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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How “cli-fi” novels humanise the science of climate change

The paradox is that the harder climate-fiction novels try, the less effective they are.

When the Paris UN Climate Change Conference begins at the end of November, the world’s leaders will review the climate framework agreed in Rio in 1992. For well over 20 years, the world has not just been thinking and talking about climate change, it has also been writing and reading about it, in blogs, newspapers, magazines – and in novels.

Climate change fiction is now a recognisable literary phenomenon replete with its own nickname: “cli-fi”. The term was coined in 2007 by Taiwan-based blogger Dan Bloom. Since then, its use has spread: it was even tweeted by Margaret Atwood in 2013:

It is not a genre in the accepted scholarly sense, since it lacks the plot formulas or stylistic conventions that tend to define genres (such as science fiction or the western). However, it does name a remarkable recent literary and publishing trend.

A 21st-century phenomenon?

Putting a number to this phenomenon depends, partly, on how one defines cli-fi. How much of a novel has to be devoted to climate change before it is considered cli-fi? Should we restrict the term to novels about man-made global warming? (If we don’t, we should remember that narratives about global climatic change are as old as The Epic of Gilgamesh and the Biblical story of the flood.) If we define cli-fi as fictional treatments of climate change caused by human activity in terms of setting, theme or plot – and accept there will be grey areas in the extent of this treatment – a conservative estimate would put the all-time number of cli-fi novels at 150 and growing. This is the figure put forward by Adam Trexler, who has worked with me to survey the development of cli-fi.

This definition also gives us a start date for cli-fi’s history. While planetary climatic change occurs in much 20th-century science fiction, it is only after growing scientific awareness of specifically man-made, carbon-induced climate change in the 1960s and 1970s that novels on this subject emerged. The first is Arthur Herzog’s Heat in 1976, followed by George Turner’s The Sun and the Summer (published in the US as Drowning Towers) in 1987.

At the turn of this century, Maggie Gee and TC Boyle were among the first mainstream authors to publish climate change novels. In this century, we can count Atwood, Michael Crichton, Barbara Kingsolver, Ian McEwan, Kim Stanley Robinson, Ilija Trojanow and Jeanette Winterson as major authors who have written about climate change. The past five years have given us notable examples of cli-fi by emerging authors, such as Steven Amsterdam, Edan Lepucki, Jane Rawson, Nathaniel Rich and Antti Tuomainen.

Creative challenges

Cli-fi is all the more noteworthy considering the creative challenge posed by climate change. First, there is the problem of scale – spatial and temporal. Climate change affects the entire planet and all its species – and concerns the end of this planet as we know it. Novels, by contrast, conventionally concern the actions of individual protagonists and/or, sometimes, small communities.

Added to this is the networked nature of climate change: in physical terms, the climate is a large, complex system whose effects are difficult to model. In socio-cultural terms, solutions require intergovernmental agreement – just what COP21 intends – and various top-down and bottom-up transformations. Finally, there exists the difficulty of translating scientific information, with all its predictive uncertainty, into something both accurate and interesting to the average reader.

Still, cli-fi writers have adopted a range of strategies to engage their readers. Many cli-fi novels could be classified as dystopian, post-apocalyptic or, indeed, both – depicting nightmarish societies triggered by sometimes catastrophic climate events. A future world is one effective way of narrating the planetary condition of climate change.

Some novelists are also careful to underpin their scenarios with rigorous climatic predictions and, in this way, translate science fact into a fictional setting. Kingsolver, who trained as an ecologist, is the best example of this – and Atwood and Robinson are also known for their attempts at making their speculations scientifically plausible. Also, cli-fi novels, particularly those set in the present day or very near future rather than in a dystopian future, tend to show the political or psychological dimensions of living with climate change. Readers can identify with protagonists. To some extent, the global community is represented in fictional everymen or everywomen. Or, often, it is through such characters that science is humanised and its role in combating climate change better understood.

Can cli-fi lead to change?

Could cli-fi affect how we think and act on climate change? The paradox is that the harder cli-fi tries, the less effective it is. Many writers want to inspire change, not insist on it: the line between literature and propaganda is one that most novelists respect. Literature invites us to inhabit other worlds and live other lives. Cli-fi at its best lets us travel to climate-changed worlds, to strive there alongside others and then to return armed with that experience.

In Paris, the UN will seek a global agreement on climate action for the first time in more than 20 years. There is plenty of climate change fiction out there to help provide the mental and psychological space to consider that action.

The Conversation

Adeline Johns-Putra, Reader in English Literature, University of Surrey

This article was originally published on The Conversation. Read the original article.