Rashida Kamara cannot recall a time when she didn’t want to be a doctor, even though in her home country of Sierra Leone only a couple dozen doctors are female. Kamara’s father attempted to persuade his daughter to pursue a more realistic career, but she was stubborn, and her grades were really good. She won a grant to attend medical school from Sierra Leone’s government and graduated in 2011. Three years later, her former professor, a top virologist named Dr. Sheik Umar Khan, called her to discuss an Ebola outbreak occurring across the border Sierra Leone shares with Guinea.
Dr. Khan asked the young doctor to make the five-hour journey east to see him later that week for a crash-course on the deadly disease. She obliged. “I was in awe of him,” Kamara says of Khan. “He was more than a teacher, he was like your daddy telling you to knot your tie this way.” Khan told her to confront Ebola head-on: “This could be good for you. You have this passion, you can do this right,” he said.
About a hundred doctors, nurses, and midwives congregated in eastern Sierra Leone for Khan’s training session. “It was as if we were soldiers preparing for war,” Kamara says. But she never expected the outbreak to explode like it did, and she never imagined that Ebola would take Dr. Khan at the end of July 2014. To her, his death was a call to arms.
Over the next five months, cases mounted in Freetown, the seaside capital where Kamara worked around the clock in Ebola treatment units. Nearly half of all the patients she saw died within weeks of checking in. “There were so many deaths,” Kamara recalls, her voice soft and steady. “Death became a part of us. I could see death, I could smell death. It was all over.”
When I ask how the experience changed her, she pauses. “I appreciate people a whole lot more,” she says. “Initially, I was blaming people: This is a communicable disease—don’t touch each other,” she says, “But then I saw the offspring with their parents in the Ebola ward, and I stopped blaming them. You start reflecting on your own family.” Her sense of family expanded until it stretched across her nation. “I had to do what I did because I cannot see my people die.”
Like other young doctors produced by Sierra Leone since the country’s brutal civil war ended in 2002, Rashida Kamara possesses uncommon bravery and loyalty. At 32 years old, she’s treated nearly 400 Ebola patients. Her colleagues—all under age 35—have cared for hundreds as well. Many older doctors who were able to avoid the Ebola treatment units, did. And the majority of international doctors who volunteered for service arrived late in the outbreak, after hundreds of people had already died. It was Kamara and her cohort who threw their hearts into service around the clock from the start, every day of the week. They form a wellspring of knowledge that could prove invaluable when Ebola—or another deadly virus—strikes again.
However, the collective voice of Sierra Leone’s young medical community amounts to a whisper. They are few, they are African, and now that many of the mentors who trained them are dead, such as Dr. Khan, they’ve lost vital advocates. Ten percent of the country’s doctors have died from Ebola. Although the need for more doctors is obvious in Sierra Leone and the two other hard-hit countries, Liberia and Guinea, the funds and political will needed to support young graduates—and to replenish their ranks—is lacking. As a result, decisions about the countries’ healthcare systems will continue to be made by the countries’ politicians and international agencies who provide and distribute aid money. It is a modus operandi that proved inadequate last year when Ebola became an unprecedented disaster.
“It’s an unfortunate situation,” Kamara says. “But it’s happening now, and it will continue to happen until we have many doctors who can sit around the table and say, okay, this is what should be done, this is what we need.”
Without an adequate health workforce, hundreds of poor countries remain vulnerable to crises ranging from plagues to floods and violence. Disasters don’t stay neatly contained. However, there are glimmers of hope. A few international organizations now aim to partner with Sierra Leone’s health workforce, helping to ensure that the country has the capacity to eventually stand on its own. And some of Sierra Leone’s young doctors have committed themselves to not only saving lives, but to transforming the country’s healthcare system from the bottom up.
The Medical School
Sierra Leone’s doctor shortage is no mystery. The nation didn’t have a single medical school until 1988, two decades after the country gained independence from Great Britain. Just a few years after the school, the College of Medicine and Allied Health Sciences (COMAHS) opened, civil war erupted.
