Another day, another disaster. The vulnerability of Sierra Leone makes any reference to “natural” disasters at best ironic, and at worst insulting. Poverty is not “natural”, and the overcrowding into poor housing that it causes is not “natural”. Even the extreme climatic and environmental conditions that precipitated the recent devastating mudslide on the outskirts of the capital, Freetown, are a function of man’s unnatural relationship with nature. But what to do about it?
As in all emergencies, it was those closest to the disaster that provided the immediate help. Those trapped in the mud would have died waiting for a search and rescue team from the “West” to get them out. It will have been their fellow survivors and neighbours, followed by local and then national teams, who will have determined whether they lived or died.
But as Sierra Leone buries the nearly 500 people known to have been killed by the mudslide, international help may well still be needed. Outbreaks of disease, such as cholera, often follow such tragedies – and then there are the country’s ongoing, long-term problems.
To be truly effective, international assistance will now have to address the needs that Sierra Leone itself cannot. And the vital needs in far off, low income countries are often those things many in the West take for granted. Things such as adequate access to appropriate (or even basic) medical care, rehabilitation, care in the community, psychological support and the rest of the wraparound assistance provided by richer countries’ well-financed health economies.
Cause no harm
So the wider world should give Sierra Leone its aid, but must make sure it is effective. We know that foreign aid can harm, be abused, and lead to dependency. But we also know that the absence of aid can harm, particularly the most vulnerable. The international community must meet the country’s immediate needs while at the same time building the capacity of Sierra Leone to deal with its own emergencies. In time, this will also support a coordinated response between other countries in the region, a policy encouraged by the UN and its partner organisations.
So what might Sierra Leone need from overseas? A legacy of the 2014 West African Ebola crisis is the move by the World Health Organisation (WHO) towards a Global Health Emergency Workforce, supported by its emergency medical teams (EMT) programme and public health rapid response teams (RRTs).
Integral to this new approach is a set of minimum standards established in the wake of international concern about the unqualified responders to the 2010 earthquake in Haiti and other major disasters. If Sierra Leone feels it requires outside clinical and public health help, it can look to a register of verified teams and choose those with the skill sets that best match their needs.
Sending people uninvited more often than not adds to the country’s burdens. But what is usually always needed by overstretched economies in times of crisis is money. Giving cash to be spent locally allows a country with limited financial resources to support its own people who are there on the ground and available immediately to help. Rather than importing goods from overseas, the means of reconstruction are purchased locally. Money can be misdirected but so can goods and services. All aid must be monitored and evaluated.
Then there’s the risk of epidemics, the fear of which is common after disasters. This is clearly a particular worry in Sierra Leone given its recent history. Flooding increases the spread of waterborne diseases in low income (but not developed) countries, and many waterborne diseases, including cholera, are still present in Sierra Leone.
The absence of a strong public health infrastructure was critical to the spread of Ebola in the region and its implementation crucial to its containment. The same vigilance and readiness to support is needed now.
It was a failure to understand the handling of the dead by neighbours, friends and relatives that amplified the spread of Ebola (showing the importance of knowing the anthropological and social norms of an affected population) – and cholera, like Ebola, is one of the few infectious diseases that remains alive long enough after death to infect those who handle the bodies.
Sudden onset disasters that kill the healthy do not themselves cause epidemics. Dead bodies, even when decomposing, are not a serious risk to public health unless the cause of death was an Ebola-like illness or another infection that survives to an extent in bodily fluids after death such as cholera.
The much commented-on mass burials without ritual we have seen already in Sierra Leone may not have been strictly necessary on health grounds, but may be an important preparation for what may have to happen if strong public health systems are not implemented quickly and maintained. There have been large cholera outbreaks in the recent past in Sierra Leone – and another is always a very real possibility.