The first case of COVID-19 in Sierra Leone was confirmed on March 31. As a pediatrician working for Médecins Sans Frontières in the country, I’m concerned that the coronavirus pandemic may indirectly increase child mortality as parents delay seeking medical care for their children.
I work in MSF’s Hangha hospital, which provides emergency medical care to children under 5. MSF built the hospital to help reduce Sierra Leone’s high level of child mortality — currently 105 deaths per 1,000 live births. By comparison, my home country of Italy has a rate of 3 per 1,000 live births. From its opening in March 2019 until the end of May 2020, the hospital provided over 7,900 consultations in its emergency room; over 3,300 of these were for children with malaria.
Overall service loss in individual countries for women, children, and adolescents varies from 10% to 60%, according to the Independent Accountability Panel on Every Woman, Every Child, Every Adolescent.
In April and May of this year, the proportion of children arriving at our hospital for triage who were “red cases” — patients in critical, near-death condition — was twice as high as in the same period last year. This increase in late presentations came after Sierra Leone’s first confirmed COVID-19 case at the end of March.
When their children are sick, some parents wait until the child is very unwell before bringing them to the hospital. If children arrive late, then sometimes there’s nothing we can do for them. When this happens, I feel powerless.
I remember one child stopped breathing at the entrance to our triage in the emergency room. He had come by ambulance from a small rural village three hours away. Despite all our attempts at resuscitation, the child passed away due to cerebral malaria. The child’s mother told me he had had a fever for three days and then got worse; he started having convulsions at home and lost consciousness.
It was heartbreaking but also made me angry — not toward the mother but the situation. If the child had come sooner, he might have been saved.
An invisible barrier: Fear stops parents from sending children to clinics
Some people are scared to access health facilities as they fear they will contract COVID-19, while others believe they will be put in isolation regardless of any test result. Fears may be exacerbated in Sierra Leone due to the traumatic Ebola outbreak of 2014 to 2016, when many people who were admitted to health facilities never returned home.
Misinformation and fear can spread very easily in remote villages where people don’t have access to radio or other telecommunications. Each day, MSF health promoters go into villages to address rumors, clarify information, and explain how diseases such as malaria can become deadly without early medical intervention. They go from house to house to speak with people directly and also hold meetings with local authority figures to get their messages across. But this process takes time, so fears don’t subside immediately.
We are now entering malaria season, which is deadliest for young children, who account for 67% of malaria deaths worldwide.
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The coronavirus pandemic is a global tragedy, but the consequences for children could be terrible if resources are diverted from malaria. The World Health Organization already predicts a doubling of malaria deaths in sub-Saharan Africa if regular prevention and treatment actions are suspended.
Here in Sierra Leone, the government announced its decision to continue its pre-pandemic plan of distributing 4.6 million bed nets to people across the country, with MSF providing logistical support in the chiefdoms of Gorama Mende and Wandor. By sleeping under bed nets, people reduce exposure to mosquitoes and hence malaria, but this does not eliminate the risk completely. All countries with a high prevalence of malaria should engage in prevention activities that reduce cases and lessen the strain on health facilities.
Alleviating fears by building trust, using mobile clinics, and teaming up with community health workers
Faced with the coronavirus pandemic it is important that health actors adapt their activities for malaria and other diseases. If health facilities are overloaded or people are scared to visit them, community-based care allows people to receive treatment without the need to travel.
Where I work in Kenema District, MSF runs mobile clinics in remote villages, diagnosing and treating people right in the community. We have increased the number of villages we visit and are rapidly expanding to reach even more, prioritizing those that are farthest from health centers and that have the largest populations.
In Gorama Mende and Wandor, MSF provides medication, training, and other support to Ministry of Health and Sanitation community health workers who provide medical care directly in villages. These CHWs can diagnose and treat malaria using rapid diagnostic tests and medication so that people can recover from malaria at home in just a few days. MSF has increased the number of CHWs we support from 35 to 47 and hopes to reach 65 by the end of the year.
The new challenges that COVID-19 poses show how the pandemic’s indirect effects are a threat to children. In countries where child health is already precarious, it is vital that health activities are continued and adapted to respond to this new reality. At the same time, we must work closely with communities while listening and responding to their fears so that parents feel confident to seek and receive health care for their children even in the midst of the health crisis.
Dealing with COVID-19 requires a huge response, but serious diseases still exist and will not stop causing preventable child deaths just because our attention is elsewhere.
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