Sierra Leone - a country where tuberculosis rolls on as ebola disappears

The ebola outbreak in West Africa seems to have passed into the category of ‘old news’ – with its final total death toll now somewhere around 11,000 (we say this hopefully because some isolated cases are still occurring). We’ve already discussed the striking contrasts between the casualties of ebola and TB on posts on our Facebook page (including that 11,000 is an average deathtoll from TB every week), but we feel compelled to develop this discourse in a different direction having recently come across an interesting article because of what it implies, not just for Sierra Leone, but also for all of those countries with insufficient health provision whose peoples continue to so at risk from TB today (and just as importantly tomorrow).

The article was unpromisingly entitled a “Mapping of Sierra Leonean Health Professionals in the United Kingdom, Germany, the United States of America and Canada” and it was published by the International Organisation for Migration in Geneva. Published last year (right in the middle of the ebola epidemic), all of the data it disclosed had been gathered in 2011-13 well before ebola had ever een seen within 2,000 miles of the country. Sierra Leone’s health system, however, was already in deep trouble. Unicef had rated it the worst country in the world for child survival, and in 2000 the WHO, while attempting to rank each of its ember states in terms of their relative health service provision, placed Sierra Leone right down there down at the bottom. A very nasty civil war between 1991 and 2002 certainly hadn’t helped (something that most of the world must surely have forgotten about given the length of time it took to finally mobilise and respond to the country’s ebola crisis last year).

In fact in November 2012 the Guardian newspaper had reported that there was just one Sierra Leonen health worker per 5,263 population (not doctor, note, but health worker i.e. midwife, nurse, dentist, radiographer. etc.). In a nation of just over 6 million people, this amounts to less than 1,200 health workers in the entire country. To put this in perspective, here in the UK the ratio is quoted as being one health worker per 77 population (a rate that’s nearly 70 times higher and amounts to over 800,000 equivalent health workers).

So it was this paltry workforce that was trying to cope with the country’s ongoing TB epidemic and they were really struggling. In the years 2008-2010 the average incidence rate of new TB cases in the country was running at  645 per 100,000. This is huge – well over twice what is classified as a national emergency. (The UK’s rate in the same period was 15; the U.S.’s 4). It was the 5th highest rate in the world and the highest one outside Southern. Despite this terrible burden of disease it hadn’t even earned a place on the WHO’s list of high burden TB countries (HBCs) where resources are continuously concentrated.

What none of them could have known was that they were about to face something a lot more frightening and less familiar than tuberculosis in ebola. When it hit it was hardly surprising that their response couldn’t cope with it and why they needed immediate help. In the early 2000s Sierra Leone had already earned the dubious distinction of being classified as the world's least developed country by the United Nations. Life expectancy was only a touch over 40. Two-thirds of women were illiterate and over 70% of Sierra Leonians were managing somehow to get by on less than 70 U.S. cents a day.

That rate of new TB cases was making for nearly 40,000 new Sierra Leonean TB cases every year – or roughly 34 per health worker (if they had all been being employed to the fight this disease which of course they weren’t). Meanwhile there is still literally no data on drug-resistance for Sierra-Leone – but that’s hardly surprising given that the health resource is so diminutive. But given that ill-managed TB programmes drugs can be pretty much guaranteed to foster a significant MDR epidemic within about 15 years it’s not exactly rocket science to suggest that there must already be a secondary epidemic of untreatable TB disease in the country and that it could already be quite big.

The article referred to above specifically related to this same pre-ebola period. What it  looked at was the war-prompted Sierra Leonean ‘diaspora’ into Northern Europe and North America, wondering exactly how many of these economic and political migrants might have been health workers. The only numbers that were definitive were from Germany where census data provided accurate information: of the 2,500 Sierra Leoneans in Germany, a grand total of 59 were categorisable as health workers (c. 2.4%) and 23 of these were doctors (c. 1%). Whilst there was no definitive data on healthworkers amongst Sierra Leonean migrants in the USA, the UK and Canada, the authors did at least have a good idea as to how many Sierra Leoneans migrants were resident in each country (34,000, 23,500 and 2,500 respectively). If we take the libery of applying those German percentages to these same numbers, though, we find something pretty startling: before the ebola crisis there may have 1,500 health workers working in these high-income countries nearly 600 of whom were doctors – at  the same time as there were possibly fewer than 1,200 health workers in total back home.

