Sierra Leone

With recent questions surrounding the June 24 election in Sierra Leone, international partners must reevaluate their response to seriously flawed elections.

Welcome to “Women Around the World: This Week,” a series that highlights noteworthy news related to women and U.S. foreign policy. This week’s post covers January 21 to January 27.

Adam Valavanis is a former intern with the Africa Program at the Council on Foreign Relations. He received a master’s degree in conflict studies from the London School of Economics and Political Science. Sierra Leone currently ranks as one of the least developed countries in the world, with a GDP per capita of less than $300 and high levels of poverty. But President Julius Maada Bio has charted an ambitious development plan for the small West African country. Since 2017, President Bio has overseen increased investment in advanced technologies in the hopes of spurring development. Much of Bio's inspiration comes from Estonia, the small Baltic state that has been dubbed a “digital republic.” The country has for years now been working to digitize government and society under the project e-Estonia. Citizens in Estonia can do things such as vote and pay taxes entirely online. Additionally, non-citizens are able to apply for e-Residency, a gambit to increase foreign investment and business in the country. In February, Sierra Leone announced a three-year partnership with the e-Governance Academy of Estonia "to establish technical collaboration on e-governance for public service delivery and administration in Sierra Leone." Bio hopes to make the country the “Estonia of Africa.”  Sierra Leone has also courted support from top research institutions such as Yale University.  At the center of Bio's plans for Sierra Leone is the Directorate of Science, Technology, and Innovation (DTSI), headed by David Moinina Sengeh. Sengeh received his PhD from MIT and was named to the Forbes 30 Under 30 list in 2014 for technology. He was part of a larger team that trained at Estonia's e-Governance Academy in May. From this trip came DTSI's six core projects: Integrated Geographic Information System, Education Data Hub, Financial Data Mapping, Ease of Doing Business, GoSL Appointment System, and Sierra Leone Drone Corridor. These projects, some of which are still under construction, are all meant to improve government efficiency and service delivery. The Integrated Geographic Information System provides minute data on things such as access to healthcare, education, and water for every region and town in the country. In September, President Bio unveiled the world's first portable DNA sequencer, which can provide "rapid, meaningful information in the fields of healthcare, agriculture, food, and water surveillance and education." The sequencer can also be used by police investigating sex crimes; earlier this year, President Bio declared a national rape emergency. The data provided by DTSI could have a transformative effect on the government’s ability to ensure its citizens' needs are met and governance is improved. Sierra Leone could provide a model for the rest of the continent, which generally suffers from a perennial lack of reliable data. Bridging the data gaps in Africa would go a long way to increasing government capacity and realizing economic potential across the continent.  

Ned Dalby is a senior research analyst with International Crisis Group and lead contributor to the new report, Double-Edged Sword: Vigilantes in African Counterinsurgencies. He joins me to discuss the origin, operation, and demobilization of these groups, their role in counterinsurgency, and ultimately, what makes the reliance on vigilante groups by the government successful in some cases and not in others. Vigilante groups usually arise in weak states with deteriorating security situations in which locals feel compelled to take their security into their own hands. The state will often try to co-opt these militias, who are afforded a level of legitimacy in their communities that the military is not, at least initially, and thus have a distinct advantage in counterinsurgency operations. The reliance on vigilantes presents interesting questions for a state's sovereignty and their legitimate monopoly on the use of force. How the military and the state treat these groups will help determine both the success of the counterinsurgency and the prospects for the eventual demobilization of the vigilantes. You can listen to my conversation with Ned here.

Below is a visualization and description of some of the most significant incidents of political violence in Nigeria from June 25, 2016 to July 1, 2016. This update also represents violence related to Boko Haram in Cameroon, Chad, and Niger. These incidents will be included in the Nigeria Security Tracker. <a href=’#’><img alt=’Weekly Incident Map Dashboard ’ src=’https://public.tableau.com/static/images/NS/NSTWeeklyJune25-July1/WeeklyIncidentMapDashboard/1_rss.png’ style=’border: none’ /></a>   June 25: Nigerian troops killed six Boko Haram militants in Mafa, Borno. June 25: Sectarian violence led to the deaths of eight in Girei, Adamawa. June 26: Nigerian soldiers killed four armed bandits in Maru, Zamfara. June 27: Unknown gunmen killed four in Igabi, Kaduna. June 28: Nigerian troops killed three cattle rustlers in Maru, Zamfara. June 29: The Nigerian military killed four kidnappers in Emuoha, Rivers. June 29: Two Boko Haram suicide bombers killed themselves and thirteen others at a mosque and a video club in Djakana, Cameroon. June 29: Pirates killed three oil workers in Nembe, Bayelsa. June 30: Nigerian troops killed two Boko Haram militants in Guzamala, Borno. July 1: A Sierra Leonean diplomat was kidnapped in Kaduna. The exact location has not yet been made public.