During the decade-long, diamond-fueled conflict, COMAHS churned out approximately five doctors per year, but the hospitals, clinics, and laboratories that comprise the health system fell into disarray. In addition, austerity measures pushed by the International Monetary Fund kept government spending on civil society workers low until 2010, resulting in unlivable wages for nurses and doctors in the public sector. Faced with a career spent in crumbling buildings, often without electricity, running water, or much of a paycheck, most doctors from each graduating class sought work in other nations.
Enrollment at COMAHS has increased in recent years. Now the school graduates about 30 doctors per year. In total, about 245 doctors practice within Sierra Leone. To put that in perspective, that’s just one fifth of the number of doctors at Emory Hospital in Atlanta, Georgia, where four Americans infected with Ebola were successfully treated in the most recent outbreak. In addition, Sierra Leone has very few specialists. There are zero oncologists in the country, zero anesthesiologists, zero radiologists, zero practicing psychiatrists, and just a handful of nephrologists and cardiologists. There is a single local ophthalmologist to handle a tidal wave of post-Ebola blindness.
The absence of specialists matters for Ebola because, in this disease, organs progressively fail. Infected Americans treated at Emory Hospital had nephrologists to tend to their kidneys, cardiologists to their hearts, and pulmonologists to their lungs. In Sierra Leone, you would be lucky if a general practitioner fresh out of medical school stopped by your bedside. A lack of specialists also means that young graduates lack mentors and cannot experience accredited rotations in pediatrics, surgery, or gynecology unless they leave the country.
For bare-bones access to health care, the World Health Organization says a country needs at least 23 medical practitioners—including doctors, nurses, and midwives—per 10,000 people. Sierra Leone’s ratio is 1.8. (Its neighbors, Guinea and Liberia, have 4.5 and 2.2 per 10,000.) The shortage occurs across sub-Saharan Africa—for similar reasons—but it is particularly horrible in Sierra Leone, where a lack of medical practitioners correlates with some of the worst health outcomes in the world. Life expectancy in Sierra Leone is 46 years old. Women stand a one in 21 chance of dying from childbirth in their lifetimes, and one of every six children dies before age five. When the WHO ranked 191 countries in terms of the performance of their health systems, Sierra Leone placed dead last.
Recognizing a crisis in healthcare long before Ebola hit Sierra Leone, non-governmental organizations (NGOs) flocked into the country to save lives. They built and manned missions outside of the broken national health system, distributed medicines, encouraged village women to give birth in hospitals, and engaged in other activities. However, they paid less attention to the welfare of the national health system itself. James Campbell, the executive director of the WHO’s Global Health Workforce Alliance in Geneva, Switzerland, suggests that’s because improving the plumbing and electricity and increasing the number of graduates from medical and nursing school takes a lot of time. Further, if charitable donors expect to see a photo of the baby their money rescued, it takes a conceptual leap to envision how infrastructure and human resource development led to that human face.
However, Ebola revealed the price of dismissing systemic holes. Largely because of the fragility of Sierra Leone’s health system, which quickly collapsed during the outbreak, U.S. taxpayers paid $1.9 billion dollars to help stamp out Ebola in West Africa and to prevent it from spreading within America. Taxpayers in the U.K committed about $364 million to West Africa to combat the virus, and the World Bank has donated more than $139 million.¹
Lately, Margaret Moeti, the WHO’s Africa Regional Director, is urging world leaders to help strengthen weak national health systems so that countries can halt future outbreaks of Ebola, or some other disease, before they spiral into global disasters. “When people think global health security, they think disease surveillance,” said Moeti at the UN Secretary-General’s International Ebola Recovery Conference in July. “But disease surveillance cannot happen in a vacuum. Emerging diseases cannot be detected and controlled if there are no laboratories, hospitals, and health personnel.”
Before They Jump
For Dr. Boie Jalloh, age 30, the wonky, high-level buzz about “health system strengthening” does not impact his reality. Although the brilliant young doctor would make Sierra Leone’s health system stronger, he has no path forward. Jalloh was drawn to the profession because Islam prizes medicine. “The Holy Koran says that if you save one life, it is as if you save the whole of humanity,” he says. Jalloh trained as a soldier during medical school in order to work as a military doctor. Discipline drew him to the army. He was reassured by the prompt and insightful lectures delivered by one of his professors, Commander Foday Sahr, the military doctor in charge of 34th Military Hospital.
