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International public health emergencies

Lessons learned in West Africa

Cunningham, Tim DrPH, RN

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doi: 10.1097/01.NURSE.0000522010.36514.dc
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SIERRA LEONE, an impoverished country in West Africa, has faced civil war and HIV/AIDS, tuberculosis (TB), and malaria pandemics, and more recently, the world's largest Ebola epidemic.1 Before the Ebola epidemic, this country faced a shortage of nurses and healthcare providers, and the epidemic further compounded this shortage.2 For years, nongovernmental organizations (NGOs), volunteer groups, and universities have sent expatriate nurses, physicians, other healthcare workers, volunteers, and students to Sierra Leone to study, immerse themselves in the culture, and provide medical assistance.3 Nurses visiting countries such as Sierra Leone need to have training or experience in cultural humility; they must show sensitivity to host healthcare workers.4

This article discusses Sierra Leone in the context of nursing care, training, leadership, and collaboration. It features the work of Andrew Sesay, a nurse who's tirelessly worked with hundreds of expatriate medical professionals who've come to his country to provide aid. He shares his perspectives on global health nursing and offers advice about how expatriate healthcare workers may best provide assistance in his home country.

Start of an outbreak

On December 26, 2013, a 2-year-old child developed a fever associated with generalized weakness. Differential diagnoses included malaria, dengue, yellow fever, and food-borne illness; few people, if any, suspected the actual cause—Ebola. The world's worst Ebola outbreak had begun that month, and except for the efforts of Doctors Without Borders/Médecins Sans Frontières (MSF), the global response didn't gain momentum until the World Health Organization (WHO) declared a global emergency in March 2014.5

Just one case of Ebola virus disease (EVD) may be considered an outbreak.6 In this outbreak, thousands of people had already been infected by EVD by the time its emergence had been publicly recognized by the WHO and the CDC. While Ebola spread through West Africa, nurses and physicians living in the countries that were most affected—Sierra Leone, Liberia, and Guinea—bore the brunt of caring for patients who were infected or suspected of being infected.7

More than 2 years later, on March 17, 2016, Sierra Leone was declared “Ebola free.” Forty-two days had passed since the last known Ebola patient in that country had tested seronegative.8 Billions of dollars had been spent. More than 11,000 people had died from EVD, and among those who died were more than 500 healthcare workers.9 Perhaps thousands more died from secondary causes such as disabled healthcare systems, inadequate care for mothers in labor, and the cessation, for more than a year, of vaccination programs.10 Now we ask, “What's next for a country like Sierra Leone?”

While working as a nurse with the NGO Partners in Health (PIH) during the Ebola response, I was honored to be mentored by Andrew Sesay, a nurse who worked through the EVD outbreak and before that, the civil war that lasted from 1991 to 2002.11 Rebel factions formed by leadership from neighboring Liberia that aimed to overthrow the central government in Freetown fought a war that caused senseless and brutal destruction.12 Sesay provided care for patients with war injuries, end-stage AIDS, and TB. In my opinion, he's now an expert in the care of Ebola patients. Sesay has worked with hundreds of expatriates who've come to his country for short periods to provide services. He's patiently trained them, helped them provide the best care possible, and protected them from physical harm.

Sierra Leone: Background

Roughly the size of South Carolina, Sierra Leone is one of 18 sovereign African nations that comprise West Africa. Sierra Leone has 1.8 medical professionals per 10,000 people; these professionals include nurses, nurse midwives, and physicians.13 The United States, in comparison, had a ratio of 24.22 physicians per 10,000 people in 2009.14 With a population of 6.5 million in Sierra Leone, this ratio has become worse because Ebola in Sierra Leone led to the deaths of 0.06% of the total population but 6.85% of healthcare workers.15

“Unofficial” nursing training

In Sierra Leone, nurse education is expensive and challenging to acquire. Many nurses like Sesay received their training from mission hospitals run by NGOs.

Sesay began his training when he was invited to work as a mission boy. A select few young men, in return for school fees at the mission, were employed to clean, do laundry, and provide hospital care much like what environmental services specialists would provide in a U.S. hospital. Of the mission boys, some would be selected to undergo more detailed patient-care training. This training included physical assessment skills; technical skills such as phlebotomy and peripheral venous access insertion and management; and nasogastric and orogastric tube placement—all basic nursing skills.

Sesay and his colleagues, many of whom had completed the equivalent of secondary school (grades 9 to 12 in the United States), also received basic technical training in radiology, orthopedics, and diagnostics. In return for room and board, these young men were offered training, sometimes deemed to be of a higher level than what the state and local governments could offer.

Sesay said that he and his colleagues were held to high standards because of the influx of nurses and physicians who'd come from resource-wealthy countries. These expatriates needed nurses who could function at a high level.

During the civil war in Sierra Leone, besides basic medical care for patients with diseases such as malaria, Sesay and his nursing colleagues provided intensive wound care. Because people sometimes had to travel for days to receive medical care, many arrived with serious infections from machete, bullet, and blunt trauma injuries.

State-sponsored nurse training and postwar work

In 2001, Sesay formalized his nursing education by attending a military training program for nurses in Freetown, the capital and largest city of Sierra Leone. Although he'd already learned to care for patients with the most common and endemic diseases in the region and had become an expert in wound care and most other nursing interventions, he wasn't officially recognized as being a nurse because he hadn't taken Sierra Leone's equivalent to U.S. nursing boards.

With a fragile peace in effect, hospitals and clinics began to reopen, offering more opportunities for nurses. Sesay could finally afford tuition for formal nursing training while supporting his family. Following his 2½ years of intensive training, which included 6 months of observation along with clinical and classroom training, he graduated among a class of 26 students.