Given that we know that the rate of deaths from ebola was so high amongst health workers in all three countries affected by ebola we can reasonably assume that the current number of Sierra Leonean healthworkers in the country today might now be fewer than a thousand. Meanwhile the world’s focus has moved on from its media feeding-frenzy on ebola to other here-today-gone-tomorrow scare stories. But whilst the nation's threat from ebola may be past (largely because the wider world did finally respond and help out), their TB problem remains pretty much business-as-usual (as no doubt is that terrible rate of child mortality). No wider response to this problem looks likely and the country itself in a worse place than it was before ebola threw it into the headlines with those rates of 645/100,000 quite probably already on the rise.

It’s not all doom and gloom, though. Sierra Leone happens to be one of the most religiously tolerant countries in our troubled world – a talent it could surely teach most of the rest of us. Its people have also, perhaps justifiably, been called the “most resilient people in the world” which is surely something to be rather proud of. And it has significant economic potential, with diamonds, gold, titanium and bauxite reserves. Though 70% of its people may live in abject poverty there are still real opportunities for economic growth if the country can be helped a little.

Neither is it any sort of post-colonial backwater because moments in its history have reflected global turning points. In 1562 the infamous slavery ‘triangle trade’ was set up between England, West Africa and the Caribbean:  Sierra Leone provided the triangle’s original African apex point with the first consignment of 300 slaves taken from its shores. Freetown, the country’s capital, was founded two hundred slave-ridden years later when 1200 ex-African-American-slaves who had been liberated by the British during the American Revolutionary war were resettled back in Africa in 1792. Later that decade they held their first elections – and all adults were entitled to vote including women. It’s  been observed (quite rightly) that Sierra Leone has as much or more right as Philadelphia or Paris to be thought of as the cradle of liberty – because this was the first time not just that women ever voted, but also people of black skin.

Britain only really began to exert colonial authority on the country after 1896 with de Beers s granted the monopoly right to mine for minerals forty years later. Independence was granted in 1961 and for the first few years everything went rather well. Then the untimely death of its first president precipitated a series of military coups which resulted in a one-party state which perpetuated itself by force until 1991. Then came those eleven sorry years of bloody civil war, when the terms “blood diamonds” and “boy soldiers” became familiar to the wider world, along with terrible stories of brutality. Two million Sierra Leoneans fled the terror and 50,000 died. Truces were declared in 2002, UN peacekeepers were pulled out in 2005 and free elections were finally held in 2007.

So the war was over, and the rebuilding was begun (though it was quickly being threatened by an uninvited arrival of Colombian drug cartels) - that was until ebola arrived having somehow jumped all the way from eastern and central Africa. Thankfully the devastating outbreak does now appear to be almost over with the authorities fully alert to what needs to be done in the event of any isolated outbreak, but that terrible TB epidemic rolls on entirely unheeded and now largely unattended, with its MDR component surely stoked by last year’s disruption to the health service and by the loss of possibly 20% of the country’s few health workers.

Sierra Leone epitomizes, we believe, all the world's low-income countries which are plagued by TB – a threat which is still being relatively ignored whilst the disease itself has been quietly setting itself up for a new offensive with its drug-resistant strains. It needs to be realised that this invisible drug-resistant pandemic is already out there not just in Sierra Leone but in every country where health care is deficient to the extent that TB programmes have been inadequately managed. The official estimates of drug-resistance don’t tell us to wake up to this because they invariably downplay the numbers in these same countries. The only way to fight this pandemic is, of course, to fight it where it’s occurring, just as was done with ebola, and all of these countries now need help. Unlike ebola, this is going to be a long and drawn out war, but it can be won if it’s done with the help and determination of the only countries in the world that have the capacity to fight it. The era of globalised exploitation is over. and it has to be superseded by an era of fair exchange. This is something which we want to explore in more detail in respect of tuberculosis in future blogs.