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In which John looks at the vicious cycles of poverty and poor health in Sierra Leone, including how the ebola crisis happened and why a center of diamond mining has become one of the poorest regions in the world.

For the last year and a half, Hank and I have been working on a big, long-term project with Partners in Health Sierra Leone. Sierra Leone has the highest maternal mortality rate in the world, and one of the highest child mortality rates, and we believe that can change with long-term investments in Sierra Leone's healthcare system. The project will be announced later this month, and this video explores some of the why.

Thanks to Jon Lascher at Partners in Health for the pictures of the Koidu Government Hospital before PIH arrived, and for taking a look at this script. Thanks also to Rosianna Halse Rojas for her help with images and editorial guidance. Any mistakes are mine alone.

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Good morning Hank it’s Tuesday,

So later this month we’ll be making a big announcement about working with Partners In Health Sierra Leone but before that, I thought it would be helpful to consider why Sierra Leone is so poor.

Now, poverty is complex and we are not gonna get to the bottom of it in a YouTube video but I do think this can be some helpful context.

Ok so, Sierra Leone, located here, is a nation of around 7.5 million people, it’s ethnically and religiously diverse- most Sierra Leoneans are descendants of people who’ve long lived in West Africa but many former slaves in the British Empire were resettled here and so there are Sierra Leoneans who trace their descendent to Canada or to England, to Nigeria and many other places.

And while I was in Sierra Leone earlier this year, someone told me that to understand its impoverishment I should look at a map showing all the railroad tracks that were built in Sierra Leone while it was a British colony; as you can see, the train tracks didn’t really connect cities to each other- they connected the mineral-rich areas of Sierra Leone to the coast of Sierra Leone so those minerals could be exported- and this is a very important thing to understand about colonisation- it was in the business of resource extraction and so the systems that were built in colonies were resource extraction systems.There was not much colonial investment in say health systems or education systems and since Sierra Leone achieved independence in 1961, it has struggled to transition away from research extraction and to build the kinds of systems infrastructure, health care, even mail delivery that would lead to a more balanced economy and a healthier population.

Now it’s easy to blame these failures on a single cause, say corruption, but while corruption is a serious problem in poor countries around the world, the bigger problem by far is that it’s very hard to build health and education and infrastructure systems in communities that have been built around resource extraction. That’s true all over the world.

But also, community cannot spend what it does not have like if Sierra Leone spent the same percentage of its economy on healthcare and education as say the United Kingdom does, Sierra Leone would have about $45 per person per year to spend on healthcare and a similar amount per child per year to spend on education. That’s just obviously inadequate, like in the US we spend over $10,000 per person per year on healthcare and over $12,000 per child per year on education.

Okay, so all these challenges were compounded in Sierra Leone by a long and extremely violent civil war which lasted from 1991 to 2002. Tens of thousands of people died, millions were displaced, the healthcare system was devastated, HIV infections increased, deaths from every cause increased and education and professional development were interrupted as schools closed or students had to flee violence like Dr. Bailer Barrie who founded the widely respected Well Body Clinic in Sierra Leone had to leave his studies for a time to escape to a refugee camp and I heard similar stories from several healthcare workers. Because the civil war was on all sides partly funded by trade in diamonds and other valuable minerals, the war was especially devastating to Sierra Leone’s diamond mining district Kono. 

And as we travelled through Kono, I kept thinking about that old Faulkner line about how 'The past is never dead. It’s not even past’ and the government paid for a mercenary army and weaponry in part by selling the rights to the counrty’s largest diamond concession and so today, almost none of the wealth generated by Kono’s diamond mines ends up in Kono and this has led to a paradox that is common in poor countries- while Kono is one of the richest parts of West Africa by some measures, in terms of poverty rates, malnutrition, disease burden and child and maternal mortality, it is one of the poorest and least healthy places in the world. Because while diamond mining produces a lot of money, there aren’t actually that many jobs for Sierra Leoneans in the mines, meanwhile all around the mine, just outside the fence you will see many people working at breaking stone to eventually be sold as gravel.

This is how you end up with a country where a hundred million dollars in diamonds gets exported annually and 6% of all women die in childbirth and this poverty can become a vicious cycle. I think the Ebola outbreak really epitomises how impoverished and fragile healthcare systems can lead to emergencies.

When Ebola first appeared in Sierra Leone in 2014, the entire country had about 150 doctors- for context, my home state of Indiana has a similar population and over 16,000 doctors. Lack of running water made sterilisation difficult, there weren’t enough gloves or surgical masks and this systemic weakness is the reason that Ebola could ravage a country like Sierra Leone but not say The United States or Spain.

We met an Ebola survivor who now works for Partners In Health and who shared a bed with his son at an Ebola treatment facility. Both he and his son survived but his wife died just a few beds over. 

[Ebola survivor] “So there were only 3 beds and we came with 4. So I told them, ‘no, my son will not go.’ So I am going to share the same bed with my son. Small bed. I say, ‘no, I have no problem. As long as my son is comforted, I have no problem.’ So I was lying struggling for 9 days. They brought my wife also, and she died at that ward.”

When I asked Dr. Barrie his memory of treating patients there, he told me:

[Dr. Barrie] “Going in and seeing, like, maybe 50 patients, and then coming the next day and find only 20 alive? I mean... it’s... it’s horrible.”

The Ebola crisis was caused by a fragile healthcare system and it led to a more fragile healthcare system and that vicious cycle is often the story of poverty.

So I understand that these problem can feel far away and like they aren’t ‘our’ problems but first, you can’t separate the wealth of nations like The United States and The United Kingdom from the poverty of Sierra Leone, you just can’t. We industrialised with their natural resources and we built lucrative systems of trade by trading in West African slaves. But also secondly, if these problems aren’t our problems, I’m troubled by how we’re defining ‘us’- like I don’t want to be part of an ‘us’ that makes a ‘them’ of the world’s most venerable people. And I think the idea that Sierra Leone can somehow solve it’s own problems in isolation wrongly imagines that its problems exist in isolation.

Now of course, one of the risks of philanthropic work is that it’s possible to make things worse or to create new problems while trying to solve old ones and I think it’s important to be aware of those risks and to try to minimise them by grounding your work in listening and deep partnership but I just think it’s inaccurate to say that nothing can be done or that investment is pointless; I have seen the difference that Partners In Health and The Sierra Leonean Ministry of Health have made in the Kono district even with extremely limited resources.

I mean, 5 years ago the hospital in Kono had no electricity and very few supplies and as a result, almost no patients- today, it is well staffed and well supplied and widely utilised. There’s a blood bank and a functioning operating room for C-Sections and other procedures. Now, it’s still totally inadequate: there are only 40 maternal beds for a population of 550,000 people but the progress is real and I believe that progress will continue if the Ministry of Health in partnership with organisations like PiH is able to make the kinds of long term investments that address long term problems.

So why is Sierra Leone poor? Because its systems have for centuries been structured around resource extraction, because of war, because of disease burden and because of colonialism and its legacies.

But I am hopeful, not because I think these problems are easy to solve but because I have seen the extraordinary commitment of Sierra Leonean healthcare workers to their patients and because their patients have helped me to understand that despair is not the right response to big problems, even existential problems. There is nothing natural and inevitable about Sierra Leone’s poverty and so I don’t think it’s permanent. We have much evidence from around the world that systems can get stronger, more moms can survive childbirth and more children can survive childhood, educational opportunities can improve and infrastructure can begin to connect people to each other and not just minerals to ports. 

Hank, I’ll see you on Friday.