Dr Evans Majani Liyosi is the Country Representative of the World Health Organization (WHO) in Sierra Leone.
In this interview with Politico, he spoke about the UN health agency’s role in the country’s response to the ongoing Covid-19 pandemic.
Besides the technical support the WHO provides to the government through the Ministry of Health and Sanitation, the National Covid-19 Response Center (NACOVERC) and other Ministries, Departments and Agencies, Dr Liyosi has also been a key adviser to President Julius Maada Bio and his government from the onset of the response efforts. He explains how himself and his organization helped shape Sierra Leone’s response strategy and he delved into what he thinks the country should focus on to flatten the curve of transmission and meet post-Covid-19 challenges.
The interview was conducted by Kemo Cham, and Mabinty M. Kamara helped with transcription.
Politico: This week we will clock hundred days since Covid-19 came into Sierra Leone and it has been a rollercoaster ride. WHO has been at the forefront? What has it been like for you?
Dr Liyosi: First of all, I would start from when we first got the notification that an outbreak had occurred in China to the point when it was declared a disease of public health importance. You know it falls under global health security and Sierra Leone as a member of WHO we had to play a big role in preparing the country ahead of the transmission.
We wanted to ensure that the country has testing capacity for Covid, ensurile that the airport was ready for screening new people who were arriving, ensure that quarantine measures were put in place for people who were seen to have a higher risk, and ensure that surveillance teams were prepared, and communication messages were put in place.
So Sierra Leone continued to be ahead of the game in terms of preparedness.
We saw further very robust measures taken by the government when they realized that globally and even in Africa cases were increasing, including in our neighboring countries – Guinea and Liberia. So the government did very well, through His Excellency the President, by closing the airport.
Closure of the airport and international borders actually delayed the first case and we hanged on for a while, until eventually we got the first case which was actually an imported case. And we were expecting to get an imported case.
The strength the Ministry of Health and the government had was the capacity to be ready for testing, the capacity to have the test kits, and at that time Sierra Leone was one of, I think, top three countries in Africa that had testing capacity. So we were really ahead of time.
Immediately after we had the first cases in the country, and as I said WHO played a big role even in preparing the laboratory team, we took the first group of medical experts from this country – three of them - specialist doctors, those that were eventually deployed at the 34 Military Hospital and now trained and mentored other people. We took them out of the country to Brazzaville (Republic of Congo) to join other group of experts for training on how to manage Covid. So it is that group of clinicians that came back to Sierra Leone to now do a training of trainer’s for others.
Other than that we also played a big role in training sample collectors across all the districts. We were training a couple of them in each district, so that in case any suspected case was reported in any district, they were able to collect the sample. It was not just training, it was training and giving them the materials to collect samples and training them on how to transport those samples and establishing this transportation chain into the city.
So immediately we had the first case, and I was happy that the sample was collected, tested and confirmed to be positive, we had a lot of fear. So we had now to fight COVID and fight fear among the population, which was not very easy.
You could realize that the first cases that occurred there was a lot of stigmatization especially to their families. I was very vocal on protecting those people and their families.
Many people still believe that that initial policy of protecting patients' identity played a big role in where we are today – proliferation of cases.
General protection is what we needed to do and put up robust measures to ensure that we delay a huge transmission.
With all the preparations you mentioned, we ended up where we never wanted to be, with huge cases. What happened, do you think?
Eventually we knew we would have a case. And myself I kept saying, it’s not if, but when. The only thing that was there was to try and delay and the delay was giving us time for preparation.
So the first cases came in the moment there were those last flights that came in and the cases that we started struggling with were those cases that just sneaked in around that time. So there was no way out, given what was happening around and Sierra Leone was not an Island.
It’s not also fair to say that we were expecting more cases and we got few cases. What brings us where we are the measures that were taken to delay and to slowdown the transmission. But if everything was just open, the transmission would have set in and we could not even manage the number of cases.
I am actually thinking we have more case than we should, but it seems you believe that the preparations we did worked. You mentioned the first case which we know was an imported case, but the second case we still don’t know where it came from, whether it’s linked to the first case. If they were not linked, where did it come from?
That is why I’m saying, you need to look at the strategies that were put in place at that time. Most of the time we were testing people who were arriving and put them in quarantine, and I remember at that time even the quarantine facilities were compromised. We made a lot of noise to ensure that quarantine measures were strict and people followed rules.
