British doctor Oliver Johnson is fighting Ebola on the frontline in Sierra Leone’s capital Freetown. He leads a team of volunteer doctors and nurses from the Kings Sierra Leone Partnership at the country’s Connaught Hospital. They have been treating cases in an isolation unit since the outbreak emerged in March.
The virus is now present in Sierra Leone, Liberia, Guinea, Nigeria and Senegal. It has so far killed more than 1,550 people and infected more than 3,000. Last week the World Health Organization (WHO) warned that cases could exceed 20,000 before the outbreak is halted. There is no known cure for Ebola.
In this interview, Oliver Johnson talks about the situation in Sierra Leone, and warns that without urgent international assistance Ebola threatens to undo all the reparations the country has achieved since the end of its decade-long civil war in 2002.
During the civil war, much damage was done to the health system. Some of that was because hospital buildings were destroyed. But a lot of it was because senior staff were either killed or left.
The war was also damaging because many NGOs took over health services. This undermined confidence in the government health system, which was already weak. NGOs don’t stay, and when they go they often leave a massive gap because people have become dependent on them. Government facilities get weakened by having an NGO next door that’s providing really high-quality care.
If you look at what is going on now with Ebola, health-service buildings are untouched, by and large. The infrastructure is not the issue. But more than 50 health workers in Sierra Leone, and more than 130 across all Ebola-affected regions, have been infected. Two in Sierra Leone were senior doctors. Dr Sheik Umar Khan was the country’s leading virologist. Dr Modupeh Cole held one of only three consultant positions at the main referral hospital. The loss of Khan and Cole is a big gap that will be difficult to fill.
Many Sierra Leonean senior staff live between Freetown and London and a lot of them are on holiday at the moment. We’re yet to see whether or not they return, because many are now afraid to come to work. They are scared the hospital isn’t safe. We’re desperately trying to keep confidence up in the government health system, but after this epidemic, we’re going to have a job to do to restore confidence.
We need to do two things. There has to be a technical effort to make sure staff have the right training and the right supply of drugs, aprons, soap and water. We also need to make a psychological effort. The leadership required across the health system to convince people that it’s safe will play a big part.
How long that takes depends on the international community and the Sierra Leonean government. Once you close a hospital it collapses confidence. So far Connaught, the main government referral hospital in Sierra Leone, has stayed open. But it’s a constant effort and we simply don’t have enough support from the international community right now.
‘We’re turning the clock back to exactly what we were trying to get away from: a pop-up NGO, aid-run system, rather than strong, government-led heath system run and led by Sierra Leoneans’
Kings has a whole team out here and so far we’ve been able to keep up staff confidence and keep the hospital open. The children’s hospital down the road is closed. This is an important point. Kings has stayed. Most NGOs in the country have pulled out. They have evacuated their staff, which means those long-term efforts to strengthen the health system have all been interrupted. Everything is on hold.
It will be very hard for some NGOs that left the country to come back and restore those relationships. A lot of local staff will say: ‘You left us when things got bad.’ A lot of people might be suspicious. They’ll say: ‘You told us we were colleagues and partners, but when things got tough you ran away’. Kings is one of the only organizations that have stayed. And that’s one of the reasons why Connaught has stayed open.
The other issue now is that NGOs are taking over the health services again. Médecins Sans Frontières and the Red Cross were winding down here since the war. But now all those organizations are back running services. There’s a danger that if we invest only in NGOs right now we’ll restore a situation where the NGOs run the health system for a couple of years and then leave. We’re turning the clock back to exactly what we were trying to get away from: a pop-up NGO, aid-run system, rather than strong, government-led heath system run and led by Sierra Leoneans.
Right now we’ve got strong leadership from the government. But the support from the international community continues to be virtually non-existent. We’ve seen so little support on the ground. As far as I’m aware, Kings is the only organization still working clinically in a government hospital. All the others have left, apart from the WHO in Kenema’s hospital in the interior.
We need massively more support from the international community to strengthen government hospitals, so that normal services can continue and staff can be safe and not die. We need to keep staff confident to make sure patients keep getting good quality of care and keep attending. We don’t want to create a parallel NGO structure.
We need NGOs to be willing to work in government hospitals and a lot of them are afraid. They’re saying to Sierra Leonean doctors and nurses: ‘You should go into the isolation units.’ They won’t go in themselves. International NGOs are advertising fundraising, but when it comes to it they’re not actually willing to go shoulder-to-shoulder with colleagues on the ground.
Health workers wouldn’t be dying here if we had good infection control. When the outbreak ends, that’s what we’re going to have to focus on. We’ll need a major programme around infection control and strengthening the health workforce. We’ll also need to restore patients’ trust in the government health system.