A visitor (Wilson Amadu) to Allen Town PHU has his temperature taken before entering the PHU. All patients and visitors are screened for symptoms of Ebola before entering the PHU. Photographer: Michael Duff.A visitor (Wilson Amadu) to Allen Town PHU has his temperature taken before entering the PHU. All patients and visitors are screened for symptoms of Ebola before entering the PHU. Photographer: Michael Duff.A visitor (Wilson Amadu) to Allen Town PHU has his temperature taken before entering the PHU. All patients and visitors are screened for symptoms of Ebola before entering the PHU. Photographer: Michael Duff.

What Sierra Leone’s Ebola experience can teach us about Covid-19

What Sierra Leone’s Ebola experience can teach us about Covid-19
Story6 May 2020

For many of us around the globe, Covid-19 is our first experience of an epidemic of any kind, let alone a pandemic. For the people of Sierra Leone, there is an eerie familiarity to what is unfolding in their country. But how will their experience of the Ebola virus shape their response to this crisis?

As of May 6, Sierra Leone has 225 confirmed cases of Covid-19 and 14 confirmed deaths. The country underwent full lockdown for a 3 day period in early April, and remains now in a state of partial lockdown, with curfews in place every evening. Borders have been closed since March 27. They are still in the early stages of this outbreak, but this is not a new experience for most Sierra Leoneans.

In May 2014, an outbreak of Ebola that originated in Guinea made its way across the border into Sierra Leone. It marked the start of an epidemic that would take almost two full years to be officially declared over. Just shy of 4,000 people lost their lives to the deadly virus in that time.

While the coronavirus is a very different to Ebola, many of the response strategies – quarantine, school closures, safe burials – are all too familiar to the people of Sierra Leone. What the rest of the world is only just grappling with now, Sierra Leoneans have already learnt the hard way.

Daddy Mansaray wearing a mask as a preventative measure against Covid-19, at his residence in Bassaia Village Tonkolili District Northern Sierra Leone Photo: Mohamed Saidu Bah / Concern Worldwide
Daddy Mansaray wearing a mask as a preventative measure against Covid-19. Photo: Mohamed Saidu Bah / Concern Worldwide

Information and trust

Probably the most valuable weapons in the fight against Ebola were information and trust. A major issue in tackling the outbreak was the spread of misinformation and a lack of trust in the authorities and organisations who were heading up the response.

Grants and Information Officer, Charlotte Woellwarth has been working with Concern in Sierra Leone since 2014 and experienced this phenomenon first-hand.

There were a lot of rumours going around during Ebola and a lot of people in Sierra Leone to this day still don't believe it existed.

Charlotte Woellwarth - Grants and Information Officer , Concern Sierra Leone

We have seen many examples of this across the world with Covid-19. Finding ways to counter such rumours is key, but this can be a huge challenge in a context where people do not have access to the same technologies we rely on so heavily here – and where the adult literacy rate stands at only 43.2%.

Getting the message out

A major focus of Concern’s response to Ebola was helping to get the right messages out there. These messages were going to save people’s lives, and ultimately help to bring an end to the outbreak, so we did this using all available means. We produced and shared educational materials such as leaflets and posters, and we produced radio ads to ensure the message was received far and wide.

We also trained staff and health volunteers to share those messages within their communities. The fact that the information was coming from trusted community members made a huge difference. Gradually, strategies like this began to work.

Katie Waller, Concern’s Director of Strategic Partnerships in New York was based in Sierra Leone back in 2015, working in maternal health.

When West Africa started getting clear health messages – the same messages repeated over and over again, getting in the hands of trusted people – that's when you saw a shift in some of the behaviours.

Katie Waller - Director of Strategic Partnerships , Concern US

Our team’s expertise and experience in this field has meant they’ve been able to turn around similar materials relating to Covid-19 very quickly and we have the systems and networks in place to share the message widely.

Concern Worldwide Sierra Leone Learning Coach Mohamed Gobril Sesay raising awareness on COVID-19 Bassaia Village Tonkolili District Northern Sierra Leone Photo: Mohamed Saidu Bah / Concern Worldwide
Learning Coach Mohamed Gobril Sesay raising awareness on COVID-19. Photo: Mohamed Saidu Bah / Concern Worldwide
A resident of Bassaia Village Tonkolili District Northern Sierra Leone looks at a COVID-19 poster distributed by Concern Worldwide after a sensitization session. Photo: Mohamed Saidu Bah / Concern Worldwide
A resident of Bassaia Village looks at a COVID-19 poster distributed by Concern. Photo: Mohamed Saidu Bah / Concern Worldwide
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Traditional practices

One of the barriers to building trust during the Ebola outbreak was that some of the messages being shared came into direct conflict with the traditional beliefs and practices of many Sierra Leoneans.