With a rapidly growing and urbanizing population, persistent poverty, and weak governance, Sub-Saharan Africa is likely to be the source of new epidemics that potentially could spread around the world. Understanding the disastrous response of African governments, international institutions, and donor governments to the Ebola epidemic is essential if history is not to be repeated yet again. That makes Laurie Garrett’s essay, "Ebola’s Lessons," in the September/October 2015 issue of Foreign Affairs, essential reading. Laurie Garrett steps back to understand the course of the Ebola epidemic and the mistakes made in the world’s response to it. Within African countries she profiles the lack of institutional capacity to facilitate an effect response: Liberia had two medical doctors for every 100,000 people when Ebola came. Liberia, Sierra Leone, and Guinea were unable to identify Ebola quickly and bring it under control. The developed world showed little interest until their own citizens were under threat; then, they hysterically overreacted. The relevant international health institutions, especially the World Health Organization (WHO), were inadequate for a variety of reasons. Garrett is also not afraid to address cultural obstacles to overcome. With respect to burial practices, for instance, “People across the region whispered that they were more afraid of angering their ancestors than they were of the disease.” Garrett’s picture of incompetence and short-sightedness is not pretty. But, she also describes heroes, notably Medicines Sans Frontiers (MSF), as well as specific individuals. There were the local, traditional chiefs in Liberia who independently initiated the necessary steps to quarantine victims of the disease, thereby stopping its spread. She also gives full credit to the American and British governments’ efforts – once they were finally mobilized. Of particular value is Garrett’s analysis of the World Health Organization and its future necessary remodeling. Garrett quotes a senior WHO official who, in my view, hits the nail on the head: “We’re in an extremely dangerous position, being pressured to make incremental changes until member states are assuaged, but not so much change that the organization, internally revolts.” Garrett quotes the official as going on to say that the WHO “has got to evolve, to be more than a mere technical organization. It must be a health emergency manager.” Garrett’s article is a gripping read. She tells an important story that is accessible to non-specialist readers. Policy makers in Washington, New York, and Geneva should heed her specific recommendations.

Emerging Voices features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is from Amit Chandra, an emergency physician and global health consultant based in Washington, DC. This year marks the end of the fifteen-year Millennium Development Goal (MDG) framework. The health MDGs focused on single, discrete issues including hunger, maternal and child health, and major infectious diseases, and they successfully targeted the spread of HIV and tuberculosis. Slated to replace the MDGs, the Sustainable Development Goals (SDGs) similarly focus on single issues—hunger, sanitation, and an expanded list of key diseases. Continuing this approach fails to address today’s global health challenges, in particular rising mortality associated with non-communicable diseases (NCDs), road traffic accidents, and Ebola-like infectious disease epidemics. To combat these threats, we need to strengthen countries’ entire health systems, specifically incorporate data to identify problems, expand technical capacity, and boost financial and human resources for health. In many developing countries, health systems now face the dual burden of NCDs and persistently high rates of infectious diseases like HIV, TB, malaria, and tropical diseases. Studies estimate that over 900 million people in developing countries have high blood pressure, though only one third of them (300 million) are aware of their disease, and only one third of those aware (100 million) are currently on treatment. Unlike with most infectious diseases, people can live for years with high blood pressure, diabetes, or early stages of cancer without symptoms. Many in the developing world lack access to primary care, and so their first contact with a doctor may only occur when their conditions escalate. In this way, weak health systems turn  preventable and treatable chronic diseases into silent killers. Tackling NCDs requires universal primary health systems that provide prevention, screening, and treatment services to entire populations, not just to the few identified with a particular disease. Health systems also matter for lowering traffic fatalities. Road traffic accidents cause over 1.24 million deaths per year worldwide. In the developing world, an injured person lying on the roadside often depends on bystanders for transport to the nearest hospital, which is unlikely to provide surgical care. A robust health system would enable coordination between health, law enforcement, and public policy leaders to reduce traffic fatalities. Take Rwanda for example. In 2001, the country had one of the highest traffic fatality rates in the world. To address this problem, the government passed mandatory seat belt and helmet laws, increased enforcement of speed limits, and implemented a public awareness campaign. Drivers of motorcycle taxis, a popular method of transport, are even required to carry an extra helmet for their passengers, which they sling over their elbows while looking for customers. As a result, road traffic deaths fell by over 30 percent. On a recent trip to Kigali, I was impressed to see near universal helmet use among motorcycle drivers and passengers. The absence of adequate health systems can permit novel, unexpected infectious disease outbreaks to escalate and spread. The recent Ebola epidemic in West Africa—often cited as an example of the failure of the World Health Organization (WHO)—is first and foremost a failure of the national health systems of the three countries most affected by the disease. Guinea, Liberia, and Sierra Leone’s inability to effectively respond to the initial outbreak led directly to the spread of the disease. Too few hospitals and clinics, a dearth of doctors and nurses, and limited public outreach capacities contributed to a climate of misinformation and a breakdown of public services. Preventing future outbreaks will require more than a WHO emergency fund; it will require national health systems capable of detecting, treating, and isolating a surge of sick and exposed patients. Now, as we determine the scope of the SDGs, we have an opportunity to strengthen health systems. National governments should be encouraged to provide basic health services to their populations. The global health community can support this effort by financing health management training and an expanded health provider workforce. To quote the UN Secretary General’s report on the SDGs, meeting these goals by 2030 will require that we “…act, boldly, vigorously and expeditiously, to turn reality into a life of dignity for all, leaving no one behind.”    

