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Colonialism

Sierra Leone’s Colonialism, former dictatorships, and civil war are primarily responsible for the health care state today. These governances, along with mismanagement of epidemics, have led to disarray in the health care system. Life expectancy is low, deadly diseases are still endemic, and the infrastructure is hardly present to lessen mortality. Many people in Sierra Leone are left struggling due to these political mishaps. It is important to analyze historical events to understand the current state of Sierra Leone’s healthcare system and why they were so ill-equipped to handle the Ebola epidemic and the recovery of survivors currently living in the present day. 

The British Empire settled Sierra Leone and held control and influence for one hundred and seventy four years. Waves of nationalist movements in 1961 caused Britain to lose their rule and take a step back, thus Sierra Leone gained independence from the United Kingdom after being under their rule for over a century and a half. After its independence was established, prime ministers and presidents looked to dictatorial rule to take hold of the new nation. Corruption was further used to lessen the already weak economic status then and still continues to do so now. When President Joseph Momoh took office in the 1970’s. Sierra Leone was at its breaking point; it could not long import oil and gasoline which left the country without electricity for months at a time. These events along with colonial and national influences left healthcare in a state that we still see today in the 21st century. Diseases such as yellow fever and malaria also shaped life and policies during the 20th century. As the epidemics were met throughout the 18th and 19th centuries, scientifically inaccurate information separated already disenfranchised Africans from the white colonists. The mismanagement and underfunding from the prominent health examiner Rubert William Boyce lead the Africans to be viewed as both harbingers of disease and actual diseases themselves. 

 
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Ebola Impact

The World Health Organization declared Sierra Leone Ebola free in 2016 but the lasting effects of the virus can still be seen today. It is estimated that 4,000 lives were lost to the virus and those who survived found themselves in quarantine for days, weeks or months at a time to only return to be chased and shunned out of their homes and local communities or abandoned by their spouses. Studying the long term effects of the Ebola outbreak is a very recent phenomenon and is proving difficult. There is little public health data on the disease outcomes and status of the estimated 17,000 survivors in West Africa.  Little is also known about the post viremic syndrome present in many survivors like the Ebola survivors that we talked to. Despite the lack of knowledge or understanding, all of this has to be taken into consideration when addressing issues of recovery and support for survivors. 


 Although the country may have been able to “stop” the deadly disease ebola, the effects and aftershocks are still very much present.   In the years since 2016 there have been little pockets of outbreaks in Sierra Leone and surrounding countries but the results have been nowhere near disastrous as the 2016 Ebola outbreak. There are a lot of moving parts in finding a long term solution and support system for survivors but the first step seems to stem from the government and lack of proper infrastructure to execute any future medical programs or support. The widows that our class talked to mentioned the desire for medical care that reflects their needs as survivors of the epidemic. For this request and concern to be met, the status quo in the country must end. Now is the time to listen to the survivors and begin the process of repairing the country's medical system and build the long term scaffolding needed to provide adequate and proper care for everyone. These survivors need support to begin to repair the political difficulties faced. This starts with having their voices heard.

 
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Healthcare Infrastructure

The life expectancy is estimated to be about 57.8 years and over 70 percent of the population lives below the international poverty lines. Yellow fever and malaria remain endemic to the region alongside outbreaks of cholera and meningitis. As for the physical health care structures themselves, there are only three hospitals capable of doing major surgery and diagnostic lab testing and these are located in three large cities. In the 13 districts of the country, each has their own health management team made up of technical staff including doctors, nurses and other various providers. There are only 168 doctors present in the country for over 6 million people as of 2012. There is a free system of maternal care that was founded in 2010 for which pregnant and breastfeeding women are treated at no charge. This initiative was created in an attempt to reduce the high rates of maternal and infant mortality but due to the lack of infrastructure the program was never properly implemented. To make matters worse, the majority of women do not know that they have the legal right to free prenatal care. This results in poorly paid workers ignoring the laws and taking advantage of the lack of knowledge by charging high fees for something that should be free. 


Both human lives and healthcare infrastructure were destroyed during the civil war between 1991 and 2001. Most hospitals were ransacked and used as hideouts for rebel groups and those that were not used were burned to the ground. As the civil war came to an end, the number of mental health issues increased in response to the trauma and the true numbers of affected are still unknown today but were estimated in 2002 to be four times higher than the global average. Understanding all of these moving pieces are vital to seeing and understanding the 2014 ebola outbreak. The recent outbreak further exacerbated the existing issues of the healthcare system. Hospitals quickly ran out of beds and many health care workers whether local or foreign either died from the disease or were medically evacuated to Europe or the US for treatment. 

 
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Civil War

An important part in the history of Sierra Leone is an over a decade-long civil war that ended in 2002. It began in 1991 when the conflict that arose in Liberia spilled over into Sierra Leone. The Sierra Leonean army was under attack by the National Patriotic Front of Liberia (NPFL) and the Revolutionary United Front (RUF), which was led by Sierra Leone's former army corporal, Foday Sankoh, who allied with the Liberian rebels. A major component of the war was the acts of violence against civilians, not just by rebel forces but also by government troops. They were victims of horrific violence including mutilations, abductions, rape, forced labor as well as being used as human shields. Additionally, there were forced conscriptions that made many people, including children, unwilling participants in the conflict. By the end of the war in January 2002 roughly 50,000 people had died, over a hundred thousand more had endured violence and over two million people were displaced.

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Health Care System

One result of the civil war was a weak healthcare system. Many health infrastructures there were in place were completely destroyed during the war. Additionally, a lot of people moved from the countryside to the cities and towns, which made it more difficult to address the poor health and sanitation in those areas. However, factors preceding the war also had an impact on the healthcare system. For example, a combination of unemployment among youths and profitability from the diamond sector in Sierra Leone provided the environment for the formation of the Revolutionary United Front which was a major component of the civil war. There have also been structural adjustments that lead to the collapse of the education system. In 1974 roughly 15.6% of government funds were allocated towards education. That number dropped to an all-time low in 1993 when only about 3% of funds were spent on education. These are just a few factors that have impacted what the healthcare system looks like today and how it looked like in 2014 when Ebola became an epidemic.