So you will discover that there were no linkages even among the first twelve cases, and that in itself explains the fact that transmission had already set in. But because we were not testing everybody like blanket testing, it was more targeted testing, we could not be able to pick them up. We’re were only able to pick them when they were coming up.
Was that because we did not have what is required to test, because you already said we had the testing capacity?
No. The strategy we were having was that we were mostly testing people who were in quarantine, because of suspicion. And you will know that this Covid also was a surprise to everyone and it’s not a disease like any government prepared for last year. So even in terms of testing capacity, the country did not have like a huge testing capacity to be able to say let’s test everybody. So it was a very conservative approach based on the test kits we had at that time.
That was the weakness…
I wouldn’t say it’s a weakness. It was a new disease. We didn’t even have enough test kits globally. Every country was looking for the same. So it’s not that the countries didn’t know what to do. They knew what to do, but the tests were not even out there in the market.
Maybe one major thing I should first mention, in terms of how WHO helped, one and the most important thing was to help the country in developing a Covid strategic plan, where everything is now pegged and also helped the country in procuring some of the test kits and IPC materials ahead of time. We helped the country to work on few prediction models that the country could face and that is what we have actually used to bring all the partners onboard. We looked at what could be the worst scenario for Sierra Leone and what could be a fair scenario. We looked at how we could scale up response to Covid, in terms of looking at the bed capacity, in terms of looking at different quarantine measures, in terms of training health workers, contact tracing, all that. So that I would say is an area where we really played a bigger role as WHO.
If we look at what happened in neighboring countries like Guinea, we can say the preparations here did pay off. But then a question that lingers in the minds of almost everybody is that when we shut down, we were having just few cases, and now we are talking of opening when we are recording an average of nine or ten cases a day. Does this make sense to the WHO?
You need to look at two things: public health approach versus the economy. You need to have a kind of a balance between making robust response to public health but also ensuring that the country is not dying economically.
I have been part of the team that give advice to the government. From the very beginning I was very vocal to the President, I was very vocal to all the government and I was very vocal to the donor community, including in the big pillar meeting, telling them that the moment we had a few cases, we needed to come stronger on especially the lockdown.
If we have to put a lockdown, you need to put a lockdown that makes sense. A lockdown that makes sense is a lockdown of about two to three weeks. Unfortunately that did not happen and within a very short time, we started moving from clusters of transmission to community transmission.
When I realized that we now have community transmission, some of the cases had no link to each other’ like if you look at the cases for last week [June 29 to July 5] in Freetown, there is no linkages. Each of the cases are independent of their own, meaning we have now community transmission taking place.
So it makes no sense to even say we should now lock our international borders. No. It doesn’t, because what are you preventing? You already have more cases taking place within the community. So the best thing you can now do is go on to other strategies. That is where you started saying social distancing, wearing of [face] mask, sanitization, community engagement, huge campaign on risk communication and awareness, and making deliberate measures to educate the public, engaging the government, the opposition and the civil society, together, making Sierra Leoneans know that Covid has no political boarders, whether you are in opposition, whether you are in the government, it doesn’t matter. We all need to come on one platform and be patriotic as a country to address a common enemy – Covid.
So dispelling fear of being tested if you are Covid positive has been one of the biggest challenges, and trying to educate people that 81% of this disease is asymptomatic. So when you have the young people who are sick, they feel nothing, yet you continue to transmit the virus, you cough, you sneeze, you can easily transmit to any other person.
It’s not like WHO has been against the use of mask, but WHO was very conscious on how you approach the use of mask. Mask is used mostly in health centers, where you are protecting people who have been infected. You want to ensure that they are not coughing and transmitting to people around. So the first thing that came into our mind is let’s prioritize the health workers and those who are infected. By that time we didn’t even have enough face masks in the country. So you want the little you have is used by the right person.
Then, there was really not enough documentation to show that face mask actually saves life and as studies have continued to evolve, what has come out is that you know they protect you from spreading to others. And if you look at our new release from WHO, we are now supporting the use of face mask all over and mostly it’s to protect health workers and to stop those who are infected from spreading to anyone else. But then, you need to have the proper mask. You need to wear it very well and it should be in three packages…otherwise it just gives a wrong sense of confidence. People wear on mask and they don’t cover their nose.
Social distancing is one of the most used words throughout this COVID-19 pandemic. Public transport and the markets, it seems nobody has answers to them.
I personally have visited all the crowded markets to see them for myself. I went on that Lumley Roundabout market, to see how people trade and to see how many people were wearing masks. It was pathetic.