The New York Times and other media are reporting a drop in Ebola infection rates and empty beds in the emergency field hospitals set up by the U.S. military in Monrovia. While there is Ebola all along the border between Liberia and Ivory Coast, Abidjan has not reported any cases. The World Health Organization has stated that Nigeria and Senegal are Ebola free. Perhaps even more important, no new Nigerian cases have been announced since the WHO’s declaration. Especially in Liberia, a public communications campaign on Ebola has taken off. But, it is too soon to break out the champagne. Dr. Bruce Aylward, MD, the WHO official in charge of the Ebola campaign, cautions that infection rates can oscillate, and that mishandled burials could “start a whole new transmission chain and the disease starts trending upward again,” according to the New York Times. He also noted that there is a case of Ebola in Mali, which up to now has been infection-free. According to Dr. Aylward, 13,703 people have been infected by Ebola, all but 27 in Liberia (where about half of the victims were found), Sierra Leone, and Guinea. The mortality rate is about 70 percent. Dr. Aylward’s caution is well placed. There is anecdotal evidence of families hiding Ebola victims from the authorities, of whom they are often deeply suspicious. The emergency field hospitals are mostly in Monrovia; Ebola established itself in rural areas first, many of which are nearly impenetrable because of the lack of roads and other infrastructure. There have been nine people in the United States diagnosed with Ebola, one has died and the others have recovered or have a good prognosis. The American experience may indicate that the horrific West African experience of Ebola is a reflection of a mostly non-existent public health system. Yet, an American hysteria about Ebola, in at least some places, seems unabated, with popular calls for draconian quarantine requirements and the severing of transportation links between the United States and West Africa.

