A health worker treats a child with ebola in Sierra Leone. Photo: Francisco Leong/AFP/Getty Images
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Warnings over collapse of health system in the wake of ebola in Sierra Leone

Prior to the outbreak there were signs of progress in the country’s public health operation, which are now under threat.

Sierra Leone’s health system is showing worrying signs of collapse in the face of ebola, as the epidemic puts exceptional pressure on already weak systems in West Africa. This is a hugely frustrating and sad situation as the country had started to make progress in public health in the years prior to the outbreak. Despite the progress, however, the health system was not strong enough to absorb a shock on this scale and rebuilding infrastructure and trust will require major investment in the post-ebola period.

Taking Sierra Leone as an example, bearing in mind that the health system performance in Guinea Conakry and Liberia are somewhat comparable to their neighbouring country, we can see how the impact has been felt across all aspects of health.

In 2013, for the first time since the end of the war, Sierra Leone succeeded in eliminating the deficit of its country balance sheet, leaving no doubt that the country was in a period of recovery for the first time since the end of the war in 2002. Nevertheless, in 2014, Sierra Leone was still ranked amongst the poorest countries in the world. In 2013 the per capita expenditure on health was a mere $7.60, far short of the recommended $54. It is anticipated that the short-term impact of the ebola outbreak will affect the economy in Sierra Leone by a reduction in growth of GDP from 11.3 per cent to 8 per cent, which may mean that the government’s contribution to health activities outside of ebola will reduce in real terms. As campaigners mark the first-ever Universal Health Coverage Day on 12 December, this serves as a serious blow to the chances of bringing quality healthcare to all as a basic human right.

Signs of progress in public health prior to the ebola outbreak included the fact that between the periods assessed in the 2008 and 2013 Demographic and Health Surveys, the proportion of births taking place in a health facility has doubled (from 24.6 per cent to 54.4 per cent) and the proportion of women receiving a postnatal check-up within two days of delivery increased to more than two thirds (from 58.0 per cent to 72.7 per cent).

Despite these achievements, Sierra Leone still faces one of, if not the highest level of maternal and child mortality in the world.  The maternal mortality ratio shows no sign of improvement at 1,165 maternal deaths per 100,000 live births; the under-five mortality rate is 156 deaths per 1,000 live births; and the neonatal mortality rate is 39 deaths per 1,000 live births, which remain unchanged since 2008. The increases in health service uptake between 2008 and 2013 have not resulted in improvements in health outcome indicators, reflecting issues related to poor quality of health services.

Health workers are overstretched with an ever-growing burden of ebola cases, and the ebola-related fatalities of 101 of the 128 health workers infected impacts not only the workforce numbers but also morale, further reducing capacity of the health system to provide adequate care.

Facilities are under-equipped with essential infrastructure and equipment to provide even basic essential health services. Based on the Ministry of Health and Sanitation’s recent Facility Improvement Team (FIT) assessment, the pressure of ebola on the healthcare system is resulting in the closure of health facilities and a drop in those that are equipped to provide emergency obstetric and neonatal care.  Further, Government data shows that since the ebola outbreak, fewer people are attending public health facilities for essential health services; between May and July 2014, the proportion of women attending for their first antenatal care visit dropped by 17 per cent; for their first postnatal visit, fell by 18 per cent; and for a delivery, fell by 16 per cent. In terms of child health, over the same period, the proportion of children who received oral rehydration solution and zinc treatment for diarrhoea within the first 24 hours fell by 33 per cent and those receiving full immunisations dropped by 12 per cent.

The trust in health services has been further eroded by inadequate communication with, and involvement of, community members in the first few months of the outbreak. Serious misconceptions about ebola persist; a third of survey respondents in a survey believed that ebola was airborne and one out of every five people believed that ebola could be cured by traditional healers. With a case fatality rate estimated to be at least 70 per cent, health facilities are perceived as places where one catches the disease and dies.  Further, anecdotal reports appear regularly in the media about pregnant women being triaged out of care due the level of ebola transmission risk they are perceived to present to health workers.

The collapse of the health system demonstrates Sierra Leone’s poor resilience to absorb shocks. The focus of everyone is rightly on bringing the ebola epidemic under control, but at what cost? The impact of the drop in service utilisation on morbidity and mortality from other preventable illnesses is yet to be seen. An estimated 382,000 women will become pregnant over the next 12 months in Sierra Leone. Based on the pre-ebola levels of care without any consideration of the health system collapse, 2,400 women per year die due to preventable conditions related to pregnancy and childbirth. Malaria accounts for a quarter of all deaths in the country, and is the leading cause of death among under 5s. Measles outbreak is another risk for all three countries, which will be difficulty to contain if current resources do not broaden their focus to redress the gap in providing basic essential health services.

