The Other Ebola Battle: Fair Pay for Local Health Workers

Nurses log their hours into notebooks like this one. I used these to help verify that staff had worked hard during the peak of the outbreak. Image by Amy Maxmen. Sierra Leone, 2015.

Anyone who stepped into the public hospitals and clinics of Sierra Leone – and from what I’ve been told, of Guinea and Liberia – must know that local nurses, lab technicians and other health workers often went without pay for their dangerous work. Pictured above is graffiti on one wall of the Ebola area at Kenema Government Hospital. It says, “Pay my day; Please pay us, all ours.” Image by Amy Maxmen. Sierra Leone, 2015.

Ebola pummeled the public health system for the first half of the outbreak. At Kenema Hospital alone, 37 health workers have died, including West Africa’s only Ebola specialist, Dr. Sheik Umar Khan. According to the World Health Organization, 815 health workers were infected by Ebola during the outbreak. Two-thirds of them died. Above, a lab technician at Kenema Hospital tells me about his best friend and colleague, who passed away in August. Many international aid workers largely vacated the three hardest-hit West African countries when Ebola began to spiral out of control, roughly from July to October 2014. By the time I arrived in December, however, the world had donated hundreds of millions to control the contagion. The money was visible in the form of humanitarians flying around the country in helicopters, cruising through towns in shiny white land cruisers, and buzzing around the best hotels. Normally, that fact alone wouldn’t bother me. Image by Amy Maxmen. Sierra Leone, 2015.

But the contrast between them and local frontline staff risking their lives for next to nothing was staggering. After watching a U.N. helicopter take off, in the company of an unpaid ambulance driver, I decided to investigate why staff at one of the largest public hospitals in the country were missing their promised hazard pay. Image by Amy Maxmen. Sierra Leone, 2015.

Part of the answer regarding missing so-called hazard pay has roots in the fact that Sierra Leone is one of the poorest countries in the world. As such, dull yet essential services like human resource database management are basically non-existent. So even when the World Bank and African Government Bank offered a grant to cover payments, it was a massive challenge to figure out who deserved them. Hospital and staff records are often maintained in hand-written logs like the one above. Image by Amy Maxmen. Sierra Leone, 2015.

This is one page of an Ebola logbook. I’ve scribbled out specific addresses in the photo to protect identities, and blocked names. Note the ages and death rate. Image by Amy Maxmen. Sierra Leone, 2015.

Here’s one page from the daily records of the Ebola center at the public hospital. I read them like an intermittent diary of what had occurred. Image by Amy Maxmen. Sierra Leone, 2015.

The supervisors of many hospitals wrote letters pleading for the payments that the government and the international aid community had promised them. This one from Kenema Hospital reads: “Sir/madam, we kindly crave your indulgence to look into this matter for prompt actions to address these issues. We hope to hear from you soonest. Yours faithfully, Health workers.” Image by Amy Maxmen. Sierra Leone, 2015.

Image by Amy Maxmen. Sierra Leone, 2015.

With a survival rate of around 60 percent, the 34th Military Hospital in Freetown might have been the best clinic in terms of Ebola care in Sierra Leone. Yet many of its brave national doctors and nurses were paid late and less than what they were promised by donors – as were health workers elsewhere. Another letter of complaint was dated December. When I saw it in February, some staff had still not been paid. Although Ebola had largely been vanquished from Kenema district in February, the ward remained a triage unit. Patients came to them with high fevers, and the hospital didn’t want to take any chances while they waited for test results. In general, the nurses were enormously discouraged – deflated by the horrors they had witnessed, the friends and family they had lost, and the lack of payment that would have acknowledged their worth to society. More than $3.3 billion has been donated to Ebola. Image by Amy Maxmen. Sierra Leone, 2015.

I spent two months in Sierra Leone during the Ebola outbreak. Since I’ve returned to the U.S., people often ask me how it was. I tend to say, "horrible." They usually reply, "I bet." Then I mumble about how it was horrible for reasons they don’t imagine. They’re picturing photos from the news – dead bodies, hysterical patients, alien biohazard suits– all of which are real. But that wasn’t what gutted me.

Other people struggle for a positive angle. They’ll mention uplifting Ebola news. For example, DNA sequencing suggests the virus has not become more infectious; new materials absorb liquids infected with the virus; and there are these stickers that help patients identify nurses draped in protective gear. But their good-natured sentiments make my heart ache, and it’s not long before I confess disenchantment. We, as a global community, have thrown more than $3 billion at Ebola, but the brave nurses who risked their lives to quite literally stop the virus have been mistreated.

I recently attended the World Health Assembly in Geneva, where I witnessed a tribute ceremony to health workers. Speeches were made, candles lit and refreshments served. Nice gestures, but by now I’ve spent enough time with nurses to feel quite confident in saying they’d prefer cash, respect and true partnership.

Last month, Newsweek published my investigation into why so many frontline nurses were underpaid throughout the outbreak – and why there’s little hope that nurses will be paid fairly afterward.

As I reported in Newsweek, the problems during the outbreak appeared to be twofold. First, Sierra Leone's national health system has been so underfunded for so long that it was a monumental challenge to document all of the country's care workers and set up payment distribution channels to them. Second, donors set aside relatively little money for local front-line staff within Sierra Leone's health system in the first place. Less than 2 percent of $3.3 billion in donations to fight Ebola in West Africa was earmarked for them.

In writing this piece, I don’t mean to insult any well-intentioned program. Instead, the question I ask – and that I’d like taxpayers from donating countries to consider – is should we shift priorities, so that health workers in the countries’ health systems get the support they need to do their jobs?