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In any infectious disease outbreak, healthcare workers and administrators bear the brunt of myriad challenges. Health workers are often under-equipped, short of staff, some are pressed back into service after retirement, and they work long hours in dangerous high-exposure conditions. Yet, they seldom receive the support, or the appreciation, they deserve. They often experience stigma, even violence against them, as they do their jobs. District-level health administrators manage the outbreak with often limited practical support and resources, treading a fine line between implementing national responses and managing local realities. Most importantly, the experiences and stories of these frontline responders are rarely listened to or learned from.
During the outbreak in Sierra Leone it became clear that healthcare workers and administrators in the early affected districts were often the unsung heroes of the epidemic. In Bo District, the Ebola Gbalo research group documented how district officials, facility-based health workers, community health workers and local community leaders (including chiefs, teachers and others) rallied together to respond long before national or international resources arrived.1
The first cases were thought to have entered the country from Guinea and were documented (undiagnosed) by a local school teacher in February 2014. Ebola was not officially recognised until May when an outbreak, and two weeks later a state of emergency, was declared in Kailahun District. Once Ebola was confirmed, health workers who were treating the early cases were phoning their colleagues to tell them about the symptoms they were seeing – which were not typical of Ebola symptoms in outbreaks elsewhere (the previously characteristic bleeding was not common, just fever and diarrhoea).
One senior medical officer in Bo District told us how he heard of this, from a friend who was treating the sick and became infected himself, and then died. ‘I talked with him over phone. He was still alive that time. He told me that the illness started with fever and also advised me to take time since I am working in a big hospital … I can still recall his voice.’
Because of frontline workers passing on information and advice based on their direct experiences and observations, Bo District was already on high alert by May. The Bo disease control head called community health workers in his district every day to hear of new cases. Personal relationships meant communications were not bureaucratic and the District Medical Officer (DMO) was well placed to get a good sense of what was happening as it evolved.
The DMO and District Chairman joined forces to establish their own district task force and co-ordinated with pre-existing international development partners in the District. They fundraised locally to pay for food in quarantine, for prevention equipment (buckets for chlorine), for radio campaigns on handwashing and safe burial (no washing). But, with no national or international donor support, they had insufficient resources to secure holding facilities and isolation wards or to properly train and equip their health workers. District Surveillance Officers were investigating cases but had nowhere to take them.
Bo suffered its first major outbreak in early June, quickly identified by district surveillance teams. However, the District had still received no resources to help prepare medical facilities and staff. Given the lack of resources and the increasing threat of infection, the town chief and District task force quarantined 27 townspeople from Kalia in an old school building, who consequently died in appalling circumstances, with no medical care. Further infection spread was prevented, but the deaths had a lasting effect on reducing people’s trust in the health system as well as on the health workers who could only stand by, helpless, without protective equipment.
Health workers faced considerable hostility in some communities – as one national medical officer told us, ‘nurses went through hell’. Some of this hostility was certainly because of the District’s inability to handle the early Kalia cases when insufficient resources existed to properly hold and treat them. Some was also the result of poor existing relations between health authorities and other local authorities (particularly in remote areas which lacked trust in the health authorities). Hostility was also exacerbated by suspicions that Ebola was a political ruse as well as the panic and confusion that was created by poor media communications which exaggerated death rates and caused confusion over the symptoms and what Ebola really was.
Positively, several years after the epidemic was contained, key infection control measures (regular handwashing; widespread use of gloves) seem to have been retained by many health workers in Bo in their general practice, perhaps more so than elsewhere in the health system.
Government awareness of the need for rapid response also remains high. Sierra Leone declared a State of Emergency on 24 March in relation to Covid-19, despite having no confirmed cases.
One suspected case reached Bo District on 20 March, where once again health workers and district authorities worked together as they did during Ebola. The suspected case, arriving from Congo to Bo Township, was quickly followed up. The DMO was alerted by a private practitioner, through the continuing practice of providers regularly sharing information on infectious disease cases with district authorities. The district surveillance team immediately visited the person’s home, confirmed that their symptoms matched the clinical Covid-19 case definition and so took a specimen sample for testing. The suspect was kept in isolation at the district hospital, but the test fortunately came back negative.
There are salient lessons from the Ebola response for the global Covid-19 outbreak.
Like Covid-19, the symptoms frontline health workers were seeing in Ebola patients in Sierra Leone were non-specific and were similar to other common illnesses (fever, mild diarrhoea, sometimes vomiting). Indeed, some patients tested positive for malaria and/or had other known illnesses (like TB) so were treated for these without immediately being diagnosed with Ebola. This meant that the knowledge and experiences of front-line health workers were critical for raising suspicions, and making them alert to practising infection control with all patients in the early and middle phases of the response before standard operating protocols from the national level were in place with correct information.
As new infections like Covid-19 take hold, it will be important to listen to and learn from frontline healthcare workers as they observe presenting patients and can alert district (and national) authorities about specific combinations of symptoms, as well as population beliefs and perceptions that may obstruct rapid response. Had the Wuhan doctor who sounded the alarm been listened to, China would have responded quicker.
Health workers and district authorities (health, local government, traditional) must work together to pool and coordinate efforts as Bo District did, particularly where central support is slow to arrive. However, this is often difficult in a top-down model of epidemic management led by a set of national actors influenced by international actors that are less sensitive to local specificities of service delivery and social norms. Developing consistent messaging on symptoms and actions (including ‘social distancing’) that are locally appropriate is also key; the role of the districts and frontline workers are critical in this respect.
The consequences of poorly equipped facilities and health workers at the frontline of outbreaks can have long lasting effects as the Kalia case shows. In the UK, medical staff and their associations are deeply concerned about the failure of government to ensure they have the personal protective equipment (PPE) and medical equipment (particularly oxygen and ventilators) that they need to do their job.2 It is critical to get money and resources to frontline areas as fast as possible to enable rapid response and ensure trust in the health system. For poorer governments, rapid foreign aid is essential to enable adequate protection – but may be in short supply as richer nations struggle to cope with their own Covid-19 crises.
Even if resources are forthcoming, their efficient deployment may require widespread testing, raising further logistical challenges. In the Ebola outbreak, detecting clusters of infection and stringent contact tracing was critical to enable targeted quarantine and focus scarce resources on equipping local treatment centres in the worst affected areas (or if necessary building temporary ones) including properly protecting frontline health. workers with PPE.
We must respect, protect and learn from our frontline health workers and administrators – without them no country can rapidly tackle the Covid-19 epidemic.
- The Ebola Gbalo Research Group, ‘Responding to the Ebola virus disease outbreak in DR Congo: when will we learn from Sierra Leone?’, The Lancet, 29May 2019. Available at:http://dx.doi.org/10.1016/S0140-6736(19)31211-5.