In the midst of an epidemic

BY CAROLINE SCOTTER-MAINPRIZE

‘No one knew how to deal with it when the outbreak first struck – it was chaos. There was no leadership. There seemed to be no coordination with the international agencies. There was no means of social mobilisation to engage with communities and limit transmission of the disease. We lacked equipment and resources and our own healthcare infrastructure was revealed to be very weak. No wonder it spread so fast.’

Chevening Scholar Alimamy Serry-Bangura had been qualified as a medical doctor for only two years when Ebola virus hit his home country of Sierra Leone in West Africa. It was to become what the World Health Organisation (WHO) later called ‘the most severe acute public health emergency seen in modern times’. He worked with colleagues to treat sufferers in hospital before contributing to community engagement in Kambia District in 2015. While there, he had the role of lead clinician on the EBOVAC (Ebola Vaccine) trial with the London School of Hygiene and Tropical Medicine (LSHTM).

On duty: Dr Alimamy Serry-Bangura had only been a doctor for two years when Ebola struck

STATE OF EMERGENCY

After an 11-year civil war and a cholera outbreak in 2012, Sierra Leonians were almost inured to crisis and, according to Alimamy, were not inclined initially to pay much attention to Ebola. ‘It was only when the President declared a “state of emergency” in July 2014 that everyone suddenly realised it was serious,’ he said. ‘And immediately everything went into recession. Nobody went out into the bush; nobody cultivated the land. Nobody harvested the crops or went to the markets. Everyone was scared. They didn’t know where the infection was coming from, they didn’t know who was infected. They didn’t even want to go to hospital because that signalled that they were dying.’ Health workers were stretched thin, often pulled out of other areas to work in Ebola wards. This had negative effects on services such as maternity care, immunisation against a range of diseases, and malaria treatment. The impact on the agricultural sector meant that many people were battling malnutrition.

A CHANGE IN ATTITUDES

Ironically, according to Professor John Edmunds from LSHTM, who specialises in designing control programmes against infectious diseases, Ebola is not very contagious relative to some other more common diseases such as measles or chicken pox. It is spread through contact with bodily fluids rather than being airborne and can be limited by good infection control. However, mistrust between the population and the government in Sierra Leone ‘made it difficult for public health messages to get through’. Professor Daniel Bausch, a physician and virologist who directs the UK Public Health Rapid Support Team, a joint programme of LSHTM and Public Health England, agrees that lack of trust was a major problem. Top-down solutions, with an influx of health workers from abroad, big cities, and other African countries, could be unsettling for people in rural communities, particularly if they were being told to change long-held traditional practices such as burial customs. ‘It’s one thing for us to say, “stop doing that because our scientific research shows it can have significant consequences”,’ he said. ‘It’s another thing for people not to continue with something that has meaning and significance for them, and is an important way of dealing with the trauma of losing loved ones.’

A hospital in Sierra Leone, 2014

Alimamy and his colleagues, though, were close to the communities and visibly affected by Ebola themselves – 11 of his fellow doctors died. This made it easier for them to identify and engage leaders at a local level who collaborated to change behaviours and support the national response team. ‘We knew we had to move out of the clinic and the hospital setting because we had to find out where the cases were coming from.’ said Alimamy. ‘When we stepped out into the community ourselves, that’s when people started to feel confident. With strong local leadership, people took ownership and made it their personal responsibility not to travel and to change what they did to avoid spreading the disease.’

A BETTER FUTURE

The region’s social and economic recovery will take a long time, with urgent and substantial investment still needed in education and healthcare. However, Alimamy has noticed the beginnings of quiet change in some attitudes. ‘I did some voluntary work with pregnant mothers and young children in one of the rural health clinics,’ he said. ‘I realised that people are now much more trusting of the system and more likely to seek proper medical help. This is important, because even when Ebola is controlled, malaria and other diseases are still there and still killing. The government and international community are helping but we want to get a critical mass of healthcare workers going back to strengthen the system and help create a better a future.’