirus patients at 34 Military Hospital in Freetown.

The response to Covid-19 was fast, and it was easy to do because of our experience with Ebola. We knew how to manage a crisis – what structures to put in place. But just because we went through Ebola doesn’t mean we can deal with any pandemic that comes. The problem is that in a poor country without resources you can never really be ‘ready’.

In Europe, hospitals were overwhelmed by numbers, which are hard to predict. But they had a system in place. Our health system is weak. In 34 Military Hospital we have 10 ventilators. But to intubate someone you need to sedate them first. We don’t have sedation drugs, we don’t have an intensive care specialist or specialized nurses and we don’t have enough nurses to maintain a patient with a mechanical ventilator. But before that, the thing that will kill the patient is likely to be the lack of insulin, antibiotics or steroids – or even intravenous cannulas. So – what do you want me to do with a ventilator?

The basics are not in place. Most of the hospitals here don’t have oxygen. They might not even have running water, or electricity to be open for 24 hours. Patients need to pay for their own medication to treat common conditions. Now, if you put Covid into that system…

We are dealing with it, but because individuals have had to fight to get things: doctors buy drugs for their patients, friends with private pharmacies donate drugs, the Lebanese community gives us cylinders for oxygen, the Indian community pays for some medication. You end up begging for favours because we don’t have the money, nationally, to buy these things.

I’m not blaming anyone. But we need to recognize that Sierra Leone doesn’t have the financial capacity. Later, when this is over, we have to reflect on how to improve the basics so next time this happens we don’t find ourselves trapped with no resources.

Community advocate

Mohamed Camara is an activist and On Our Radar reporter from Magazine Wharf slum community in Freetown.

In my community, houses are close together. Social distancing would be a very difficult. It’s crowded – you might have seven or eight people living together in a small, single room. We’re a close-knit community, we see each other as family and we share what we have.

So far, we’ve had no cases in Magazine – either confirmed or suspected. But if there is a Covid-19 case in our community it will spread like a fire in the Amazon. We experienced one of the worst outbreaks during Ebola here, and were the last to be declared ‘Ebola-free’.

This environment is not safe, it’s not hygienic – that’s how I contracted polio as a child. Freetown’s drains empty out into Magazine Wharf; it’s muddy, people rear pigs in the rubbish. During the rainy season, the community is flooded, and this can cause cholera.

The three-day lockdown was a bit crazy here because people rely on the income that they earn each day. The government just imposes things without trying to minimize the impact. If there’s a total lockdown, there will be chaos if people have no way to survive.

We also had 14 days of restricted movement. Most people make a living from petty trade, fishing or cutting firewood so it’s very difficult for them if you stop them moving across the district. And food prices are rocketing up – people are taking advantage. How can we adapt to the new rules, if the government doesn’t pay attention to this?

People are suspicious – that’s another problem. They aren’t really wearing masks and social distancing because they don’t trust the government. People are saying each president brings a virus: first Kabbah: HIV, Koroma: Ebola, now Julius Bio has come with coronavirus. They think the government wants to get rich, not to protect them. When the election comes, they say, we will vote these guys out.

Junior doctor

Mamadu Baldeh heads up the Infectious Diseases Unit at Connaught Hospital, the main tertiary referral facility in Sierra Leone’s capital of Freetown.

We have 10 beds in the Infectious Diseases Unit, which serves as our isolation ward. So, we work on having a rapid turnover of patients: get suspected cases tested, send people to treatment centres, the general ward or discharge them.

As of now, we’re not overwhelmed with Covid-19. But work is hectic. In one day, I might see 10 new patients, dispatch 10 more patients and write their referrals. Everything has to move fast and it’s exhausting – at the beginning I was even sleeping at the hospital.

Now there are two more doctors with me, and we work on rotation. My facility is full right now, which is why I have time to do the interview – but if more patients come in, we may have to start looking for another isolation facility. Ours is already the biggest isolation ward in Sierra Leone. We have supplies of Protective Personal Equipment (PPE) but sometimes we do run out of things – boots or gloves.

Until now, we have lost 11 people to Covid-19 in my unit. At first, people were dying because they couldn’t afford to pay for their medication. Since then a Sierra Leonean journalist called Vickie Remoe has raised funds through a public campaign and – thank God – Covid medicines are free to patients.

But donations can’t fix everything. Right now, you see ambulances everywhere. Now we have oxygen. The challenge is that they don’t disappear, without a crisis like Covid.

We need a national effort, to remodel all aspects of the health sector: resources, budget, personnel. Many Sierra Leonean doctors who train here leave in frustration. But I trained in Venezuela and I saw the dedication of the Cuban doctors who do so much with limited resources. And then I came back to serve.

Additional reporting by Moses James, from the On Our Radar reporter network.

Staff at Connaught Hospital and 34 Military Hospital are supported by Kings Health Global Partnerships and Partners in Health.