KONO DISTRICT, Sierra Leone — Thud. Almost every night, the tailor’s wife crushes cassava while making dinner for her children and husband. Thud, thud. Salome Kamara sits on a short wooden stool and braces her bare feet against the dirt floor of her mud-walled home to better hold the heavy stick that she pounds against leaves placed in a large wooden container carved from a tree trunk. The stick is unwieldy — about as tall as the brightly dressed 28-year-old and as thick as her arm.
Beginning last year, two dramatic events began to occupy Kamara’s thoughts, even as her daily routines stayed the same. The first was all around her, in Sierra Leone’s rural Kono district: Ebola grew from a distant rumor to a deadly plague, killing hundreds of locals. Residents panicked, some health workers fled, and gun-wielding military men arrived to enforce a series of lockdowns and quarantines. But as the crisis unfolded, something else momentous was happening: Kamara learned that her fourth child was on the way.
The bigger Kamara’s belly got, she later recalled, the more awkward it was to hold the cassava-pounding stick. And never was it more uncomfortable than on the last night of this past March. After she cooked her family’s dinner, Kamara lay down in darkness to sleep; her house, like most in Kono district, has no electricity, and her mattress is formed from bags of grass. At about 4 a.m., she was awoken by sharp pains in her abdomen. Her baby was coming.
Kamara was soon joined by her mother, her mother-in-law, and a traditional birth attendant (TBA). At 5:30 a.m., Kamara heard the first cries of her newborn. But her labor wasn’t over. To Kamara’s surprise, a twin baby lay inside her, and this one was positioned incorrectly: Its feet faced forward, a worrying complication. In nearly one in five footling breeches, as the position is known, the umbilical cord becomes compressed, cutting off the flow of oxygen to the baby’s brain, which can lead to brain damage or death. The remedy in a modern hospital would likely be a cesarean section, but in Kono district, where only a handful of doctors serve a population of more than 500,000, a breech birth can be fatal for both mother and infant.
Kamara faced a choice. She could stay at home and have the TBA assist her, hoping for the best. After all, TBAs have been overseeing births in Sierra Leone for hundreds of years. But recently, public health officials have increasingly been warning that babies born under the guidance of TBAs are more likely to die than those born in medical facilities. A study published in April by Doctors of the World found that in Sierra Leone’s rural Moyamba district — across the country from Kono — babies born at home are 165 times more likely to die than those born in a clinic with a skilled health professional.
For Kamara, an alternative was nearby. Just a few miles away, down a deeply rutted dirt road, the Koidu Government Hospital ran a maternity ward. People in her community, however, had told her that workers there charged bribes to deliver babies. Besides, the hospital was reeling from the effects of Ebola; though most cases were by then being treated in specialized centers and Kono district had reportedly been Ebola-free for a month, the hospital remained deeply stigmatized, according to physician Ronald Marsh, the facility’s medical director. “The patients are afraid,” Marsh said in April. “It’s quite difficult for them to come in.”
Two nurses in the maternity ward had died after catching Ebola from a woman suffering a miscarriage. Kamara wasn’t eager to go there. She lay back on her bed and looked at the women in the room. With time quickly running out, she weighed her options.
Sierra Leone’s mortality rate for infants, young children, and mothers are all near the worst in the world, as is the country’s life expectancy for women (just 46). The lifetime risk of dying during pregnancy or childbirth for a mother is one in 17. About 3 percent of babies are stillborn. For every 1,000 children who successfully run the gantlet of the birth canal, 39 die within the first month of life — from bacterial infections, pneumonia, and other ills. For the five-year period ending in 2013, even incomplete data that do not include certain categories of infant death show that, as very young children age, the death toll climbs: to 92 before their first birthday and to 156 by age 5, with many succumbing to malaria or parasitic organisms that live in untreated drinking water.
The sum total of all these dangers is one comparative statistic that puts the Ebola epidemic in perspective: The deadly virus that motivated billions of dollars in international aid has killed nearly 4,000 people in Sierra Leone. (Total infections in the country as of Nov. 22 were 14,122.) The number of children under age 5 who die each year from other causes is 10 times that.
Yet there are signs that the two trends are dangerously intertwining — that the ravaging toll Ebola has taken on Sierra Leone’s health-care system may mean even more mothers and children will die in years to come.
