INFECTIOUS DISEASE Who are Sierra Leone ’ s health security efforts for? After the west African Ebola outbreak of 2014-16, international agencies have helped to establish disease surveillance operations in the region, find Mara Kardas-Nelson and Raphael Frankfurter, but Sierra Leone’s health security efforts may not be improving outcomes for patients Mara Kardas-Nelson journalist 1 , Raphael Frankfurter doctoral student 2 1 Berkeley, California, USA ; 2 University of California, San Francisco Department of Anthropology, History, and Social Medicine, USA Sahr Tengbeh is a nurse who oversees a government clinic in eastern Kono, a remote forested region of Sierra Leone near where the 2014-16 Ebola epidemic is thought to have emerged. Every Monday he rides his motorbike for several kilometres until he finds a phone signal. He carries what he considers the most important of the many forms he fills in as part of his clinical and administrative duties. It tallies the number of patients who visited the clinic in the past week displaying symptoms of diseases considered “high priority” by the Ministry of Health and Sanitation and its partners, such as the World Health Organization and USAID. Calling the district headquarters, about 60 km away, he reports the numbers of patients considered potential public health threats. Tengbeh ’ s hours of counting, motorbike riding, and calling contribute to Sierra Leone’ s national disease surveillance system. Throughout the country, thousands of such health outposts generate massive amounts of data that eventually end up in the capital, Freetown. Focus on data This focus on collecting and analysing data has emerged in the wake of the country’ s recent Ebola outbreak, which, together with outbreaks in Liberia and Guinea, constituted the world’ s largest epidemic of the virus. The rapid spread of Ebola, across borders and initially undetected, showed how disease flare-ups in countries with weak healthcare systems can quickly become global problems. Sierra Leone’ s health authorities and the global health community worry that this could happen again. Funders such as the UK Department for International Development, the World Bank, and USAID have together offered hundreds of millions of dollars over a five year period to the west African region to support disease detection and related efforts as part of a global emphasis on “health security. ” Each organisation defines health security differently and so there’ s no standardised set of interventions, which may include mass animal vaccinations or promoting better handwashing and hygiene. Broadly, health security efforts seek to identify and mitigate disease threats early, before a potential spread within countries and across borders. This is exemplified by the Global Health Security Agenda (GHSA), initially launched in 2012 and now endorsed by 64 countries. The US championed GHSA in response to potentially fast spreading diseases, such as severe acute respiratory syndrome, avian influenza, and HIV. The agenda seeks to support countries to better “prevent, detect, and respond to infectious diseases. ” Emphasis on disease surveillance The agenda focuses on disease surveillance, laboratory testing, workforce development, and other such disease preparedness and emergency response systems. On the ground in Sierra Leone, however, efforts primarily translate into a renewed emphasis on disease surveillance. The country has overhauled its Integrated Disease Surveillance and Response system (IDSR), a regional framework for disease detection implemented across Africa from the mid-1990s. In its current iteration of IDSR, Sierra Leone has identified 26 “priority diseases, ” 18 of which are deemed dangerous enough to be immediately reportable. Tengbeh ’ s efforts are considered part of this new IDSR system. He and thousands of other health workers across the country watch for and report on diseases that might emerge from wildlife, livestock, and mobile human populations in both rural forested regions and the country’ s increasingly overcrowded cities, where, given limited clinical care, diseases can spread quickly. Each week, aggregate data are analysed for emerging trends at the country’ s Emergency Operations Center in Freetown. A weekly meeting is conducted by the Ministry of Health and Sanitation and partners, such as WHO and the US Centers for Correspondence to: M Kardas-Nelson marajenn@gmail.com For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2018;363:k4196 doi: 10.1136/bmj.k4196 (Published 8 October 2018) Page 1 of 3 Feature FEATURE on 8 October 2018 by guest. Protected by copyright. http://www.bmj.com/ BMJ: first published as 10.1136/bmj.k4196 on 8 October 2018. Downloaded from