August 13th, 2014 by Rob

Most Ebola fatalities won’t be infected by the virus. There are thousands of victims in the worst hit regions of Ebola’s largest recorded outbreak, but they have not died because of the virus itself. They have died because they have avoided medical care for fear of contracting the virus. For every person who contracts Ebola, ten people will die nearby from other preventable conditions.

While health workers in the middle of the outbreak are focussed on containing and treating the current outbreak, the healthcare for the rest of the population in those areas is suffering. I needed to calculate what these additional fatalities are – the silent victims that no-one is counting – so I am sharing them in this post to let the world know that they exist. Some of the worst hit areas are in the South East of Sierra Leone. I helped install solar power at locations there in neighboring Liberia a few years ago. In the time since, I worked for Energy for Opportunity, an NGO that has installed most of the solar power in the region, including at many of the clinics now treating the patients.

Clinic in Liberia. This health  care worker has vaccines in the cooler strapped to his bike. Using the clinic as a base, he cycles to the surrounding villages to deliver the vaccines. Between the quarantine of clinics; the refocus of the attention of the healthcare professionals towards ebola; and the population's distrust of healthcare professionals, services like these are suspended.

Clinic in Liberia. This healthcare worker has vaccines in the cooler strapped to his bike. Using the clinic as a base, he cycles to the surrounding villages to deliver the vaccines. Between the quarantine of clinics; the refocus of the attention of the healthcare professionals towards ebola; and the population’s distrust of healthcare professionals, services like these are suspended.

The clinics are hubs and lifelines for the populations in the region. The children were playing with a cardboard box that we had used to ship equipment when installing power at a health clinic in 2007. They stood to attention when the healthcare worker on the bicycle came along and said a few quick words to them in a language that I never learned. He was clearly respected, whatever he said. Our solar power installations were providing reliable electricity to ensure that the vaccine fridge remained a stable temperature for the vaccines before they were delivered in the clinic and by bicycle to the surrounding area. This is how the clinics in the area should look, not the hazmat suits that have been in the news.

I took the picture above in LOFA, Liberia, but for this post I’ll focus on three of the worst hit districts in neighboring Sierra Leone: Bo, Kailahun and Kenema.

These three districts are among the worst hit in the current outbreak. The districts have a combined population of about 1.2 million, which is about a fifth of Sierra Leone’s population.

Non-Ebola fatalities in regions with an Ebola outbreak

The Ebola fatalities are probably about 400 in total across the three districts. Without a further outbreak, the final number will be close to this. People will carefully calculate and record the actual fatality rate after it has run its course. No-one is keeping record of the other avoidable fatalities in these regions over the last few months, and no-one will go back and record them later.

The best that we can do to track the non-Ebola fatalities is look at the populations in the district and the known mortality rates.

With 45,000 births in the three districts per year, that’s about 4,000 in the last month. The country has a high infant mortality rate of 114 per 1,000 births. This means that about 430 infants died in the last month, almost all preventable.

Malaria is the leading cause of death in the country. It is rarely fatal when treated, but contributes to 15% of deaths in the country. With a death rate of 16.9 per 1,000 people, this means that about 260 people have died of malaria in the region in the past month.

Both have risen in the absence of healthcare. It is difficult to calculate how much the infant mortality and malaria death rates have risen near the Ebola outbreaks. If we assume that healthcare has returned the 1950s standards, it means that 880 infants died and 470 people died of malaria in the last month. That’s 450 more infant deaths per month and 230 more deaths due to malaria.

With other causes, the full number of preventable deaths will have risen more than 1,000 per month. Infant mortality and malaria are the two largest figures, but there will be many more preventable deaths. For one, the maternal mortality rate is the highest of any country in the world, and no doubt many more births are now at home instead of at clinics.

The crisis and fear of clinics will last several months. This means that for the 400 deaths to Ebola, that there will be 4,000 deaths in the same region from preventable causes, mostly young children. So even in the worst areas, for every person who contracts Ebola there are ten people nearby who will die from other preventable conditions. We can’t predict who they will be but we know they are there.

The right decision to act

It feels cold to calculate deaths through abstract statistics, but it is all we can do when faced with tough decisions and no capacity to track all illnesses directly. This week I have been faced with decisions about evacuating colleagues and families from the region and with crafting messages to the affected populations. They are not easy decisions.

I have seen criticism about governments closing international borders and blockading internal roads too soon or too late, and similar criticisms about limiting travel and airlines. Every person who has made a decision to close regions has known that they were condemning many more people to worse healthcare. I think this has been lost on many of the critics. I am grateful to the people who made these tough decisions, knowing that it would have weighed on each of them heavily.

The decision applies to more than just border closures. When broadcasting to the affected region, there is also the potential to do more harm than good. If the communication of information about Ebola causes too much caution or fear, it can create a bigger, silent crisis. If a moderately bad message to the population increased fear enough that people would wait just one week longer after the outbreak has run its course before being comfortable enough to visit a clinic when needed, then the death-toll from that one extra cautious week would still be greater than the death-toll of the outbreak itself.

The sacrifice for all of us

The people who died in Bo, Kailahun and Kenema from conditions that would otherwise have been treated, died for the rest of humanity. Thousands of people will die over this period so that Ebola would not spread to the rest of our world and most will be children. I wish they were playing with cardboard boxes instead.

- Rob Munro
August 2014

Sources:
http://en.wikipedia.org/wiki/Demographics_of_Sierra_Leone
http://www.aho.afro.who.int/profiles_information/index.php/Sierra_Leone:Analytical_summary_-_Health_Status_and_Trends
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60034-8/abstract