One example of this is the popularity of traditional healers. Rather than attending a hospital or health centre, people would go to see traditional healers when they fell ill. This meant they didn’t receive the medical attention they desperately needed and the likelihood that they would spread the virus increased. So, we began to reach out to traditional healers, asking them to change their practices and refer people to medical facilities instead.

Mabrat Abdulai is a Learning and Knowledge Management Officer for Concern in Sierra Leone and explains that this was not an easy process.

“At the start, it was difficult for them, because that was their only means of making a living. So us telling them to stop their usual practice, it was not easy. But later with education and constant training, they were able to stop their practice. When they themselves started becoming infected, that scared them, so they stopped immediately.” 

Those hard-won relationships with the traditional healers have been maintained in order to tackle malaria and other diseases. They have since become vocal health advocates in their communities, and are in the perfect position to convey the right messages about Covid-19.

Charlotte Woellwarth adds that this has contributed to a swift response to the current outbreak.

“Because we've already established a relationship with them, I'd say the hardest bit of the work is done. They already know how we work and we understand them. So I think we might be able to do something very productive with this. The trust is there.”

A burial team collects a corpse from inside a house in the east of Freetown, Sierra Leone.
Concern took over management of Safe and Dignified burials during the Ebola crisis. Photo: Michael Duff / Concern Worldwide

Handwashing

That trust is vital, and this time it is there from the outset. Not just at a community level, but at a national level too. There will always be disbelievers but for the most part, people realise the risks posed by Covid-19. The people of Sierra Leone already know what it’s like to live through something like this. They know the pain, the loss, the trauma. They do not want to live through it again.

It’s a global issue this time so a huge number of people are really taking it seriously. Health protocols are being observed.

Mabrat Abdulai - Learning and Knowledge Management Officer, Concern Sierra Leone

One of the few positive legacies of the Ebola outbreak is the proliferation of public handwashing in Sierra Leone, as it became one of the most visible features of the battle to contain the virus.

“Before you went in any building, there was a hand-washing station out front, so everyone had to dip their hands in the bucket of bleach water that was set up everywhere. Even if you were driving town-to-town, you had to get out of your car and wash your hands and they'd take your temperature,” says Katie Waller.

Handwashing stations have remained a common feature of life and people are definitely used to washing their hands before they enter a building. It’s something that never went away but has really stepped up a gear with the arrival of this pandemic. People are very aware of the necessity of hand hygiene. However, not everyone has the supplies to practice it properly.

Concern is addressing this by setting up handwashing stations at strategic locations like transport stations, petrol stations and markets. These consist of large buckets, soap and water tanks. But it’s not just the material items that are in short supply.

In Sierra Leone, most people pay for their water and that includes the water they wash their hands with. However, not everyone can afford to buy all the water they need, so our team has started trucking clean water daily to the slums of the country’s capital, Freetown.

A screening area and hand washing station were part of the infection prevention control during the Ebola outbreak in Sierra Leone.
A screening area and hand washing station were part of the infection prevention control during the Ebola outbreak in Sierra Leone. Photo: Michael Duff / Concern Worldwide.

Social distancing

While hand hygiene is being widely implemented, social distancing is, unfortunately, a very different matter. According to the 2017 Human Development Index, 52.9% of people in Sierra Leone live below the poverty line. In real terms, that means that over half the country live day to day. If they don’t leave their house to make money today, then they won’t eat tonight.

Social distancing in Sierra Leone is near to impossible. It’s day by day here. You buy a cup of rice, you can't buy a bag for the month. You have to go the market, which is crowded, so you can't do social distancing. And to get to the market you have to get on a bus crammed with other people. People here know what they should do, but doing it is another matter,” says Charlotte Woellwarth.

Although the knowledge, experiences and practices developed during the Ebola outbreak have given Sierra Leone some advantages in the fight against coronavirus, the reality is that economic status of the country makes it ill equipped to cope with Covid-19 and its many consequences.

This photo taken in 2014 shows the scale of housing development around the hills of Freetown, Sierra Leone. Photo by Kai Matturi, Concern Worldwide.
This photo taken in 2014 shows the scale of housing development around the hills of Freetown, Sierra Leone. Photo by Kai Matturi, Concern Worldwide.

Health system

Sierra Leone’s health system is simply not prepared for what is to come. Health outcomes are already poor and the average life expectancy is only 54.3 years of age. Just last month, there was only one ventilator in the entire country, serving a population of over seven million people. That number has recently been increased to 50, in anticipation of the inevitable surge in demand, but it falls dramatically short of what is required. Most severe cases will never get access to a ventilator.

In some ways, Ebola has helped to improve the health system in Sierra Leone, as the number of health centres in remote locations has increased considerably. However, with no ventilators reaching those locations, their effectiveness in the fight against Covid-19 will be questionable. Where they could make an impact is in helping to reduce the number of secondary deaths that come with a health crisis such as this one.

