The middle of the middle

Several people have asked about the current state of the epidemic. There are various reports published by the United Nations and World Health Organisation which tell us that the epidemic has slowed considerably in Liberia and Guinea. Liberia has been reporting fewer than 20 cases per week recently, for example. Unfortunately Sierra Leone has not reached that point. It is true that in some Eastern areas they have not seen a case for over a month which is very reassuring. In Western area and Freetown however there has been no decline in cases although it isn’t clear to me whether they are still increasing. The bottom line is that the end of the beginning has probably happened but in Freetown at least we have not yet reached the beginning of the end. Perhaps the safest thing to say is that we are probably in the middle of the middle.

When the end finally approaches I’m pretty sure we’ll be stuck with a ‘last mile problem’. I suspect the number of cases will drop to low levels but there will continue to be isolated clusters of cases. Essentially healthcare facilities will have to continue to be on high alert an screen all patients at the front door. Suspects will still need to be isolated but an ever increasing proportion will be negative. When a small facility has not seen a confirmed case for a couple of weeks it might be difficult to avoid complacency but it must be avoided at all costs. It only takes one case to slip through to the wards to infect a new batch of healthcare workers and the cycle of fear and infection will restart. Similarly it only takes one unsafe funeral or a sick person staying at home with family and a new cluster will begin. I can see this going on for months and will be very tricky to solve.

One way or another, possibly with the help of a vaccine I think the end will eventually come and there will be a momentous day when Sierra Leone is declared Ebola free. I hope it will be in 2015 but can’t really be sure.  At some point more foreign healthcare worker will leave than arrive, tents will be taken down, command centres will close their doors and the whole relief effort will cease. If this were the Olympics we would have planned the legacy along with the main event. Given the speed with which this relief effort began it is only now that we might consider the legacy.

The legacy will have both a positive and negative side. To date 106 healthcare workers are known to have died in Sierra Leone. Given the scarcity of nurses and doctors before Ebola this is a huge number which will have a big impact on future services. There will also be a whole year with no nursing or medical graduates to fill the gaps. The economic and social legacies will be enormous; already nearly 5,000 children have lost one or both parents and the economy is on its knees.

So the negative legacy will be big but what of the positive legacy. Most of the health infrastructure was built in such a hurry that it is temporary and will have to be taken down. However, Ebola has shone a spotlight on this part of the world and reminded us what a poor state healthcare was in even before the outbreak. This can only help improve investment in healthcare going forward. While most temporary foreign workers will leave, some will come back as tourists and importantly some of us have been so enchanted by this country that we may come back for a much longer term deployment.