The Lesser Known Challenges in Healthcare Systems of Ebola Affected Countries
By Zeno Masereka
On August 1st, 2015 I woke up to a message notification alert from the World Health Organization (WHO) about the efficacy of the new Ebola vaccine. The Ebola vaccine has been proven to be 100% effective in protecting humans against one of the most deadly germs — Ebola Virus. This was my second happiest moment ever since I came to West Africa to fight Ebola; my first moment of excitation was the recognition of the good efforts of healthcare workers by Times Magazine in 2014.
This has not only given me hope to survive throughout this epidemic here in Sierra Leone, but it has also strengthened my resolve and commitment to continue supporting Sierra Leoneans to overcome this deadly epidemic.
Outside this normal notion of hope and relief from the lethal fangs of the Ebola Virus Disease here in West Africa, I have taken some time to think about the real reasons why the current epidemic has claimed over 10,000 lives in a space of 12 months across West Africa. I have decided to neglect the scientific reasoning of Ebola as a highly virulent germ, but instead looked at the basic and uncomfortable reasons why Sierra Leone, Liberia, and Guinea lost many people to the virus unlike past outbreaks on the African continent.
There are untold stories as to why Ebola is still around despite the fact that following simple hygienic principles like hand washing and decontamination using locally available detergents and cheap chlorine bleach can control the Ebola germ. Over the past 7 months I have taken a very robust look at the normal operations of conventional healthcare services in Liberia and in Sierra Leone. I have looked at my daily memoirs in Liberia while working at an Ebola treatment center for an American NGO — The International Rescue Committee — and in Sierra Leone where I currently work on an Ebola recovery program for another humanitarian organization — AmeriCares.
In Liberia, one Ebola patient was not cooperative with a Liberian physician assistant who was translating for the expert doctors during a ward round in the Ebola Treatment Unit in Bong County where I was working. The doctors decided to leave the patient and go to the next patient, completing the ward rounds while everyone was still doing well inside the heavy and hot personal protective equipment. After giving this uncooperative patient her drugs for the day, and drawing her blood for the tests, she called me back and told me the answers to every question that was asked. When I asked her why she was not disclosing when everyone was present, she told me that the Liberian physician assistant was very rude to her in the local language, which none of us foreign experts would understand. Three more patients in the ETU also echoed this sentiment.
I raised the issue with a Liberian-American physician, who surprisingly told me that Liberian doctors and nurses are traditionally rude in speech to sick people. I told him this is wrong and he agreed with me, but he said it is a very huge problem in the country. When I tuned into a local radio station, I heard an advert by the Ministry of Health urging people to stop going to pastors and traditional healers first before seeking care at ETU’s. In Liberia people prefer to consult a pastor or a traditional herbalist before going to a hospital. This led to late reporting and presentation of Ebola patients for care at ETU’s. There is a very minimal chance of survival for an Ebola patient if he shows up late for treatment. No leader was addressing the problem of poor professional communication skills among Liberian nurses and doctors that hinders early reporting of Ebola patients. This had an obvious impact on the mortality rate in this current Ebola outbreak. And yet, I did not see any evidence of health authorities correcting this systemic problem — even when they are aware of it.
In May 2015, I went to Sierra Leone where I found more systemic challenges within the country’s health system that no one talks about. The country was still reporting cases until two weeks ago. Part of the untold reason is that some parts of the country did not implement full-time quarantine because these areas are home districts to strong and powerful politicians who did not want disruption of their businesses, but instead used this opportunity to cash in from market monopoly when other businesses were told to close. This is strange but true. Also, the country has a confused human resource structure. State Enrolled Community Health Nurses and Community Health Officers– who are not trained in mainstream bedside clinical management of sick people — are the ones who perform the day-to-day activities in district referral hospitals; at times they even head such hospitals in rural-remote districts of Sierra Leone. This cadre of health workers is trained for Community Health Centers, not hospitals.
It is a big and disastrous mistake that the Ministry of Health posts inappropriately trained health workers to hospitals in Sierra Leone.
No one is raising these issues, and it is business as usual.
I discovered this loophole in the Sierra Leonean health system when I analyzed the pre-training surveys for the IPC (Infection Prevention & Control) training that I have been doing since June this year. Before the training, none of the nurses or Community Health Officers knew how and when to wash his/her hands, how to manage medical waste on the ward, or how to remove soiled gloves. These are points of contamination for any health worker in a hospital set-up. This epidemic has claimed the lives of many health workers in this region who contract Ebola in hospitals. I have now discovered that the cause of this high mortality of health workers in this current epidemic is not only the absence of adequate protective gear as many think, but also the poor training curricula of front-line health workers in Sierra Leone. Surprisingly no one is talking about this.
When health systems expose health workers to dangers that claim their lives — it creates bottlenecks in quality health service delivery. When no one is willing to address such kind of a challenge — then there is no room for improvement. When the health workers themselves are comfortable working in fields they are not trained to work in — for the sake of community respect and glorification — to me this is another dangerous challenge. When powerful politicians break disease control interventions for monetary reasons — this is also another systemic challenge to public health.
When healthcare workers scare away patients, whom they are trained to serve — this is a catastrophic challenge as well.