By Stephen V. Lansana
Fatmata Kamara (Not her real name) narrowly escaped from the 34 Military hospital after she went there for pre-natal care. The 7-month pregnant mother of two said she suffered fromsevere fever and headaches, chronic cough, body pain, and frequent cold flashes. She could not breathe. As soon as she described her symptoms, the nurses wanted to test her for COVID-19. Fatmata panicked, fearing that she will be quarantined and never see her family again. She wanted to escape.
COVID-19 is the disease caused by the deadly novel coronavirus SARS-CoV-2 recently declared a pandemic.
Malaria and COVID-19 symptoms are strikingly similar
Even though it turned out that Fatmata suffered from malaria, the nurses were justified to suspect that Fatmata may have COVID-19. Astudy conducted by Zambian and UK scientistsfound that “Malaria shares some of the highly recognizable symptoms with COVID-19, such as fever, difficulty breathing, fatigue and headaches of acute onset.”The study, published in the International Journal of Infectious Diseases,concludedthat a case of malaria may be misclassified as COVID-19 if symptoms alone are used to define a case.
In Sierra Leone, this reality poses several other risks. Pregnant women like Fatmata, as well as sufferers from malaria who experience cough, headaches, and fever, may choose to stay away from hospitals out of fear of being tested for COVID-19 and quarantined.
Fatmata, whose real name is protected at her request, lives with her family in a shanty home, also known as “pan-body” in Krio, in Goderich, just six miles south of Freetown. She restson a wooden bench as she tells her story, slightly trembling with fear. Her blue head-wrap contrasts against her torn, colorless clothes. “As soon as I finished explaining my conditions,the nurses became afraid and wanted to take my swab. My blood pressure went up. I told them that I am just a pregnant woman who is having complications in pregnancy,” Fatmata recounted.
Fortunately, Fatmata was seen byDoctor Sankoh before she left the hospital. “Doctor Sankohtold the nurses I am having such conditions because of my pregnancy. So, the doctor conducted testsand administered treatment for malaria, cough and the other conditions and I went home,” she said. The visit was so traumatizing that Fatmata decided to never set foot in the hospital again.“Because of fear of coronavirus, [my husband] advised me to take home treatment instead of visit the hospital. I agreed with my husband not to visit the hospital again,” Fatmata said.
Fear of Coronavirus slashed hospital attendance almost by half in April
Irene Sesay,matron in-charge, at the Princess Christian Maternity Hospital (PCMH), popularly known as Cottage, said that hospital visits by pregnant women dropped since of the declaration of the COVID-19 pandemic. According to data tallied by PCMH, 1,634 patients sought pre-natal health support in January of this year. In April, the numbers dropped by almost half, to 834 visits. Looking at patients admitted for treatment, PCMH reported a drop from 808 in January, to just 430 visits in April.
Sesay said that fear of the healthcare staff that could spread the virus is one reason for the downtrend. People remembered the Ebola times, when healthcare staff were believed to unknowingly spread the virus.
“They are also afraid of using the health facilities [thinking]that the nurses will accuse them of having COVID and contain them in the hospital. So, they are afraid of quarantine and isolation,” the Matron stated. Sesay worriesthat pregnant women who may have needed urgent medical care stayed away from hospitals resulting in aggravated illness and possible death. “We have to communicate with media houses to reassure pregnant women and other people that the hospital environment is safe,” she stated.
The situation is similar in the provinces
Hassanatu Jalloh, Mothers’ Club member from Massam Kpaka in Pujehun, described how a close relative of hers miscarried because she was too afraid to go to the hospital for care when she developed complications. Since the outbreak of coronavirus in Sierra Leone, Hassanatu observed how pregnant women gradually stopped going to the clinic for care. She said most fear that the nurses will accuse them of having coronavirus and keep them in quarantine.
Hassanatu and her Mother’s Club members continue to advocate and raise awareness amongpregnant women, but the work is an uphill battle, she said.
