In Sierra Leone, one of the poorest countries on earth, a patient's chance of surviving Covid-19 can come down to money.
One-third of Covid-19 admissions die in Connaught Hospital, central Freetown, with survival rates decreasing when a patient's family cannot afford to buy canisters of oxygen.
The hospital has its own oxygen plant, but medics say it is not fully functional, and when it works it does not produce as much as is needed. The relatives of Covid-19 patients are often advised to go and fill their own oxygen canisters at a commercial plant, for a cost of 750,000 leones (€62) per refill, plus a 1.5 million leone (€124) deposit for the canister.
This sum is hugely prohibitive in the West African country of roughly 7.8 million people, where 2019 World Bank figures listed the per-capita annual income as just $540. A coronavirus patient might need between one and four canisters of oxygen a day, for up to three days, to recover – a fortune for most families.
At least one patient, whose family could not raise the money required, was told there was little else the hospital could do, according to a healthcare worker who requested anonymity because they did not have authorisation to speak to the media. The patient died shortly afterwards.
Another patient died because of delays transporting oxygen, the healthcare worker said.
Delta variant
Although Sierra Leone, like many African countries, registered few cases during the first year of the pandemic, a surge began two months ago, which medics say is being fuelled by the arrival of the Delta variant.
Officially Sierra Leone’s caseload remains relatively low, at 6,228 cases and 118 deaths, but the country was put on the UK travel red list this month amid concerns about under-testing. June figures showed 6.8 per cent of people who arrived in England from Sierra Leone tested positive for the disease.
In just over a month, between June and July, Connaught Hospital saw 109 cases, about 70 per cent of which were serious and 38 of whom died.
"They come in when they can't breathe anymore. Most people, especially their relatives, tell you they've been unwell a while but thought it was malaria or something else," said Dr Joseph Kamara, the hospital's medical officer in charge of Covid-19 care.
He said it has been difficult having conversations with patients’ families about the costs involved. “Even if you can’t afford [to buy oxygen] we’ll give you what we have but that’s no guarantee that you’ll survive,” said Kamara. “We tell the relatives they need more.”
When the oxygen comes there are limited ways to administer it. “For those who can’t breathe, that’s it, we don’t have ventilators,” he said.
Just four of the 12 beds in the Covid-19 isolation ward were in use when I visited. The only obvious indication of what the building is now used for was a piece of red and white striped tape stretched across the entrances and windows, as a warning not to enter. The day before a 44-year-old man had died.
Quack doctors
Many Sierra Leoneans are hesitant to come to hospitals for a range of reasons, including concerns about prices and a lack of trust in the healthcare system. Medics say this was exacerbated by the Ebola outbreak in 2014-2015, when there was a widespread belief that being admitted to hospital could hasten death.
Instead some citizens turn to so-called quack doctors – often untrained or badly trained salespeople who go from house-to-house in poorer areas selling a collection of pills or setting up IV drips.
Connaught Hospital does not have the capacity to routinely test staff. Kamara said he has only been Covid-19 tested once, after he developed symptoms (the test came back negative), but he is not aware of any employees who contracted the disease.
Sitting in his office, as a heavy downpour, typical of rainy season, fell outside, Connaught Hospital director Dr Mustafa Kabbah listed off the hospital's needs: more staff, PPE, a proper water supply, sustained electricity and a back-up system.
“Sometimes power shortages affect patients’ care,” he elaborated. “[and] the oxygen supply is not enough for what we need. If the patients’ relatives can get it from somewhere it is highly welcome. “
He said the Covid-19 surge in Sierra Leone had still not reached the crisis levels seen in Europe so far, “but the potential is there...We don’t know the direction it’s taking but we are preparing. It’s this Delta variant that came in and is causing a lot of problems.”
While they try to transfer new Covid-19 patients to two other hospitals focused specifically on treating them, recently the hospitals have been too full to help, Kabbah said.
Admissions
Connaught Hospital has a 350-bed capacity for all admissions. It is located in a bustling part of Freetown, surrounded by tuk-tuks and street traders. Each month 3,000 patients are treated for a range of diseases, injuries and other ailments.
Twenty minutes’ drive away, hindered by traffic, is Super Holdings Company Ltd, the commercial oxygen plant that relatives of Covid-19 patients are sent to.
Abusainy Dumbuya, the sales co-ordinator, explained it can only do oxygen refills now after it ran out of cylinders to rent out. Each day the plant sells about 30 refills to private customers, while 70 go to Covid-19 treatment centres, where they are sometimes sold at a higher price.
In total, 220 people work in this plant, which also makes industrial oxygen and plastic. Dumbuya said it has had to reduce the production of other products to fill the Covid-19 oxygen need.
“The demand used to be intermittent but the past two months there had been demand,” he said. “People come here crying, saying we have to help.” In those cases, he tells people to pay what they have – the lowest he has accepted was 350,000 leones (€29) for a canister. “We realised as a company the situation is desperate.”