I moved into the public transport to see what was happening. It was not good. And I had been extremely strong to the government at the highest level – ministerial level, to all the partners that I have worked with in this country, including the National Coordinator, that it’s not about saying people should wear mask. We need to go beyond that in enhancing those measures, educating our security apparatus, educating people who manage markets, so that whoever is selling and whoever is buying, they have masks. And if people are going into a market place and they don’t have mask, there should be someone there ready to provide them the mask. So unless we strengthen enhancement of measures by security apparatus, we will not succeed. I am just happy, somehow, the kind of started happening in some places, but it is an area of weakness that we should continue to strengthen – enforcement of measures.
It’s actually enforcement of IPC measures, in the hospitals, by our health workers, in the markets, by the general public, the common transport, by all transport users, and the security apparatus should be enabled to also do that. Big, big package of risk communication should be made everywhere. In fact, what I would like to see in this country is to put sign posts in public places: Are you wearing a mask? If not, is your neighbor wearing a mask? Ask the driver to stop the vehicle and let the person get out if he is not wearing a mask. Those kind of messages. You enter a vehicle and see something. It touches those who are able to read.
So those kinds of measures that target everyone, measures that have to do with enhancing, when you bring them together, it can work.
A lot of people said Sierra Leone, Guinea and Liberia had a unique advantage in tackling Covid-19 because of their Ebola experiences. Have you seen this at play here?
Personally I was not here during the Ebola, but I can surely tell you that these countries had big advantage. People had memories that they brought over into covid. People knew the issue of sanitizing. I compare Sierra Leone with other countries like in East Africa that had never seen this kind of diseases. Here you even had structures to start with. I did not struggle to establish a coordination forum. We had the EOC still alive, working. We had people who had worked in that EOC and had memories of what they did.
The only difference I saw was people approaching Covid with an Ebola mentality, creating a lot of fear. Yet Covid has a very low death rate, compared to Ebola. There was a lot of fear and that is why the first cases were very stigmatized. It was very difficult for them. They approached Covid with an Ebola mentality and that is where now risk communication had to come and play a big role, tell people that this disease is actually more lethal for people who have other infections and also is affecting more elderly people than the youth.
So it took time to educate people and it took time for even people who had been told you are positive and sees himself to accept that. And until that thing is not totally gone, but it is something we have to continue to educate the people about.
We saw a lot of studies during the 2014-2016 Ebola epidemic. Is the WHO involved with any study on Covid-19 in the country?
We have a couple of countries that are involved in trials and I am happy that Sierra Leone is one of them. As WHO, we are supporting Sierra Leone in participating in therapeutic trials. We already have those medications in the country. We have already gone through the ethical approval of Sierra Leone. We have already allocated small budget that is supporting this therapeutic study.
So Sierra Leone is among about four countries that are actually participating in these trials.
Therapeutic trial means trying to see how different drugs can be effective against Covid.
We have a principal investigator, 34 Military, Jui and Kenema hospitals are some of the facilities that we have earmarked to use and is moving very, very well.
When HIV came to Africa, and a lot of studies were done in Africa to try and get cure for HIV, eventually he had all these ARVs coming. But then it was only for those countries that had the resources to buy. But African countries that participated in those, because of weak economy, we were left out. This time the approach is not like that from WHO. We continue to emphasize that countries that deliberately make efforts to participate in any therapeutic trail, they should also be remembered when the drugs are out, to also be prioritized. So this is a big noise we are making everywhere to ensure that we have a balance.
There are many things that WHO is trying to do to bring about equity globally. For example, we have now established a Covid portal for purchasing Covid related commodities, from ventilators to oxygen concentrators to IPC materials to test kits in a common way. The producers are one, everybody is buying from the same spot. What we are trying to do is to have fairness. It’s not that because a country has all the money then they can buy the whole production. It is controlled.
So Sierra Leone can buy, guinea can buy, Liberia can buy, everybody can have access, and you cannot over buy just because you have money; because the production is not as what you want, you have to control what goes where, if not you have rich nations emptying all the stock and there is nothing for the poor nations.
So as WHO we are really controlling that portal of supply of Covid materials.
We have also looked at how we are challenged in Africa, especially after closing the boarders. I personally negotiated into hiring these WFP flights; they are called humanitarian flights, aimed at bringing two things: bring in supplies. All those Alibaba test kits and IPC materials have been made possible because of WHO/WFP negotiations. And I was really happy when I put this to the government of Sierra Leone and I was discussing with the Minister of Health, Dr Wurie, as well as the minister for Defence. They really supported me, until we had that approval from the government and the flight started coming in.