A nurse in Kenema, who also requested protection of his identity, said that fear of COVID-19 forced parents to bring their sick children to thehospital when their condition worsens, and sometimes it is too late to save them.Many have lost their lives because parents feared the hospital settings.
In Pujehun, Mustapha D. Mansaray, a Community Health Worker in Massam Kpaka, said that he sometimes enlists the support of the traditional leader to convince parents to take their children to the hospital for malaria treatment. But sometimes this help comes too late. He described the recent case of a mother whose 9-month old baby died on the way to the hospital because it took too long to convince her.
Locals may be hiding their dead
According to Musa D. Sheriff, Diseases Surveillance Officer in Pujehun, 32 children under the age of five died of malaria since the beginning of the year in his district alone. That is an average of one child every week, in just one district, but he thinks the real numbers are higher. Since the outbreak, he said, people began to hide their dead, and not report them to hospital officials. They fear that if they report a death, hospital staff will come and test the family and place them in quarantine.
Dr. Kwabena Larbi, Chief of Mission for Impact Malaria, a program run under the U.S. President’s Malaria Initiative, also tracked hospital attendance before and after the coronavirus outbreak. Preliminary numbers show that hospital attendance dropped by 10.5% in April, 20.5% in May and 13% in June compared to the same months in 2019.
“We did a small analysis from January to June 2019 and compared it to January-June this year. We saw a significant drop in the number of people who attended health facilities. There are a lot of reasons for this drop, but I think COVID-19 is one of the reasons why fewer people were going to health facilities; because of the fear,” Dr. Larbi said. He added that this is preliminary information, and more data is necessary to draw reliable conclusions. The numbers show that in May, 43,000 fewer people turned to hospitals for care.
“The attendance dropped especially from March when Sierra Leone registered its first case of COVID-19,” Dr. Larbi added, and explained that health staff from the provinces reported a behavioral change in their patients, who intentionally lie to healthcare staff and deny any symptoms that would make them COVID-19 suspects.However, denying these symptoms may also lead to undiagnosed malaria, and lack of proper treatment.
“Some patients don’t come to the hospital at all, and those that come try to direct the health workers to other conditions to avoid becoming COVID suspects. These are some of the anecdotal, or hearsay reports,we received from health workers, andit is not backed by data,” Dr. Larbi clarified.
He compared this behavior to that exhibited during the Ebola outbreak. “People think that when they visit health facilities they might be mistakenly suspected as COVID-19 cases and they may be quarantined. There is also a perception that our health workers have COVID-19 and that the health facilities are a risky place that they might get COVID-19even by just going there,” he described.
Dr. Larbi believes that scientific studies are necessary to determine the exact behavior and causes, and to find solutions.
COVID-19 pandemic could erase 20 years of anti-malaria progress
The hospital attendance downtrend poses significant concerns among organizations fighting malaria. On April 23, the World Health Organization urged countries to move quickly to save lives from malaria and minimize disruptions to malaria prevention and treatment services during COVID-19. In that call, Sierra Leone was commended, along with Benin, Chad, and the Democratic Republic of Congo, for initiating their insecticide-treated net (ITN) campaigns despite the challenges of COVID-19. The WHO warned that if the ITN campaigns were suspended in 41 countries worst affected by malaria, the number of deaths from malaria may double compared to 2018. “This would represent a return to malaria mortality levels last seen 20 years ago,” WHO stated.
Dr. Alhaji Sayni Turay, Assistant Program Manager for Sierra Leone’s National Malaria Control Program, confirmed that anti-malaria campaigns were not suspended during the COVID-19 outbreak because malaria is an endemic killer disease, meaning that it is a constant threat to the people’s health. “It is killing lot of people in this country, especially pregnant women and the under 5s [children under the age of 5 years old],” Dr. Turay said.
The WHO declared the coronavirus outbreak a pandemic on January 30. Two months later, on March 24, Sierra Leone declared a 12-month long state of public health emergency and confirmed its first known case of COVID-19 on March 31. Travel restrictions and other measures were announced on April 9, as malaria-fighting organizations had to scramble to continue their programs ahead of the rainy season.