One week before Jalloh arrived for his internship with Sahr at 34th Military Hospital last year, a patient was diagnosed with Ebola. Jalloh was directed to work in the hospital’s Ebola unit, which was open to the public. He was joined by four other military doctors, whose ages ranged from 28 to 32 years old. Despite their lack of experience, the military hospital emerged as perhaps the best in Sierra Leone. Ebola patients had a 69% chance of survival, as opposed to 26% elsewhere. Jalloh thinks that’s because the young doctors refused to follow the protocol from Doctors without Borders.
The rift began when one of Jalloh’s colleagues tested positive in September and was admitted to an Ebola treatment unit operated by Doctors without Borders. When Jalloh came for a visit, he was distressed to learn that his pale and lethargic friend wasn’t receiving intravenous fluids. At this point in the outbreak, Ebola wards in the public system and those operated by Doctors without Borders were overwhelmed. In response, the organization decided to give fluids only orally. They didn’t want to introduce needles into an already risky workflow. “We were under pressure to set an example and show that it was possible to treat Ebola safely, in an effort to mobilize others to intervene,” said Brice de le Vingne, a director of operations at Doctors without Borders, in a report released by the organization earlier this year
However, Jalloh and the other young medics from 34th Military Hospital had witnessed the rapid recovery of Ebola patients given IV fluids early in the disease—even before a positive diagnosis. “We had held a meeting amongst ourselves and decided that we would use aggressive supportive therapy as soon as we suspected Ebola,” Jalloh says. Waiting to insert an IV line until a patient’s organs fail is like trying to save a person after they’ve jumped off cliff, Jalloh explains. “It’s better to stop them from jumping.”
In January, Jalloh flew to Geneva, Switzerland, for a WHO meeting on clinical care for Ebola. There, some of the world’s experts still questioned the role of IV Fluids in Ebola treatment wards in Africa despite strong support for early use by Jalloh, West African national experts and the WHO. “I was so frustrated,” Jalloh says. “As Sierra Leoneans, we know the healthcare seeking behavior of our people. When they get sick, they’ll first buy paracetamol [Tylenol] from a peddler. When that doesn’t work, they’ll go to a pharmacy and buy whatever drugs the pharmacist recommends. Then when enough options fail, they’ll go to the hospital.” At this stage, Jalloh says IV fluids can be a matter of life or death. As for the danger that needles pose to health workers, Jalloh asks for the evidence that Ebola infections came from IV delivery versus a lack of protective gear or other causes.
Despite the hard times, Jalloh treasures moments of raw emotion. He recalls how an older woman afflicted by the pains of Ebola prayed for him—rather than for herself—just before she succumbed to the disease. After treating more than 500 Ebola patients, Jalloh wants to specialize in infectious disease so that the knowledge he’s gained can be sharpened in time for the next outbreak. However, there’s no place to do so in Sierra Leone.
Partners in Health
A couple of years before the outbreak, Oliver Johnson, a physician from King’s College London, decided his contribution to global health might be greatest if he could mentor local doctors and nurses within public health systems—as opposed to offering his own care outside of them. In 2013, Johnson helped launch King’s Sierra Leone Partnership , which is embedded within the nation’s largest public referral hospital, Connaught in Freetown. One of Johnson’s early recruits was a Spanish infectious disease doctor named Marta Lado.
A few months after Lado’s arrival, Ebola hit. Johnson and Lado buckled down, taking their vow of partnership to heart. They helped Connaught create an isolation area for patients with symptoms of the disease, and Lado taught a handful of local nurses and nursing assistants how to wash infectious feces, vomit, and blood from patients. She worked alongside them, and once Ebola dwindled in the capital city this summer, she remained although her term was up.
“If I want to get through this and not have post-traumatic stress syndrome, I need to stay for the good times,” she tells me. “I have a team of 50 people, and none of them have had a holiday for one year, so why should I? We’ve lost friends and seen terrible things,” Lado says. “But now we are trying to make something good from all of that.”
