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Feature Infectious disease

Who are Sierra Leone’s health security efforts for?

BMJ 2018; 363 doi: (Published 08 October 2018) Cite this as: BMJ 2018;363:k4196
  1. Mara Kardas-Nelson, journalist1,
  2. Raphael Frankfurter, doctoral student2
  1. 1Berkeley, California, USA
  2. 2University of California, San Francisco Department of Anthropology, History, and Social Medicine, USA
  1. Correspondence to: M Kardas-Nelson marajenn{at}

After the west African Ebola outbreak of 2014-16, international agencies have helped to establish disease surveillance operations in the region, find Mara Kardas-Nelson and Raphael Frankfurter, but Sierra Leone’s health security efforts may not be improving outcomes for patients

Sahr Tengbeh is a nurse who oversees a government clinic in eastern Kono, a remote forested region of Sierra Leone near where the 2014-16 Ebola epidemic is thought to have emerged. Every Monday he rides his motorbike for several kilometres until he finds a phone signal.

He carries what he considers the most important of the many forms he fills in as part of his clinical and administrative duties. It tallies the number of patients who visited the clinic in the past week displaying symptoms of diseases considered “high priority” by the Ministry of Health and Sanitation and its partners, such as the World Health Organization and USAID. Calling the district headquarters, about 60 km away, he reports the numbers of patients considered potential public health threats.

Tengbeh’s hours of counting, motorbike riding, and calling contribute to Sierra Leone’s national disease surveillance system. Throughout the country, thousands of such health outposts generate massive amounts of data that eventually end up in the capital, Freetown.

Focus on data

This focus on collecting and analysing data has emerged in the wake of the country’s recent Ebola outbreak, which, together with outbreaks in Liberia and Guinea, constituted the world’s largest epidemic of the virus. The rapid spread of Ebola, across borders and initially undetected, showed how disease flare-ups in countries with weak healthcare systems can quickly become global problems.

Sierra Leone’s health authorities and the global health community worry that this could happen again. Funders such as the UK Department for International Development, the World Bank, and USAID have together offered hundreds of millions of dollars …

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