In 2003, few hospitals and clinics could pay salaries for state-trained nurses. As a state and community health nurse, he and fellow graduates applied for work mostly with NGOs such as MSF, which provided life-saving and essential healthcare in regions around Sierra Leone during and after the war. Sesay worked for the organization for 2 years from 2005 to 2007 when its mandate to provide care ended. Unfortunately, it was not long before the EVD outbreak brought MSF back to Sierra Leone.

Ebola and nursing leadership

In May 2014, MSF had already mobilized teams in West Africa to address the EVD outbreak. Sesay and his team of nurses and physicians began to create protocols for addressing and caring for patients who'd arrived at their clinics.

In Port Loko he was a key player in planning and designing patient treatment plans, logistics, and coordination of small clinics known as peripheral health units (PHUs). In Port Loko, PHUs served as a base for primary healthcare and were the first facilities to see patients with EVD. These clinics rapidly became holding centers for patients with EVD who were dying. Sesay worked relentlessly with NGOs and governmental organizations to establish Ebola treatment units (ETUs), where patients who had EVD or were suspected of having it could be more safely treated.

Besides understanding and teaching the use of personal protective equipment (PPE), Sesay was one of the first to work with teams of logisticians with PIH to plan how to keep healthcare providers safe when treating patients with EVD.

Sesay said that one of the most challenging aspects of EVD patient care was the PPE itself. The protective coveralls used in this response were nonpermeable and the heat inside them rapidly grew unbearable. To prevent heat-related illnesses such as dehydration, heat exhaustion, and heat stroke, healthcare professionals working in the PPE were severely limited in how long they could remain working inside the contaminated areas of the ETUs providing direct patient care.

When cases of EVD in Sierra Leone became more prevalent after May 2014, some patients were treated by a healthcare worker for only 20 minutes or less per day because of the large number of patients, the limited number of healthcare workers, and the limited time workers could spend with patients. Teams of logisticians worked with Sesay to try to design ways to make patient care as efficient as possible while keeping healthcare workers safe from the risks of heat-related illness and infection.

As more and more communities saw an increase in the number of patients with EVD, more expatriates and NGOs began to engage in the EVD response. Adding complexity to this already-difficult emergency was the influx of nurses, physicians, and other healthcare workers who'd volunteered to provide patient care. The unprecedented global response brought both challenge and relief to nurses and physicians living in Sierra Leone, who'd been working to end the epidemic from its inception.16

Sesay was now responsible for coordinating expatriates who arrived in groups almost weekly. He welcomed groups of expatriate healthcare workers and also helped develop satellite Ebola care centers called community care centers (CCCs). CCCs provided initial diagnostic care for patients suspected of having EVD. They allowed patients who'd tested negative for EVD to remain closer to their communities rather than having to be transported to a centrally located ETU that might be far from home.17 Some ETUs could provide 24-hour/day patient care as of December 2014 because enough providers were available to support the strained healthcare workforce in Sierra Leone. Many ETUs still didn't have staff or supplies to provide round-the-clock care similar to that provided in U.S. hospitals.

Sesay translated for, negotiated with, and facilitated many expatriates and projects at once. Fluent in the five local languages common in Port Loko as well as in English, this nurse leader applied his years of war experience, skill in managing chronic and infectious disease, and most important, ability to collaborate with an ever-changing mix of expatriate healthcare workers as he played a critical role in the EVD response.

Perspectives on nursing collaboration

I asked Sesay, whom I considered to be an expert in infectious disease, humanitarian response, and nursing leadership, for words of advice for expatriate nurses who want to provide assistance in new and challenging settings, often for relatively short periods (1 year or less). He maintains the following five nursing values are paramount for nurses visiting his country and community:

  • Be observant.
  • Be tactful.
  • Always have a smiling face (be accommodating).
  • Be interested and interesting.
  • Be neat and tidy.

In addition, he speaks of the immeasurable value of the knowledge shared by foreigners working in his country. First, most of his early training as a nurse came from expatriate physicians and nurses. He remarks that each new visitor brings a wealth of knowledge and experience. Sesay and his colleagues have relished the new knowledge that's come from around the world.

He comments, however, that communities with an influx of expatriate healthcare workers also face risks. Sesay has spoken about how often expatriate nurse leaders have come to his country and continued their leadership roles without making a serious effort to understand the host culture. When expatriate healthcare workers come to a country for a very short time (2 weeks to 1 month), Sesay says that some cultural issues such as miscommunication, mistrust, and disrespect can be exacerbated.

He suggests that expatriate healthcare workers first take ample time to learn about the country and culture that they'll be visiting. Then, when they arrive, he encourages them to take more time at first to learn about the host country from their healthcare colleagues. By that, he means healthcare workers need to meet and learn the names of the nurses who'll be their colleagues and ask them questions. No formula determines exactly how much time that will take, but Sesay encourages nurses visiting his country to take a step back for at least a few days. Before expatriate healthcare workers propose changes to care plans or systems, he asks that they learn about the system that's currently in place and work to understand the historic context that makes the current system function.

Expatriate healthcare workers must work with a mindset that after they depart, their local colleagues will remain, maintaining health systems and their community's well-being. Short-term programs that send expatriate nurses into challenging situations often don't prepare them for this reality.

I believe that Andrew Sesay is a model nurse leader who, in addition to providing expert nursing care to his patients, has a unique responsibility to mentor expatriate nurses. All nurse mentors and educators are responsible for preparing nurses and students to understand local nursing practice and be culturally competent. Without this knowledge, nurses working in settings outside of their home cultures and countries run the risk of causing more harm than good. Sesay concludes with the idea that if nurses can exhibit the five nursing values while they take the time to understand the host culture before they try to propose change, they can work productively in any environment.



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