With funds from the British government, King’s Partnership recently constructed a permanent isolation ward at Connaught Hospital to be staffed by those who worked beside Lado during the outbreak. By offering mentorship, in addition to improving the physical spaces where nurses and doctors work so that they’re able to perform their jobs safely and effectively, Lado hopes to encourage them to stay. She says, “We want young doctors to feel that this is a part of their future.”
More than 25 years ago, Paul Farmer, a physician and medical anthropologist at Harvard, co-founded an NGO called Partners in Health with many of the same underlying ethos as King’s Partnership. Farmer’s credo appealed to a young Sierra Leonean doctor, Bailor Barrie, who won a scholarship to study with him at Harvard a couple of years ago.
By the time he reached out to Farmer, Barrie had co-founded an NGO called Wellbody Alliance. However, the group was far too small to improve the health of people across the nation. Only the government could do that, Barrie realized. “If you believe health is a human right,” he says, “then who is supposed to provide rights? The government.” Yet with a budget smaller than Mississippi’s—the poorest state in America—and a much larger population, Sierra Leone’s government has neither the money nor expertise needed to build a functional system essentially from scratch. By joining forces with Partners in Health, Barrie hoped to have the resources and expertise needed to help his government.
Already, Partners in Health seems to have had a hand in turning around Rwanda’s health system over the past decade. Between 2000 to 2010, maternal mortality has dropped by 59.5% in Rwanda and childhood death by 70.4%. Meanwhile, in Wellbody Alliance, Farmer saw an opportunity to build upon the inroads Barrie had already laid in Sierra Leone. This summer, as the Ebola outbreak ebbed, Partners in Health merged with his organization.
A few weeks ago, I met Barrie for lunch in Freetown. The following morning, he was headed north with Farmer. Their goal is to revive the main government hospital in the northern district of Kono along with 82 small public clinics across the region. They’ll be paying adequate salaries for about 40% of the government staff so that nurses can focus on just one job rather than hustle on the side. The organization will also bring in medicines, improve infrastructure, and recruit doctors from around the world to provide mentorship. “You can’t just bring in doctors,” Barrie explains, “because if there’s no stuff for them to work with, and if there’s no system in place, they can’t work. So I say, start with the full package in one district and provide a model for what the government system should look like.”
In his later years, Barrie intends to return to COMAHS to teach. The more doctors and nurses who are well-educated, the more leaders the country will have who prioritize the nation’s healthcare system. “Sierra Leone will only change when you have a critical mass of people that think, ‘Let’s move forward,’ ” Barrie says. “Those young ones in medical school, they should be mentored with a social justice and global health mentality.” He adds, “That’s the only way to start.”
Down the Ladder
King’s Partnership and Partners in Health are outliers in the global health community in prioritizing the mentorship of Sierra Leone’s next generation of doctors. If there’s an international leader in this arena, it is China, which frequently offers Sierra Leoneans scholarships to their medical schools.
Perhaps because China has a vested interest in Africa’s iron, oil, and other extractives, the nation is better attuned than others to the wishes of its partner in trade. And what so many Africans want is what underprivileged people have wanted for centuries: education and opportunity.
In his office within a shabby government building in downtown Freetown, SAS Kargbo, the director of policy and planning in Sierra Leone’s Ministry of Health, emphasizes his appreciation for China’s medical school scholarships. He momentarily ponders how he might strengthen ties with the former Soviet Union, too, which offered similar scholarships 20 years ago, or Cuba, which gives medical school scholarships to promising students in neighboring Guinea. “Maybe I will approach them, I’ll ask if their countries could train 50 doctors per year,” he says. “And maybe they’ll say okay, but you pay their monthly allowance. And that will be fine.”
In contrast, Sierra Leone’s former colonial masters, the British, provide aid for healthcare, but generally not in the form of medical school scholarships. Instead, the latest trend in Western assistance for health focuses on community health workers. In Sierra Leone, these workers often have no education beyond high school, but they can be taught in a matter of weeks to give vaccines, antibiotics, birth control, and now to report potential cases of Ebola. Proponents of community health worker projects argue that training them provides a faster and cheaper solution to reducing high rates of maternal and infant mortality than the slow production of doctors and qualified nurses. Plus, legions of community health workers cover more ground than handfuls of highly trained medics.