Malaria may be more dangerous than COVID-19
Dr. Turay explained that suspending the anti-malaria campaigns because of the pandemic could have had disastrous consequences. Therefore, his teams had to adjust to special travel restrictions and safety measures and push on with the anti-malaria programs nationwide.
“In fact, malaria is more dangerous than the COVID-19. If you take the statistics of malaria to check how many deaths we have recorded as a country since COVID-19 started, you will find that the latest [as of July 27] death of COVID-19 is 66,” Dr. Turay emphasized. He stated the number of malaria-related deaths is significantly higher.
Fighting an endemic during a pandemic
Although the coronavirus movement restrictions were somehow relaxed for anti-malaria fighting groups,Dr. Larbi noted that the constraints delayed some malaria-prevention activities. Even to simply move the anti-malaria materials from the port and to the distribution point, the teams needed special permission from the government. Moreover, obtaining travel permits was not always a smooth process and it contributed to delaying some activities.
Restrictions also had an impact on whether anti-malaria staff could meet health workers at remote health facilities to provide mentorship on effectively fighting malaria. “Because of COVID-19, we couldn’t do that until after the restrictions were recently lifted or at least eased. Now, we have started in earnest to visit our health workers, holding meetings, of course with the COVID-19 cautions being applied,” Dr. Larbi stated.
However, despite the challenges, 4.6 million bed nets were distributed across the country. “This distribution came at a very crucial time when COVID-19 was confirmed in the country,” Dr. Larbi said, and ahead of the rainy season.
“I am not an infectious diseases expert, but what I know is that every disease kills. And so, it is not either or, what we need is that while working together to get COVID under control, we should also not forget other killers, including malaria. So, we need not to focus on one at the detriment of the other. We need to work together even as COVID is raging in the country, the government is making all efforts to get COVID under control and we should not forget the other diseases that are exerting huge toll on the lives of our people.”
A warning for the rainy season
The current rainy season presents a double jeopardy, as more people will become infected with the malaria parasite, but fear of quarantine may keep people away from seeking professional healthcare.
Dr. Turay warned that health officials must look into mosquitos’ breeding pattern, as more rain accumulations and dirty potholes will increase with the rainy season. Mosquitos breed, or reproduce, in dirty water accumulations, most often found in the slum communities.
Sorie Alpha Kamara, acting Environmental Officer at theFreetown City Council (FCC),agreed that lack of sanitation can lead to the transmission of both malaria and the new coronavirus, because both diseases are associated with poor sanitation practices.
Kamara stated that in the early stages of the COVID-19 outbreak,Freetown MayorYvonne Aki-Sawyerr, ordered an intensive cleaning exercise, but only about 60% of the municipality drainages were cleaned. It is now up to every single person to continue to clean their compound and properly dispose of the trash to prevent dirty water accumulation.
The unlearned lessons of the Ebola outbreak
The negative impact of tough restrictions during healthcare crises has been documented during the Ebola outbreak in 2015. Surveys conducted by the United Nations (UNDP) in Guinea, Liberia, and Sierra Leone found a substantial decline in the number of persons seeking healthcare because they feared Ebola transmission and quarantine. A second study found that, “mandatory curfews, border closures, and disruption of transportation routes made obtaining medical services or continuing drug therapy challenging. The reduced demand for and availability of healthcare in the Ebola-affected regions exacerbated the severity of illness and number of deaths caused by malaria, HIV/AIDS, and TB.” (Parpia, et.al.Effects of Response to 2014-2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa).
More acute appears to be the lack of trust in hospitals, the healthcare staff, and the quarantine process, all of which have been documented in 2015 during the Ebola outbreak and resurfaced almost in identical form in 2020. Five years later, these problems have remained unaddressed, at the unnecessary cost of many lives.
(MamusuTuray Senesie of Radio Wanjei Pujehun contributed to this investigation.)