As Ebola crowded out other health concerns in 2014, the country’s already tremulous health infrastructure fell apart. “Sierra Leone is still struggling to emerge from the ravages of a devastating war,” says Anders Nordstrom, representative to Sierra Leone from the World Health Organization (WHO). “The Ebola outbreak has added strain to an already fragile system.” In November 2014, six months after the country’s first Ebola cases were documented, the WHO reported that “few patients have access to healthcare facilities, with many facilities closed.” Many health workers died or quit out of fear. Attendance at clinics dropped by as much as 90 percent, the WHO report found. Frightened parents kept their children home with life-threatening diseases. Vaccination programs that were only just starting to effectively combat other killers, such as measles and Lassa fever, were decimated.
As a result, local doctors and international NGOs, including Care USA, estimate that for each person Ebola has killed through direct infection, more than one Sierra Leonean will perish from the secondary effects of the crisis. At the end of August, deep into the country’s rainy season — when many water-borne diseases are easily contracted — Nordstrom acknowledged that cases of Ebola have slowed to a trickle; in fact, the country had just experienced two weeks without any newly reported cases. But he said that the warning bell of the epidemic’s far-reaching consequences is ringing loudly.
“Now is the time…. We can really apply a massive effort to tackling this appalling loss of life,” Nordstrom said urgently. “This should really be treated as an emergency.”
Sierra Leone’s health misery used to have more company. In 1981, its infant mortality rate — 166 per 1,000 children under 1 year old — put the country in a statistical dead heat with, among other countries, neighboring Guinea. But where Guinea has dragged itself at least partway out of this trough, Sierra Leone has lagged. A Sept. 9 report from the United Nations estimates Sierra Leone’s 2015 infant mortality rate at 87 and Guinea’s at 61. Similarly, 35 years ago, the life expectancy for women in Guinea and Sierra Leone was separated by only two years (43 versus 41). Now there’s an 11-year gap: 46 in Sierra Leone and 57 in Guinea.
What happened is the story of a long and largely unsuccessful battle fought to improve Sierra Leone’s health-care system, much of it against the backdrop of bloody conflict. In 1988, the country seemed poised to address one of its key health needs by founding its first medical university, the College of Medicine and Allied Health Sciences, in Freetown, the capital. The college was supposed to act as a pipeline, sending medical staff to critically underserved areas throughout Sierra Leone. But at the same time, the public was growing increasingly dissatisfied with the corrupt rule of Maj. Gen. Joseph Saidu Momoh. In 1991, just as the medical college was turning out its first batch of professionals, the Revolutionary United Front (RUF), a rebel group, sparked an insurrection. Among its many stated principles, the RUF promised to implement free health-care nationwide.
Revolution, however, turned into an 11-year-long civil war, during which bands of rebels armed with machetes and firearms roamed the country, terrorizing citizens. Hopes for an improved medical system quickly faded. In 2000, an article in the New York Review of Books called Sierra Leone “The Worst Place on Earth,” based on the country’s last-place ranking in the U.N. Human Development Index and its abysmal health indicators, including infant mortality. Many existing health practitioners fled the country, never to return.
In 2002, just after the war ended, the new president, Ahmad Tejan Kabbah, issued a decree that certain vulnerable groups would no longer have to pay for their health care at any facility in the country; pregnant and nursing women were included in the directive. But implementation was spotty at best. Some medical workers were so poorly paid that they had little incentive to stop charging patients. In 2008, six years after Kabbah’s decree, 80 percent of Sierra Leonean women polled in a health survey conducted by the national government reported that the biggest obstacle preventing them from accessing care was cost.
In April 2010, legislators passed a free health-care initiative, which, among other things, stipulated a significant salary boost for health workers. Robert Yates, a health economist with the United Kingdom’s Department for International Development (DFID), was quoted trumpeting the law in a 2011 New York Times article that noted an increase in the number of young children getting treatment at medical facilities and a drop in the malaria fatality rate for children treated in hospitals. Moreover, a new government survey in 2013 found that the percentage of women reporting that cost was the biggest obstacle to accessing care had dropped to 67 percent.
