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Feature Ebola

Will a new doctor emerge from Sierra Leone’s Ebola epidemic?

BMJ 2019; 366 doi: (Published 19 August 2019) Cite this as: BMJ 2019;366:l5161
  1. Elisabeth Mahase
  1. The BMJ

As a health assistant, James Swarray overcame stigma and his own fear to help patients in his home country of Sierra Leone during the height of the Ebola epidemic. Now he faces one last hurdle in his dream of becoming a doctor

When James Swarray, a health officer in Sierra Leone, stepped into the red zone on his first day at the Moyamba Ebola clinic, he wondered if this was the end.

“The victims of the Ebola virus were crying, vomiting, defecating, and shouting because they were distressed,” he says, speaking to The BMJ from Bo, the country’s second largest city. “I thought, ‘Is this going to be my last day on Earth?’ The rate at which Ebola was killing, the mayhem it was causing—it wasn’t comparable to anything else I’d seen before.”

Swarray started working in the clinic in December 2014 when the outbreak was well under way, with 20 206 cases and 7905 deaths reported in Guinea, Liberia, Mali, and Sierra Leone.1

“No one wants to die”

The situation didn’t get any easier for Swarray in the next few weeks. He struggled to sleep, worrying that he might have been exposed to the virus. He also felt isolated, facing stigma from people in the community who were scared that he would infect them.

“No one would talk to me,” he says. “I’d leave early in the morning and come home late at night, because I didn’t want to deal with the stigma. I was really down. For me to even have a decent place to stay was difficult, because no one wanted to share a house or an apartment with me. No one wants to die.”

But he didn’t let that stop him. Determined to use the skills he’d learnt when studying to become a health officer, he found a way to adjust to life as an Ebola worker, found support in the close team at his clinic, and continued working until the end of the outbreak in 2016.

He was also driven by another goal: his dream of becoming a doctor, something Sierra Leone desperately needs.

Doctors are scarce

With just 2.4 doctors per 100 000 people as of 2010, Sierra Leone has the fifth lowest doctor-population ratio in the world.2

“We have problems in the pipelines,” says Dan Youkee, a clinical research fellow from the Sierra Leone Partnership at King’s College, London, who spoke to The BMJ from Sierra Leone’s capital, Freetown.

“We have problems producing enough doctors,” he says, as the only medical school in the country graduates 30 to 50 doctors a year. “We then have problems retaining them and making sure that, when they come to the capital to train, they don’t stay in the capital.

“We have a big urban-rural divide in Sierra Leone and find it difficult to attract healthcare workers to the rural places, which means that rural communities are underserved.”

This problem only worsened during the Ebola outbreak. “There was a cessation of medical education from 2014 to 2015 because of the outbreak,” says Youkee. “So, there was an already overstretched health workforce, and for another year—because the University of Sierra Leone was closed—we didn’t produce a new cohort of graduates.

“Plus, we lost over 200 healthcare workers to Ebola.”

False promises

While working at the Ebola clinic Swarray believed that his dream was within reach. He says that the government promised him a scholarship to study medicine but that, after the outbreak, it never materialised.

Youkee isn’t familiar with Swarray’s individual situation, but he says that the details don’t surprise him. During the outbreak, he says, the government made many “false promises” to Ebola responders.

“Healthcare workers were told that they would be absorbed on to the government payroll. That didn’t happen,” says Youkee. “Many healthcare workers in Sierra Leone are actually volunteers, so despite them having graduated they didn’t receive an official salary from the Ministry of Health.

“Another promise was to university graduates, which was that, if you were an Ebola survivor, you’d be allowed a scholarship to higher education and to resume your studies.”

He adds, “There was a betrayal of promises made. These promises were made by the previous government in power. The current government has now started to act on this and begun to absorb healthcare workers [on to the payroll].”

It’s who you know

But, with little money and no scholarship offered so far, Swarray isn’t optimistic that he’ll get into medical school, even with the new government.

“If you’re not the son of a minister [or] you’re not connected politically, you will not be able to get a place there,” he said. “I’m so frustrated—I’m limited in what I can do. I see the people whose parents were in powerful positions and were able to send them to study medicine in South Africa, Nigeria, overseas. These people return to Sierra Leone for holidays and then go back overseas to work.”

He’s most frustrated by the departure of those lucky enough to get training, especially as he’s seen first hand the impact of having no medical staff in rural areas.

“I’ve spent three years as a health assistant, and I’m now finishing my bachelors in community health and clinical sciences. I want to be a medical doctor, and yet, after seven years of study, I’m still an assistant,” he says.

The degree he’s currently studying for is a requirement for many international scholarship programmes. And he’s got financial help from a UK doctor who worked with him in the Ebola clinic, who saw that he had huge potential but would be hampered by his lack of privilege.

Misconceptions and witchcraft

Swarray’s ambition to become a doctor arose during his initial training to be a health assistant, when he realised that his village had many misconceptions about medical conditions—something that could be resolved through education and awareness.

Although currently away at university, he travels back to his home village every weekend to try to help people. He says that he’s spoken to many people from his community who believed that their illness was caused by witchcraft or bad dreams until he gave a medical explanation. But he’s also aware that he can do only so much without being a trained doctor.

“Until we have people trained in medicine who can come back home and solve this problem, people will continue to die of these preventable conditions,” he says.

An end in sight?

As Swarray gears up for the final exams of his community health degree, he’s planning his applications to medical school, including in other countries. To study abroad he needs a full scholarship, and he’s set to apply far and wide to places such as Germany, the UK, and the US. The prospect is daunting, but he’s holding on to the hope that he’ll finally gain a place.

“You can’t imagine what this would mean to me,” he says—“and what it would mean to my country.”


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