Reconstructing the health system in the post-ebola period will require significant investments in every aspect of the health system. Additional human resources for health will be needed not only to compensate the deaths of health professionals during the epidemic but also to fill the pre-existing gaps to be able to deliver the quality of services needed to improve health outcomes, and restore trust in the health system. In the meantime, authorities including the World Health Organisation, donors and implementing agencies must address the routine health needs of people in these affected countries, particularly those conditions that require simple interventions to prevent death and morbidity in areas such as malaria, vaccine-preventable diseases and the needs of pregnant women and their newborns.

Karl Blanchet is Lecturer at the London School of Hygiene and Tropical Medicine and a member of the Public Health in Humanitarian Crises Group. Sara Nam is a Technical Specialist in Reproductive and Sexual Health with Options Consultancy Services Ltd.

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All the Premiership teams are competing to see who’s got the biggest stadium

It’s not just a financial, but a macho thing – the big clubs want to show off that they have a whopper.

Here in NW5, where we live noisily and fashionably, we are roughly equidistant from Arsenal and Spurs. We bought the house in 1963 for £5,000, which I mention constantly, to make everyone in the street pig sick. Back in 1963, we lived quietly and unfashionably; in fact, we could easily have been living in Loughton, Essex. Now it’s all changed. As have White Hart Lane and Highbury.

Both grounds are a few metres further away from us than they once were, or they will be when White Hart Lane is finished. The new stadium is a few metres to the north, while the Emirates is a few metres to the east.

Why am I saying metres? Like all football fans, I say a near-miss on goal was inches wide, a slow striker is a yard off his pace, and a ball player can turn on a sixpence. That’s more like it.

White Hart Lane, when finished, will hold 61,000 – a thousand more than the Emirates, har har. Meanwhile, Man City is still expanding, and will also hold about 60,000 by the time Pep Guardiola is into his stride. Chelsea will be next, when they get themselves sorted. So will Liverpool.

Man United’s Old Trafford can now hold over 75,000. Fair makes you proud to be alive at this time and enjoying the wonders of the Prem.

Then, of course, we have the New Wembley, architecturally wonderful, striking and stunning, a beacon of beauty for miles around. As they all are, these brave new stadiums. (No one says “stadia” in real life.)

The old stadiums, built between the wars, many of them by the Scottish architect Archibald Leitch (1865-1939), were also seen as wonders of the time, and all of them held far more than their modern counterparts. The record crowd at White Hart Lane was in 1938, when 75,038 came to see Spurs play Sunderland. Arsenal’s record at Highbury was also against Sunderland – in 1935, with 73,295. Wembley, which today can hold 90,000, had an official figure of 126,000 for the first Cup Final in 1923, but the true figure was at least 150,000, because so many broke in.

Back in 1901, when the Cup Final was held at Crystal Palace between Spurs and Sheffield United, there was a crowd of 110,820. Looking at old photos of the Crystal Palace finals, a lot of the ground seems to have been a grassy mound. Hard to believe fans could see.

Between the wars, thanks to Leitch, big clubs did have proper covered stands. Most fans stood on huge open concrete terraces, which remained till the 1990s. There were metal barriers, which were supposed to hold back sudden surges, but rarely did, so if you were caught in a surge, you were swept away or you fell over. Kids were hoisted over the adults’ heads and plonked at the front.

Getting refreshments was almost impossible, unless you caught the eye of a peanut seller who’d lob you a paper bag of Percy Dalton’s. Getting out for a pee was just as hard. You often came home with the back of your trousers soaked.

I used to be an expert on crowds as a lad. Rubbish on identifying a Spitfire from a Hurricane, but shit hot on match gates at Hampden Park and Ibrox. Answer: well over 100,000. Today’s new stadiums will never hold as many, but will cost trillions more. The money is coming from the £8bn that the Prem is getting from TV for three years.

You’d imagine that, with all this money flooding in, the clubs would be kinder to their fans, but no, they’re lashing out, and not just on new stadiums, but players and wages, directors and agents. Hence, so they say, they are having to put up ticket prices, causing protest campaigns at Arsenal and Liverpool. Arsène at Arsenal has admitted that he couldn’t afford to buy while the Emirates was being built. Pochettino is saying much the same at Spurs.

It’s not just a financial, but a macho thing – the big clubs want to show off that they have a whopper. In the end, only rich fans will be able to attend these supergrounds. Chelsea plans to have a private swimming pool under each new box, plus a wine cellar. Just like our street, really . . . 

Hunter Davies is a journalist, broadcaster and profilic author perhaps best known for writing about the Beatles. He is an ardent Tottenham fan and writes a regular column on football for the New Statesman.

This article first appeared in the 11 February 2016 issue of the New Statesman, The legacy of Europe's worst battle