We have seen quite a change. We continue to receive supplies, including today (Tuesday July 7) when we are receiving extra oxygen concentrators from WHO, including last week when I brought in more test kits from WHO. And you will now see a lot of things coming in to scale up the response.
You mentioned the Chinese donations. You must know that this whole thing has been shrouded in controversy and it counts a lot, if you understand why people aren’t going to hospital. Some believe that the Chinese kits are either infected or that they are not even good. And we have heard reports from other countries that justify this, for example the Tanzanian president.
Do you think this is important and how do you think we can address it?
Those kind of discussions are not helpful in this situation. We have to be very careful on how we package messages from politicians. It is good to follow a scientific approach that is evidence based. Politicians have their interests. Politicians may want to derail you from the real sense. If a politician realizes that things are not moving well in his territory, he wants to divert your thinking and attention.
So for us at WHO, we base our argument on science, on epidemiological studies that you can actually prove. A test kit that works is a test kit. The gold standard for testing Covid is through PCI. We also have the Rapid Diagnostic Test, they can give you a positive but their sensitivity is quite low. So whether it’s coming from China or Germany, when you run quality control using independent tests, it will give you the same result.
So I don’t like to make judgment based on what politicians are saying, but I like to make judgment based on science and studies.
Finally, you have emphasized on the need for risk communication and the need for social distancing and all that. But is there any other area in the response that you think the government and its partners should focus on more?
We are today in a community transmission. Covid is going to be with us for a while, until we have a vaccine and a cure that can take us across the bridge. So what we are doing [Yesterday (Sunday July 5) I had a very long meeting here with the National Coordinator] is to come up with structures to increase the testing capacity in this country for a thousand and above. I have already given resources to train 30 more scientists, because the weakness in Sierra Leone’s response is human resource. So what WHO has done is that we have committed ourselves to train 30 more lab technicians to test. We have identified the number of laboratories. We have today five laboratories, but as I am talking to you, we are supporting the opening of more laboratories in Makeni, Bonthe, Kambia, and we are putting structures in place to open the airport; what you need to do before you open the airport, those measures that need to be in place, this is what we spent the whole Sunday doing.
I have volunteered to ensure that the 30 laboratory scientists that will be trained, I will continue to support them with incentive until the end of the year. That’s six months. This is because we want to train but also keep them. And we want to ensure that geographically they are well distributed in the country. And we want to ensure that before the airport is opened, we have provided our technical advice on what needs to be in the airport, including training, luggage handling, dealing with frustrations that can come whereby you have 100 people and you don’t know what to do with them, while journalists are with you.
So what we are telling the government, and I said I am giving brifing up to the highest level of government, is: do not open the airport when you are not ready. Have the necessary measures to protect the health workers, the cargo handlers and the people who are arriving, including testing and releasing the results within 24 hours. Knowing some people are coming to Freetown but others are going to the districts, you cannot afford to keep them hanging for long.
At WHO, our strength is on analysis, strengthening perseverance and doing predictions. We supported the country in moving from 24 beds we had at the 34 Military Hospital to now more than 800 beds capacity, of which not even 50% is filled.
I just looked at the data today. We have 848 beds, but today, as I am talking to you, only 282 beds are occupied. So more than 50% of beds not occupied. For me that is good confidence.
And we have moved from just having 34 Military Hospital to having eleven other treatment centers in the country that together come to this 848, include other centers in districts like Kono and Kenema, where patients can be admitted and be treated.
And in the very beginning, Freetown was the epicenter of the transmission. But we have seen the transmission defused into the districts. We have move from Freetown having more than 74% and now it only got 50% of the cases. All the other cases are in the districts. The big ones are actually in Kenema, Bonthes, Bo and Kono.
And that’s worrying, isn’t it?
No, we have a community transmission. And once it sets in to a community transmission, the best you can do is to increase the testing capacity, like what we are now doing. This is deliberate, because the president emphasized to me as the head of WHO: “we want you to support the country in increasing testing”, and that is what I have actually spent much of my energy on. I met him a week ago. I have spent much of my energy to work in that direction.
So we will have these 30 trained. I just recruited one international staff to mentor and support them. And now I am brining in again two international lab people who can actually work on the desk day and night and support.
