Pandemic Lessons from Sierra Leone

The African President of the World Health Organization (WHO), Tedros Adhanom, said on March 23rd that “Africa must wake up to the reality of COVID-19”. Indeed, despite uneven public health systems, erratic access to information, and other pressing difficulties, not the least among them being ongoing regional violence, there have already been 10,305 confirmed cases on the continent as of April 7, 2020 and 244 confirmed COVID-19 related deaths. The bulk of these are in South Africa, (1,749) arguably the country with the most sophisticated public heath infrastructure on the continent, but with unequal access to it.

Nonetheless, just about every country on the continent has some confirmed cases. Up until last week, Liberia, Guinea and Sierra Leone, the countries most seriously hit by Ebola, had none. As of this week, Guinea had 128 cases after controversially going ahead with elections against WHO advice, and Liberia had 14 confirmed cases, six of which were linked to travel in Italy. Sierra Leone had no cases until the beginning of this week, and now have six. Sierra Leone comes at or near the bottom of the African coronavirus table and the global count—finally a list Sierra Leone is happy to be at the bottom of. The Ebola outbreak in West Africa between 2013-16 has left Sierra Leone in a well-experienced position to deal with a potential outbreak of COVID-19.

The WHO has expressed particular concerns about the vulnerability of countries with weak health systems. Resource poor countries like Sierra Leone that have faced major outbreaks of infectious diseases in the past such as Ebola have chosen to draw lessons and learn from their experience. As a result, they have put in place strict preventative measures in the current crisis.

On March 19th Dr. Julius Maada Bio, President of Sierra Leone spoke to the BBC World Service about Sierra Leone’s preparedness. He explained that the fight against COVID or Ebola or any epidemic is “a collective effort involving a disciplined approach”. He assured Sierra Leonians that the government “had not been sitting around and waiting” for the virus but had put measures in place. He spoke of the three pillars of outbreak preparedness—prevention, treatment and surveillance.

The government was taking steps to ensure that they had good supplies of food and other necessities and was taking measures against price gouging and hoarding which a poor country can ill afford. While confirming that the government was looking at tax breaks or assistance for businesses hurt by the pandemic, the President’s message was that the greatest lesson the country learned from Ebola was that fighting it was a collective effort “depending on the involvement of all stakeholders from villagers to the head of government”. It was a powerful indication that Sierra Leone simultaneously understood the terrible potential of the pandemic and recognized the strength of its collective experience.

The government imposed a quarantine protocol early and widely. Since February 4th, when the COVID outbreak was not yet on the radar of most Western countries, 719 people showing symptoms linked to COVID-19 have been quarantined in Sierra Leone. Almost 400 have been released from quarantine, 336 are presently in quarantine and 66 are self-quarantining. On March 24th, less than two weeks after the WHO declared a global pandemic, and the day after Adhanom issued his wake up call to Africa, Dr Julius Maada Bio, President of Sierra Leone, declared a 12 month Public Health State of Emergency.

While this may seem extreme, it gives the population certainty, it gives the government time, and it allows for ongoing public health measures to be put in place. Sierra Leone was widely criticized for failing to act quickly enough or assertively enough when the Ebola outbreak began. It is a mistake they do not intend to repeat.
Officials of the Ministry of Health and Sanitation have been canvassing the country preaching the same message of “less touching”. Washing hands thoroughly and often is another message public health officials are spreading. Sanitizer is in place in many busy shopping and congregating areas in the capital, Freetown. These messages, however accurate, are no use without safe and reliable water supplies.

Significantly, a non-profit organization that came out of the Ebola crisis, The Water, Sanitation and Hygiene Network of Sierra Leone (WASH-Net Sierra Leone) has been partnering with government to draw up a “scenario for evidence-driven engagement” in public health, drawing on the lessons from the mistakes of the Ebola response. WASH-Net focuses on supplying safe drinking and cleaning water as the first and most important step to broaden public health access and prevent epidemics.

WASH-Net Sierra Leone has engaged with the water utilities in Freetown and those in the provinces to work with the government to ensure sufficient private sector and government investment in clean water delivery. Their efforts to bridge the gaps between good public health policy and infrastructure investment could serve as a model for many richer nations.

There has also been a sustained effort to “decongest” community sources of water by providing more water tanks and greater delivery infrastructure, from trucking in water to building aquaducts. These measures were taken in the years immediately following the Ebola outbreak and have been invaluable to Sierra Leone during the present pandemic.

While it is not to be argued that Sierra Leone has developed top tier public health infrastructure since the Ebola outbreak, there is no doubt that awareness of the importance of prevention has permeated all levels of society. Sierra Leone’s willingness and capacity to learn from its mistakes and to invest in prevention hold important lessons for every country, rich or poor.