This is a guest post by Colonel Clint Hinote. He is the 2014-2015 U.S. Air Force Military Fellow at the Council on Foreign Relations. The opinions expressed here are his own. As the United States sends military forces forward to support the effort to stop Ebola in West Africa, it is striking to see how similar this struggle is to counterinsurgency operations. While American soldiers will not be conducting any combat or law enforcement operations, counterinsurgency concepts are applicable to the deteriorating situation, and these have major implications for the broad coalition joining the fight against Ebola. (A good reference on counterinsurgency operations is Army Field Manual 3-24. This article is based on concepts presented in the field manual). The struggle is for the population It is not about battles or weapons…it is about the people. An insurgency finds shelter and support in the population. The Ebola virus spreads within the population. The true “center of gravity”—the most important thing on which to focus—is the population. Legitimacy is the main objective At its essence, counterinsurgency is a struggle for legitimacy within the population. The existing authority competes with the insurgency for the population’s support. Some call this a struggle for the “hearts and minds” of the people, but this is not entirely correct. People do not have to like or respect an insurgency in order to support and protect it. Fear of reprisal can be a critical factor in the population’s choice to accept an insurgent movement. In West Africa, fear has gripped the population. In an area decimated by civil war, governments have been unable to build the capacity to provide suitable health care during this epidemic. Public officials have lost trust, as the inadequate response has delegitimized the government in the eyes of many. Additionally, many Africans do not understand what Ebola is. They see people in rubber suits coming to their homes and taking their loved ones away. Rumors and conspiracy theories run rampant. The people are scared, and they react by keeping their sick relatives hidden in their homes. This is exactly the wrong thing to do, because it gives safe haven to the virus. Isolation is the mechanism for victory The way to win against an insurgency is to convince the people to separate themselves from the insurgents. The people must choose to remove the insurgents from their midst or tell the local authorities who the insurgents are. An isolated insurgency inevitably dies. The same is true for Ebola. There is no cure for the virus. The only way to stop it is to halt its spread from person to person. This means that the population must be willing to identify who is sick and allow them to leave to prevent further infections. Unity of command is (probably) impossible, but unity of effort is essential It almost always takes a coalition of people and institutions to fight an insurgency, and implementing a strict chain of command is usually impossible. Nevertheless, unity of effort—getting everyone working toward the same goal—is critical to success. This is also true in the fight against Ebola, as local governments, the United Nations, the U.S. military, the World Health Organization, non-governmental organizations such as Médecins Sans Frontières, and volunteer medical workers from around the globe will join together to act. They will not answer to the same chain of command, but they must act in concert with one another. A long-term commitment is required to consolidate victory Counterinsurgencies are long-term struggles. Systemic problems usually drive the creation of the insurgency in the first place, and until these underlying issues are addressed, the insurgency will simmer, sometimes mutating and reappearing later. The best counterinsurgency efforts address the root causes of the insurgency over time. This fight against Ebola must also be a long-term effort, especially among the health care institutions within the affected countries. These have been decimated, and they must be rebuilt with the expertise and capacity to provide an acceptable level of care for the population. If this does not happen, the disease will return. There is a real fear among health experts that the disease will become endemic, existing in perpetuity among humans, mutating and spreading within the vulnerable population. If this tragic development is to be prevented, a long-term commitment to building health care infrastructure and institutions will be needed. What this means… Over the coming weeks and months, much of the attention will be on building the capacity to fight the virus—including building treatment centers, training health care workers, creating logistical networks, and delivering critical supplies. While this capacity is necessary to fight Ebola effectively, it is not sufficient. The main effort has to be gaining legitimacy within the population. In the short term, this means finding the most respected voices in the communities and using them to deliver the critical message about Ebola: those who are infected must be separated so they will not get others sick. This message must be communicated using any means, including nontraditional ones (in Liberia, rap musicians are using their art to warn people about Ebola). A successful outcome depends on the population’s reception of this message.

The Centers for Disease Control has modeled the possible spread of Ebola in Sierra Leone and Liberia. (It did not address Ebola in Guinea.) Based on its computer models, it concludes that the range of victims is between 550,000 and 1,400,000, not taking into account the international Ebola relief efforts. The CDC’s worst-case scenario posts 21,000 cases of Ebola by September 30 and 1,400,000 cases by January 20, 2015. Its best case scenario has the epidemic nearing its end by the same month. The New York Times quotes CDC director Dr. Thomas R. Frieden as saying that the situation was improving because of the arrival of international assistance: “My gut feeling is the actions we’re taking now are going to make that worst-case scenario not come to pass. But it is important to understand that it could happen.” It is hard for me to share Dr. Frieden’s optimism. There is anecdotal and other evidence that the number of Ebola cases is substantially under-stated, as is the number of deaths. (The September 23 New York Times carries a story on the chaotic and overcrowded cemeteries in Sierra Leone) According to the New England Journal of Medicine, the number of new Ebola cases each week far exceeds the number of hospital beds in Sierra Leone and Liberia. It is hard to see how President Obama’s promise to send 3,000 military personnel to Liberia to build hospitals with a total of 1,700 beds can be transformative. The assistance by the United Kingdom to Sierra Leone and France to Guinea is even smaller. As my CFR colleague Laurie Garrett has eloquently written, the Ebola catastrophe in Sierra Leone, Guinea, and Liberia is roughly equivalent to the Southeast Asia Tsunami in 2004 and the Haiti earthquake of 2010. Yet the international response to Ebola has been far more anemic.

The health minister of the Democratic Republic of the Congo (DRC), Felix Kabange Numbi, has announced an outbreak of the Ebola virus in the remote Equateur province. Two cases have been confirmed by the ministry. The authorities have moved quickly to isolate the village where the disease was found. The DRC outbreak appears to be unrelated to Ebola in west Africa. The DRC strain of the virus is much less deadly, with a mortality rate of about 20 percent, rather than up to 90 percent in Sierra Leone, Liberia, and Guinea. The eastern part of the DRC has been the venue of almost constant warfare for nearly a generation. Infrastructure, including hospitals, has largely collapsed. The region would appear to be ripe for a new outbreak of Ebola. In fact, according to the World Health Organization, seventy people have died over the past two weeks from hemorrhagic gastroenteritis. But, that is not Ebola. The DRC has had long experience with responding to Ebola. There have been six outbreaks of the disease since it was first discovered in 1976. As recently as 2012, Ebola killed thirty-six people in the DRC. In west Africa, Ebola was new. Medical personnel initially failed to recognize it, and protocols for responding to it were not in place. In the DRC, experience made a difference. Because the authorities are familiar with the disease, protocols were in place. They have moved quickly to isolate it. They set up a laboratory in the affected village to verify the Ebola cases, and they have banned the hunting of “bush meat,” small animals, including monkeys, that can harbor the disease and transmit it to humans. Unlike in west Africa, the DRC outbreak has occurred in a rural area, making isolation of the disease much less difficult than in, say, the teeming slums of Monrovia.