Even me as the head of WHO I have had casualties from my own office. The doctor epidemiologist who went to investigate the first cases in Bonthe, he also got infected there.
When Connaught Hospital was closed, I am talking about the lab, I’d just recruited a new lab technician. There are many stages in doing a covid test, and because you want each of the lab technicians to have confidence, you can run the test from the very beginning to the end. Unfortunately, during this, he also got infected in that facility. So these are some of the consequences that you get as a people.
So I have had two doctors get infected, including the lead from the lab, while doing training, but he was discharged yesterday and he is back ready to help us now to scale up the response.
There is a question you asked about fears of a lot of cases in Africa. Look at Africa as Africa, in the sense that… if I can compare Sierra Leone to London. That is a city that is moving very fast. In an hour, you can have may be 30 percent of the population of London who will have moved from one place to another. But when you look at Sierra Leone, we have a very big rural community. The interaction is very much at the family level. But in these urban cities, the rural communities is more urban. Someone will get to a tube station, move from this side … the chain of movement is so high. So those are some of the reasons that they actually have slowed donw the dynamics of the transmission in Africa.
I informed you that we played a big role in developing the first strategic Covid plan for Sierra Leone. We have also played even a much bigger role in the new revised strategic plan for Covid. It’s just about to be launched. When you look at the first plan and then you look at the new plan, the new one is really improved. It’s taken care of even people in prison. It’s taking care of certain communities, including psychiatric patients, it’s looking at a holistic approach, working with all the other ministries. And it’s looking at Covid as thing that is not likely to end now.
Then how do you strengthen the health system to be able to cope up? So the new strategy is looking beyond just Covid. How you use a bad situation to improve your health system. Every investment, every single dollar that comes into the country, how do you ensure that you are buying something you will use today and tomorrow?
Yes, you have a bad misfortune of Covid, but you can also use this as an opportunity to strengthen your health system.
We are also looking at how many people are likely to die from Covid, compared to Malaria, the raining season is just setting in; compared to vaccine preventable diseases like measles, tuberculosis. And that is why, again, I have been very, very vocal, that we should not just focus on Covid. Mothers are dying because of maternal mortality, child mortality, and malaria is the biggest killer. In this country when you look at the daily deaths from malaria is between 50 and 120, every week.
Remember from the time we started the response, documented people who have died of Covid is only 63 (as of July 7). But every week we lose 50 to 120 people to Malaria. So which is a bigger enemy?
So we moved at also making sense to ensure that we continue other health services, that women can go and deliver in a hospital, that you can also protect health workers who are offering health services, otherwise you will crumble the system and it will be very, very bad.
So as WHO we also try to speak for the government in international forums and to the donors, and try to let the donors understand that they the need to help Sierra Leone. We have just been working to ensure we bring in the Cuban doctors. I think they will come this week, because the number of health doctors in this country is quite low.
We are actually working on strengthening the president’s legacy of human capital development, looking at how many doctors you need. So quietly outside Covid but we are trying to think ahead, how many lecturers do they need, how many doctors, nurses, midwives, psychiatrists… can be produced by this government in five to six years. So this is happening underground. It is not visible.
I was very happy, I met the president the other day. His big ask from me: “how are you as WHO helping me to address this big systemic gap of human capital development?” Personally, I was happy this was coming from him.
We did what we called heath labor analysis, that looks at how many doctors you have, how many is recommended by WHO, but realistically how many can you produce. In what time frame? Do you have the universities? Do you have the lecturers? Do you have the teaching schools where they can go and do practice? Do you have people in those practices, who can mentor them? Do you have theatres, equipped, that can offer as training facilities for obstetricians or gynecologists?
But I think we will get there because it starts with a plan, allocation of resources, political commitment and patriotism. And patriotism across political divisions of opposition/government. This does not help for continuity of certain things. A government should have a strategic plan if you are development a human capital, so the number of teachers, whosoever comes to takeover government, it should be the direction.
Look at how these big nations have evolved. They had a plan. Different presidents and different people can come in, but still you wanted to build a road from here to Lungi or a bridge, whoever comes he continues with that.
To also build the health system, we need to have a strategic plan and continue to work on it for 10 years. So whoever comes, this is a Sierra Leone strategic plan. If we can move in that direction, this country will go far.
I am so personate that I can bleed inside when I know that what needs to be done, when I see it is possible to be done, and I am delayed by things that can be avoided. I feel like bleeding inside.
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