Too many people are dying in Sierra Leone not from Ebola but as a result of the response to it, according to a report on the collapse of healthcare in the west African country.



Ebola has killed at least 3,900 people in Sierra Leone so far, but the epidemic has critically damaged the ability of the country’s limited healthcare system to cope with anything else, including soaring HIV and tuberculosis rates.

More people are believed to have died from malaria than from Ebola, while deaths of mothers and babies in childbirth are thought to have risen significantly.



Health and medical staff have been drawn away from their clinics into the Ebola response effort and the population has lost confidence in their health centres and hospitals. Attendance at clinics has plummeted by more than 70%.

The grim picture of a healthcare system in meltdown comes from a report from the charity Médecins du Monde (Doctors of the World), which carried out a detailed investigation in the Moyamba region where it was running an Ebola treatment centre. The report’s author, British doctor James Elston, says there is every reason to believe the situation is the same or worse in every region of Sierra Leone.

“Moyamba is one of the least Ebola-affected districts,” he said. “The more affected districts like Port Loko and around the western area [of the capital Freetown] have had substantially more cases of Ebola and more disruption. The situation is even worse in terms of people not attending and the fallout from that.”

Even before Ebola hit last year, there was chronic underfunding and resources in all health centres were stretched, said Elston. But his visits to the one hospital in Moyamba and to many community health centres revealed a shocking picture. The hospital was powered by an old diesel generator that could be used for only a few hours a day. It had no resuscitation equipment, X-ray or ultrasound machines and only one oxygen concentrator. There were no incubators or equipment to provide care for newborns. The matron told Elston: “We lose most of our premature babies.”

Many of the community health centres did not even have a safe, clean water supply, Elston found. Of 14 primary care units inspected for the report, only one had piped water and that was no longer functioning. Five were using unsafe water from a stream or open well without disinfectant. Only half had water from a protected source such as a closed well. Only four had a functioning power source and only two of those had regular power. Seven had a working fridge – the rest could not store vaccines and sometimes had to obtain them from many miles away. None had a telephone – staff had to use their own mobile phones and credit for calls. None had good facilities for delivering women in labour.

Health workers at the Kerry Town Ebola treatment centre on the outskirts of Freetown, Sierra Leone, last November. Photograph: Francisco Leong/AFP/Getty Images

Some of the problems predate the Ebola epidemic, but the report says the death toll in the region from all causes has trebled. “Analysis of burial data indicates that as many deaths were recorded in four months in Moyamba as in previous one-year periods. Forty percent of those dying at the current time are children under the age of five years.”

When the Ebola epidemic took off, senior health and medical staff were drawn into the response, leaving local clinics floundering without support.

“Since Ebola came along, core management teams have become embroiled in the response, and support for those manning the healthcare facilities has reduced,” said Elston. “These small health facilities are the only ones for the whole community – if they are not working, people have almost nothing. Since Ebola there is a lack of trust between both doctors and patients; doctors are wary of who and what they are treating and patients are fearful of who’s treating them and what might happen if they are suspected of having Ebola.”

He added: “A paramount chief said people went to health facilities for help when they got fever and were basically turned away because healthcare workers were too afraid to treat them.” That led to a massive loss of confidence among the community. Fever is an early symptom of Ebola but also of malaria.

The report also finds that admissions of children with malaria declined by 80% and admissions of children generally by 75%. “What happens to children with severe malaria whose parents are too afraid to seek treatment? What happens is that many of them die,” said Elston.

Attendances at antenatal clinics, child health clinics where routine vaccinations take place, and general outpatient clinics all halved, he found. Deliveries fell by 44%. Large numbers of women gave birth in their villages instead, often risking their own lives and that of the baby.

The report expresses particular concern about rising HIV and tuberculosis rates. Incidence of HIV is rising and it is under-diagnosed and under-treated. Stocks of antiretroviral drugs, necessary to keep people alive, regularly ran out in the minority of clinics that had any. “All the conditions for a large-scale HIV epidemic are present and a substantial increase in HIV prevalence must be considered as imminent,” says the report. “HIV must therefore be considered a major public health priority in view of the potential for catastrophic impact on population health.”

TB is the second most common cause of death in Sierra Leone, killing more than 8,000 people in 2013, but in Moyamba it frequently went undetected and untreated.

“It must be considered that there is almost uninterrupted transmission of TB in the community. Coupled with the rise in HIV incidence the population can expect a substantial increase in TB incidence and prevalence imminently,” says the report, which recommends that the response to both diseases is scaled up urgently.

“Everyone is rightly focusing hard on getting Ebola cases down to zero but a very real public health emergency happening around them is being ignored,” said Elston.

Médecins du Monde says action must be taken immediately to stop the healthcare crisis in Sierra Leone worsening, particularly as the rainy season approaches.

“The needs of the population cannot wait until after the zero Ebola cases target is achieved. It’s like using both hands to stem a bleeding wound while a bear creeps up behind you,” said Gareth Walker, international programme manager for the charity in the UK.