Yet other evidence indicates that the law’s effects have been limited. A 2012 study from ReBUILD, a research consortium funded by DFID, found that though salary increases for health workers had improved their numbers, attendance on the job, and motivation, inconsistent payments from the national government, particularly in rural areas, remained a problem. Staff shortages in public health clinics and hospitals ranged from 40 to 100 percent. An endemic culture of corruption has also lingered: In 2013, 48 percent of respondents to a national survey administered by Transparency International reported that they or a household member had paid a bribe to receive health services over the previous 12 months. Fifty-five percent described medical and health services as corrupt or extremely corrupt.
Some health workers point out that for them, bribing remains a matter of necessity: Without “those charges, they will not have enough to eat,” says Adama Momodu, who works at a community health center affiliated with Koidu Government Hospital in Kono district.
Dollar figures show just how dire the situation has become. In 2013, according to the WHO, Sierra Leone’s government covered just 14.3 cents of every dollar spent on health care in the country — the second-lowest number in the world and down from 29 cents of every dollar in 2000. The flip side of that statistic is the large amount of money coming out of the pockets of Sierra Leone’s citizens to pay for their care. In 2013, people paid 61 cents of every dollar spent on health care. (The balance came from international aid.) “Very little is said about the end users that continue to provide a large proportion of health funds in Sierra Leone,” ReBUILD noted in 2012. “In the midst of the wide spread poverty, a thorough investigation should be carried out on the coping mechanism of end users, their perceptions on health care delivery and their patterns of spending.”
Even as it has struggled to fund a functioning health system, the government has responded to concerns about the risks of home births to pregnant women, like Salome Kamara, and their infants by discouraging the use of traditional attendants. The 2010 health law, for instance, recommended that local communities pass bylaws “preventing home deliveries” and advocated “the phasing out of TBAs carrying out deliveries on their own,” which led to reports that, in some areas, TBAs had been banned and faced fines.
Still, the prospect of paying bribes in a distant hospital is often less attractive to Sierra Leonean women than that of giving birth surrounded by family at home. The fact that the setting is less hygienic and that TBAs aren’t trained to navigate many physical complications doesn’t diminish the appeal.
Some health experts are hoping to find a sort of third way to assist mothers — a setting that offers the benefits of a well-run hospital combined with the support provided by a TBA. One such person is Raphael Frankfurter, executive director of Wellbody Alliance, a small NGO that began in 2006 as a partnership between medical workers from Sierra Leone and the United States and that operates a health clinic in Kono district.
Wellbody first tried to bring more women into government-run birthing clinics by running public-awareness campaigns that paid TBAs to teach area mothers how to have safer births. But the program failed to budge attendance at Koidu Government Hospital’s maternity ward or at the hospital’s associated community clinics. Frankfurter was troubled when he learned why. “Some women were explicit,” he explains. “They would say, ‘I know that my chance of losing a baby is higher, but they don’t treat you as well at the hospital.’”
“If they go to the TBA,” Frankfurter says he realized, “it’s because the TBAs do something better.”
So Wellbody decided to come at maternal health from another angle. The NGO, which already ran a general health clinic, built a delivery center in Kono district equipped with the area’s only ultrasound machine and staffed by a mixture of TBAs and medically trained aides. “We don’t want to just coerce and swallow TBAs into the health-care system,” Frankfurter notes. “We want to learn from them and help what they do, which is provide really attentive care to women.”
Wellbody slated the center’s opening for the summer of 2014. But then, Ebola struck.
For months, health officials could do little to stem the mounting death toll. Frankfurter, who attended national strategic sessions on Ebola response, says the meetings were full of dread. “People were just looking at each other, asking what should be done,” he says. “No one had any answers.”
In Kono district, medical wards became objects of fear. Patients, some suffering acutely from Ebola, fled Koidu Government Hospital. Rumors spread that doctors were deliberately injecting locals with the virus in order to weaken political opposition to the national government. Military quarantines just made things worse. One day, Frankfurter heard a woman shouting in the street. “‘Ebola is a lie!’” he recalls her yelling. “‘They are sending people to the government hospital to die!””
Nongovernment health facilities also shut their doors. At Wellbody, attendance at its existing clinic plummeted 95 percent. Ultimately, because the facility wasn’t equipped to protect its workers from Ebola exposure, Wellbody’s leaders closed it down; the opening of the new delivery center was indefinitely delayed. “There was no other choice,” Frankfurter explains. “Everyone knew someone who had been infected. We were frightened, and we couldn’t put our workers at risk.”