This is the conclusion of Dr. Joanne Liu, MD, president of Doctors Without Borders (Medicins Sans Frontieres-MSF). Her interview in the New York Times is a compelling must-read for those watching Ebola and West Africa. Far from echoing the cautious optimism that the disease may be coming under control in certain areas, she says, “no one yet has the full measure of the magnitude of this crisis. We don’t have good data collection. We don’t have enough surveillance.” Dr. Liu ought to know. MSF has been on the front lines of the struggle against Ebola in West Africa. In the three countries most effected by Ebola, Guinea, Sierra Leone, and Liberia, the public health systems had already largely collapsed before the appearance of the disease, the result of civil war. Hence, MSF, a non-governmental organization (NGO) that is supported by private contributions and staffed by volunteers, has taken the lead in many places. But, Dr. Liu says, MSF is overwhelmed. In her interview she calls for greater involvement on the ground by public agencies such as the World Health Organization and the Center for Disease Control, as well as other NGO’s and government agencies. She makes the chilling point that the closing of hospitals due to the fear of Ebola is allowing diseases such as malaria, pneumonia and diarrhea to kill children who otherwise would have lived. The experience of Ebola in West Africa indicates that devastating pandemic diseases cannot be addressed by weak states with collapsing health systems. It’s time to reconsider the mandate of the World Health Organization, its staffing and its funding, as a possible way to fill the void.

This is a guest post by Mohamed Jallow, grants officer at IntraHealth International, a nonprofit organization that empowers health workers around the world to better serve their communities. A version of this post originally appeared on VITAL, IntraHealth International’s blog. “I am afraid for my life, I must say, because I cherish my life,” said Dr. Sheik Umar Khan, one of the leading doctors fighting the spread of the Ebola virus in eastern Sierra Leone. Last week, Dr. Khan’s fears came true when he was diagnosed with Ebola virus disease. He succumbed to the deadly disease on Tuesday and died at the very same hospital in Kenema where, just a few weeks ago, he was treating patients from the nearby district of Kailahun. Dr. Khan is only one among a growing list of medical workers who have been infected while battling the spread of Ebola across West Africa. In Sierra Leone, over forty nurses and other frontline health workers have died in the line of duty. In neighboring Liberia, two prominent doctors—Samuel Brisbane, a Liberian doctor, and Kent Brantley, an American doctor from North Carolina working for Samaritan’s Purse—have been infected with the disease while treating patients. Losing Dr. Kahn is an unmeasurable loss to Sierra Leone. According to the country’s minister of health, the doctor treated more than one hundred victims since the first reports of the Ebola outbreak back in February. The disease, with a fatality rate of up to 90 percent, has claimed the lives of more than six hundred people in Guinea, Liberia, and Sierra Leone. Sierra Leone’s health care system is already underfunded and understaffed, and now the Ebola outbreak is putting a strain on the country’s limited resources. In Liberia and Guinea, the response to the Ebola virus has inundated their respective health systems and disrupted cross-border commercial activities, the main lifeline of border communities. Liberia has announced the closure of its land borders with Guinea and Sierra Leone and has stepped up surveillance at all airports. According to the World Health Organization, Sierra Leone is among eighty-three countries facing a health worker crisis. The mounting death toll of health workers is only going to exacerbate the already perilous situation. The outbreak’s effects will linger long after the epidemic is brought under control. Moreover, the reputation of health workers is suffering. Sierra Leone is rife with rumors of health workers infecting patients, and families have at times violently attacked hospital staff and removed infected relatives from hospitals. This has, of course, contributed to the spread of the disease in other parts of the country. The long-term consequence of all this is that Sierra Leone’s health system will be weakened even further, reversing gains in providing essential life-saving interventions, especially for pregnancy and newborn services, and access to the care, treatment, and prevention of highly prevalent disease such as malaria, tuberculosis, and HIV/AIDS.