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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Relive your worst experiences for $15 an hour: how confessional journalism exploits women writers

The women’s website Bustle asks its writers to fill out a checklist covering every possible personal angle; it puts a low-market value on their most intimate truths.

Let me tell you about the worst thing that ever happened to me, the most terrible thing I’ve ever done. Let me tell you everything there is to know about me, all the buried markers of self that live under my skin. OK not that one, and I’ll keep that one too. I have to have something left over, after all. Even so, I’ve written about being the May Queen at school, and the time I got flashed in an underpass; about having depression as a teenager, and the unplanned pregnancy that became my son.

Actually, I’ve written about that last one twice: my first successful pitch for a comment piece was a response to anti-abortion comments by the then-influential semi-thinker Phillip Blond. It was a kind of pitch I now refer to now as the “what I think about X as a Y”: what I think about abortion as a woman who had and chose to continue an unplanned pregnancy. Experience is capital, and in 2009, I used it to buy my way into writing.

It’s a standard route for women writers, but not usually as formalised as it is at women’s website Bustle, which (as Gawker reported last week) asks its writers to fill out a checklist covering every possible personal angle: “I see a therapist”, “I’ve had group sex (more than three)”, “I used to have a Fitbit but I don’t now”.

Every bit of what you are, granulated and packaged for easy dispersal through a range of stories. It’s an editorial approach that gives rise to a weird, impersonally-personal tone. “Five Reasons I’m Grateful For My Parents’ Divorce”, chirrups a listicle; “that’s why I tried anal sex in the first place”, trills a gif-heavy piece about the benefits of bumming.

That’s just the shallow end of the confessional genre. The ideal online women’s interest story combines a huge, life-changing disclosure with an empowering message. Like this, from xoJane: “I'm Finally Revealing My Name and Face As the Duke Porn Star” (the last line of that one is: “My name is Belle Knox, and I wear my Scarlet Letter with pride”). Or this, from Jezebel: “On Falling In and Out of Love With My Dad” (which concludes like this: “And to the victims of their abuse, I want to say what I have finally been able to understand myself: that my attraction, and what it led to, was not my fault”).

It’s tempting to think of this blend of prurience and uplift as a peculiar product of the internet, but it’s been a staple of women’s publishing forever: the covers of women’s magazines are full of lines like “Raped for 50p and a biscuit!” and “The groom who went ZOOM!” about a jilted bride, exactly as they were when I used to sneak them from my aunt’s magazine rack to read them as a child. The difference is that, in the trashy weeklies, there’s no pretence that trauma is the overture for a career. You get paid for your story, and someone else writes it up. The end.

At Bustle, the rate apparently runs to $90 for a six-hour shift. That feels like a low market value to put on your most intimate truths, especially when the follow-up success you’re investing in might never materialise. The author of the father-daughter incest story for Jezebel told a Slate writer that, despite the huge web traffic her confessional received, her subsequent pitches were ignored. Her journalistic career currently begins and ends with her very grimmest experience.

“Everything is copy” is the Nora Ephron line. But when she said it, she didn’t intend the disclosure economy we live in now. For Ephron, “everything is copy” meant claiming control: “When you slip on the banana peel, people laugh at you. But when you tell people you slipped on the banana peel, it’s your laugh. So you become the hero, rather than the victim of the joke.”

Does the aspiring writer plucked from an editor’s checklist to retail her own Worst Thing Ever get to call the banana skin her own?

The Bustle checklist suggests not. “Don’t put anything on here you don’t want to write about,” it stresses, before adding, “that said, you can always say ‘no’ . . . You might be too busy when an editor approaches you about possibly writing an identity post, or simply not interested, and that’s okay! We won’t be mad!”

Ticking the box basically puts you in a position of assumed consent, but which hopeful young woman would dare to set her boundaries too close when an editor tells her this could be good for her career? (Yes, I know this sounds a bit like a story of sexual harassment. Funny, that.)

So many confessionalist pieces of writing tell stories about women having their limits overridden. Rape and coercion. Abuse and assault. Being talked over and ignored. But the logic of the perpetual confession journalism machine is the same: everything about a woman should be available to use, nothing a woman has to say is valid without a personal claim to authority, repackage their guts as shiny sausages and call it an “identity piece”.

Women writers shouldn’t be waiting for permission to say no. We need to tell our stories on our own terms, and we need to set better terms than $15 an hour and the hope of some exposure. The worst thing that ever happened to me? It’s mine. I’m keeping it.

Sarah Ditum is a journalist who writes regularly for the Guardian, New Statesman and others. Her website is here.