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Avoiding secondary deaths

Trust in health facilities was not particularly high before Ebola, but it had been steadily increasing through continued health education and community engagement. Those hard-won gains, however, were rapidly reversed with the outbreak. People stayed away in droves for fear of contracting the deadly virus.

Austin Kennan is Concern’s Country Director in Sierra Leone and was Regional Director for the whole West Africa region at the time of Ebola.

During the Ebola outbreak, there was a 34% increase in maternal mortality.

Austin Kennan - Concern Country Director, Sierra Leone

Austin fears that the same thing will happen again, and already our staff are noticing a drop-off in the number of people attending the health centres we operate in. Pregnant women are just one risk group but anyone with existing conditions, including malnourished children, are also at risk. The prevalence of life-threatening illnesses, such as Malaria or diarrhoeal diseases, is only set to increase with the onset of rainy season – which typically runs from May until October.

A large part of our health response is to support those clinics so that they can remain operational and continue to treat such conditions during this pandemic. We’re supplying them with vital Infection Protection Control (IPC) materials – everything from chlorine to hand sanitizer – so that they can maintain a safe and sterile environment for both staff and patients.

Infection prevention and control (lPC) training for staff at Lumpa Health Center, being conducted by staff from Concern Worldwide during Ebola outbreak in Sierra Leone.
Infection prevention and control training for staff at Lumpa Health Centre, conducted by Concern during Ebola outbreak. Photo: Kieran McConville / Concern Worldwide
Nurse Emma Senesie at a screening area at Waterloo PHU in the east of Freetown checks all patients and visitors for signs of Ebola before they enter during Ebola outbreak in Sierra Leone.
Nurse Emma Senesie checks all patients and visitors for signs of Ebola before they enter the health centre during the Ebola outbreak. Photo: Michael Duff / Concern Worldwide
Nurse Mariama Kpakiwa in personal protective equipment is disinfected at Waterloo PHU during Ebola outbreak in Sierra Leone.
During the Ebola outbreak health centre were supplied with PPE and were regularly disinfected. Photo: Michael Duff / Concern Worldwide

School closures

Schools in Sierra Leone have been closed for some weeks now. During the Ebola crisis, schools were closed for eight months, resulting in an entire lost year of schooling.  It is a year of schooling that children can ill afford to lose. At the time, we supported the government to implement a remote learning programme, using radio to deliver lessons to school children stuck at home. It was a successful strategy that helped to bridge the gap in schooling and it is one that we are thankfully in a position to lend our support to once more.

The school closures also have other, less obvious consequences for girls specifically.

Usually we see an increase in teenage pregnancies in July, August and September, when schools are closed. Now, we have an extended period of time where schools are closed and with rainy season coming, people stay indoors a lot more. Girls are particularly vulnerable financially, so it's a worrying time. Sierra Leone had a huge spike in teenage pregnancy during Ebola,” says Charlotte Woellwarth.

One of the things that can be done to manage this risk is, again, keeping health centres open and safe so that girls can continue to visit them to access birth control.

Risk of flooding

Another unexpected consequence of this pandemic in Sierra Leone is the increased risk of flooding this year. Every rainy season brings a risk of flooding but last year, it had been largely contained by a new initiative brought in by President Julius Maada Bio. A compulsory Saturday clean-up was put in place every month, where all businesses closed and everyone played their part in clearing the rubbish that clogs drainage during heavy rainfalls. However, this cleaning didn’t take place last month because the country was in shutdown, so fears of impending floods are already mounting. 

 “We already had really heavy rain here in Freetown last month and because we were in lockdown, the Saturday cleaning didn't happen, so we've seen a lot of garbage in the streets. We now don't know when the next cleaning day will be,” says Charlotte Woellwarth.

The floods create crisis at the best of times; they lead to illnesses and disrupted livelihoods. Homes are destroyed and families are displaced. During Covid-19, they could be disastrous, both in terms of the capacity to respond and the likelihood of the virus spreading.

The economy, poverty and hunger

There will be many devastating consequences of Covid-19 for Sierra Leone, both in the short-term and the long-term. But by far, the most damaging aspect of this pandemic will be economic. We have seen this ourselves in Ireland, with business closures, pay cuts and job losses. The difference is that Sierra Leone is a low-income country, with no social safety nets. With more than half the people already living below the poverty line, starvation is a very real risk for them.

Even for people who manage to stay economically afloat, there’s a likelihood of food shortages. The country relies heavily on food imports and they are already experiencing heavy disruptions and delays in their supply chains.

The single biggest difference between the Ebola crisis and this Covid-19 crisis is that during the former, the country was able to rely on international assistance coming in. This time, as every country tries to fend for itself and the world economy is in turmoil, there is nowhere else to turn.

The world cannot forget low income countries. They didn't create this but countries in Africa may well pay the highest price.

Austin Kennan - Concern Country Director, Sierra Leone

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