The idea sounds promising, and there’s some evidence that it works. In Zambia, for example, one study found that programs in which community health workers treated children with anti-malaria drugs were 36% more cost effective than the standard clinic-based alternative. Yet in Sierra Leone, Kargbo says community health workers may be even more disenfranchised than those elsewhere in sub-Saharan Africa. Training them to do more without improving their support system, management level, reading level, and pay—which is generally nil—might not do much good.
Furthermore, Kargbo fears that broadening the base of under-educated health workers while upper tiers remain anemic will keep the country dependent on international aid far into the future. It’s uncomfortable to be constantly on the receiving end of that relationship because the giver of aid calls the shots. Donors decide—to name just one example—whether to give Ebola patients intravenous fluids. If Kargbo could dictate where foreign assistance might be placed, he’d send promising students to medical and nursing school, launch an accredited program for medical specialties in Sierra Leone, and import experienced doctors to help train students. He suggests Sierra Leonean doctors now living in other countries might be enticed to return and mentor for year-long stints. “I don’t need consultants from Harvard to come and train community health workers,” Kargbo says. “We should be going up the ladder, but we are going down.”
This summer, Sierra Leone’s government released a post-Ebola recovery plan. Training more doctors and nurses was among their top five priorities. The World Bank responded to the plan with a pledge to invest in post-graduate training for medical students. In addition, the WHO is now working with the government to chart the cost and pathway toward multiplying the country’s medical staff.
The predominantly Western global health community doesn’t rally around medical school scholarships as a form of foreign aid for a few reasons, and “brain drain” is principal among them. With the potential to make more money by working in richer countries, many doctors will abandon their homeland once they’re adequately trained. However, Kargbo argues it’s a numbers game: If there are more doctors, more will leave the nation but more will also remain.
Prince Masuba, a young doctor I met at Kenema Government Hospital in eastern Sierra Leone, remains committed to his country. After leaving twice to further his medical education, he was offered a lucrative position with the United Nations and another with an NGO in Freetown, where he could enjoy reliable access to electricity and the Internet along with decent working conditions. Yet he turned those positions down in favor of the shoddy public sector in a more rural region of the country.
I join Masuba on his morning rounds one day in July. As we walk from ward to ward, he greets patients recovering from surgery. He explains to me how he’s reluctant to discharge them because their villages are far from the hospital, and they’re therefore unlikely to return for check-ups. In the interim, he has to figure out how to feed them. He notes which patients cannot afford the medicine they should be taking and may face death as a result. He points out the lack of electricity in the female ward and then comments on a tin shack that is the nurses’ quarters. It leaks when it rains. His budget is stretched too thin to make the myriad improvements that are needed, but he never considers giving into frustration and abandoning his post.
“When you start to run a hospital, you feel the problems, the gaps in the system, the laggardness of workers,” Masuba says. “But I come in early every day to set an example, and everyone starts to notice.” The longer Masuba remains in the system, the higher he climbs and the bigger his impact. “If I want to change things,” Masuba tells me, “I have to stay and not just run away for money.”
His is the idealism of youth. It’s easy to imagine that such idealism would be long gone in Sierra Leone, wiped out first by the brutal “blood diamond” war and then by the worst Ebola outbreak in history. Yet somehow, hardship seems to have honed young doctors’ skills and made fierce their allegiance to this nation. Their experiences have given them the knowledge and confidence needed to push back against policies that grate against their instincts. They’ve performed surgery by the light of a mobile phone. They know that nurses need life jackets to visit villages in the rainy season, once streams become impossible to cross.
A couple of weeks ago, Rashida Kamara left Sierra Leone to attend a masters program on infectious disease at the University of Liverpool. “After it’s over, I want to come back to practice medicine,” she says. “There are so many things coming up—cholera, measles, other communicable diseases, and once I have more training, I will be in a better position to help.”
This article is part of the “Next Outbreak” series, a collaboration between NOVA Next and The GroundTruth Project in association with WGBH Boston.