Over the past year, health groups have been trying to quantify the impact that this collapse of the health-care system has had on Sierra Leone. Nationwide, UNICEF has documented a 27 percent decline in the number of women coming to health clinics for prenatal visits or delivery and a 39 percent decline in malaria treatments for children under 5. The U.N. Population Fund predicted in February that maternal deaths during childbirth would double to more than 2,000 per 100,000 this year, a return to levels seen in the 1990s. And the Assessment Capacities Project, a consortium of three international humanitarian NGOs, has estimated that, between March 2015 and February 2016, 330 more women would die because of disruptions to maternal care and that “an additional 8,593 deaths of children under five are expected as a result of health service interruptions, including 2,554 newborns.”
Records at Koidu Government Hospital show 226 Ebola deaths in Kono, but Marsh, the medical director, says that is only a small part of the story. He doesn’t have a working figure of the number of deaths indirectly caused by Ebola, but says “of course, it’s way more” than the official tally. The hospital estimates, for instance, that Ebola-related disruptions have prevented 3,300 newborns from being registered — a first step in getting medical treatment under the 2010 free health-care initiative.
Ironically, some experts see a bright spot amid these horrific numbers. Ebola has brought a great deal of attention and foreign aid to Sierra Leone (and to other countries affected by Ebola). In July, the acting administrator of the U.S. Agency for International Development, Alfonso Lenhardt, said the United States alone had spent $2 billion in the affected region since the outbreak started. If similar support could be commanded for a few years more, some experts say, in Sierra Leone the resources could be used to build a new, more effective health-care infrastructure on the ashes of the old one.
“I do believe we now have a golden opportunity to change this situation,” the WHO’s Nordstrom says. “Now we need to build on this very strong response to fight Ebola, to tackle other health needs.”
In January, the WHO noted in a report that Sierra Leone is better prepared for future outbreaks. Medical personnel know how to use protective equipment, for instance, and new intervention resources are on the ground, including 11 well-equipped blood labs, operated by the government and different international groups, that are collectively able to process more than 1,000 samples a day. While these were set up to evaluate potential Ebola cases, they could also be used for a wide variety of disease testing. In addition, blood transfusions are now safer and more widely available, the WHO said, because of training and equipment brought in during the epidemic’s nadir; this could help local health workers treat persistent killers — malaria, dengue, Lassa fever, yellow fever, and even certain childbirth complications.
Still, many of the same old problems that have long plagued Sierra Leone’s medical system remain. “There are very practical things that must be done urgently,” Nordstrom notes. “For instance, ensure that every health facility has running water.”
Frankfurter said he witnessed a veritable flood of medical personnel from the Red Cross, Doctors Without Borders, and other organizations come to Kono district to help when Ebola was at its peak. But by this June, many of them had begun to withdraw.
“I know that their mandate is to help disasters,” Frankfurter says. “But here, everything is a chronic disaster. It’s hard to say Ebola’s any different than having three doctors for 500,000 people. They’re both disasters.”
Wellbody, which saw its donor-driven budget double in 2014 thanks to Ebola, was finally able to open the doors to its delivery center on April 1, 2015. Salome Kamara was the first woman to visit: With her second twin baby in footling breech position, she made the difficult decision to deliver outside her home, under the care of both TBAs and medical staff.
At 8 a.m., when happy news came from the delivery room, Kamara’s husband, mother, and stepmother celebrated loudly outside. A few hours later, Kamara sat on a clinic bed, nursing her second twin. One Wellbody staff member brought her a plate of food, while another adjusted her feet on the bed to make her more comfortable. Kamara had expected to be charged for the delivery. Instead, she was given a gift: a brightly colored lapa, which is wound around the waist and worn as a skirt.
Kamara’s experience illustrates the knife’s edge on which Sierra Leone teeters when it comes to health, particularly that of its most vulnerable citizens. Over the next 12 months, an estimated 260,000 women will give birth in the country — and each one faces the threat of interrupted access to care because of Ebola’s lingering impact. Some will get the help they need, as Kamara did; other will not. And even for the babies who survive birth, risks will loom for years to come.
The day after giving birth, Kamara and her mother put on their sandals and walked home, each cradling an infant as motorbikes passed on the dusty road. When she arrived, Kamara put down her babies and picked up her stick. It was time to pound cassava. There were now seven mouths to feed.