An Infrastructure Issue

**IMPORTANT: This article contains mentions of drug use. If you feel uncomfortable with these topics, please refrain from reading.

In the case of a public health emergency, how do first responders and government officials react? What are the first steps taken to treat community or national-level illness and what barriers prevent or hinder legislators from implementing successful policy to reduce the issue? 

In this article, I hope to dive into a recent and growing crisis: the Kush epidemic in West Africa, and specifically Sierra Leone. With a geographic area smaller than the state of South Carolina and a population of less than 9 million people, Sierra Leone is a small and often overlooked nation in the African continent. (1) While the nation is rapidly growing both demographically and economically, a growing Kush drug epidemic has taken hold of the nation and of nearby Liberia and Guinea. (2) Focusing my article on Sierra Leone, I hope to explore the role infrastructure plays in dealing with emerging public health crises. 

In the past few years, African governments have dealt with a complex drug issue. A 2020 study has shown that African nations account for roughly 87% of global illegal opioid seizures. (3) The same study has suggested that in the future, this issue will only grow as increased transportation between large cities will expand the market for illegal drugs. Kush is a synthetic, addictive drug similar to cannabis that induces a prolonged feeling of euphoria in the body; the drug is relatively cheap and available and has thus proliferated quickly in the region. (4)

The statistics reveal an alarming trend: although Kush was synthetically created only 5 years ago, roughly 1 million individuals in Sierra Leone are thought to be addicted. (5) This number is shocking, representing more than 10% of the total national population. In fact, public health professionals believe that roughly 12 individuals die from Kush addiction in the nation every day. This epidemic has affected the economy as well; Kush is illegal in Sierra Leone and over the past 5 years, over 100 drug users and dealers have been convicted and jailed by the police. Regardless, the drug has been used by thousands of young individuals, largely because it provides short-term relief to the lived experiences of poverty. (6)

The Kush epidemic has had far reaching impacts on the Sierra Leone status quo. Individuals addicted to the drug are often unable to attend school or work, preventing economic growth. Furthermore, the growth of the epidemic has also coincided with a growth in crime and political unrest, fueling tension between societal groups. (7) Finally, a growing Kush addiction amongst Sierra Leone individuals has put further pressure on already limited medical resources, particularly health infrastructure and working health professionals.

Thus, to describe the ongoing Kush epidemic in Sierra Leone, a 3-stage model can be created. A current lack of opportunities and significant levels of poverty have fueled Kush addiction, which has in turn contributed to ongoing worker shortages (particularly in healthcare), crime and instability, and a deviation from expected economic growth.

Referencing my prior arguments, any successful attempt to combat this ongoing addiction must tackle both sides of the issue (stages 1 and 3). By treating both the root causes and long-term effects of addiction, policymakers and medical professionals might create a sustainable solution that prevents the epidemic from growing and that also addresses the ongoing effects of addiction in society.

So how can Sierra Leone legislators tackle this issue based on empirically successful strategies used in other nations and what issues might officials face when attempting to create change?

• Community-Level Intervention: In some nations, government officials have relied on educating drug users and providing users with healthy activities in a neighborhood setting. (8) By providing information at church, school, or work, government officials can ensure that drug users learn about different ways to seek help and alternatives to drug use.

• Harm Reduction Program: In my previous article titled “Persistence and Prosecution: The ‘War on Drugs’”, I discuss harm reduction programs as interventions that reduce the consequences of a stigmatized activity without prohibiting the activity itself. By providing care to drug users and offering optional treatment, some governments have achieved success in reducing the negative effects of addiction epidemics. (9)

• Targeted Rehabilitation Program: While some governments have opted to provide treatment to drug users in their nations to reduce the spread of addiction, these programs have often been very costly. Limited by a lack of healthcare infrastructure, these programs have not always been the most successful.

• SBIRT: The Ugandan Screening, Brief Intervention, and Referral Program is a tool used to treat substance use issues by screening patients and either briefly treating or referring drug users to other healthcare providers. (10) If a similar program is implemented at a community level using local level providers, the SBIRT program may help reduce addiction in the nation.

If you notice, the programs I have just described are health focused, educating and treating drug users. However, comprehensive solutions to this issue will be focused on providing individuals in Sierra Leone with opportunities. Whether that be through job training, a stronger economic safety net, affordable housing, expansions in social security, or increased investment in schools, Sierra Leone economists and government officials must work to understand individuals’ lived experiences of poverty and develop research-driven ways to reduce the issue.

But, from a health infrastructure perspective, what barriers might prevent policymakers from reaching success? There is significant data about the limited healthcare infrastructure in Sierra Leone. Government officials spend a very low percent of the national budget on healthcare; combined with a lack of healthcare resources and active professionals, the Kush drug epidemic has truly strained existing systems.

At the end of the 20th century, Sierra Leone underwent a long civil war, leaving over 50 thousand dead. Furthermore, public health resources were further strained in 2014 with the Ebola epidemic, in 2017 with a large mudslide, and recently with the COVID pandemic. Sierra Leone reports poor neonatal mortality, infant mortality, stillbirth and child death rate outcomes. (11) Astonishingly, Sierra Leone has over 1400 healthcare facilities yet roughly 50% of the providers in the nation are volunteers. It is thus critical for government officials to identify the resources, specifically the “staff, stuff, space, and systems”, for any proposed intervention to succeed.

As I reflect on the Kush epidemic in Sierra Leone, I hope to conclude this article by discussing the current state of this issue. 

The Sierra Leone government has implemented a Free Healthcare Initiative to improve access to healthcare services. (12) While this solution holds promise, it may be putting further strain on the limited healthcare infrastructure in the nation. Caritas is an international organization working to raise awareness about the epidemic and provide care to drug users; unfortunately, due to limited healthcare resources, they too have experienced barriers in reaching success. 

Perhaps the best solution to this issue is to build healthcare infrastructure. Partners in Health is one organization partnering with the government to build facilities in regions with low access as a means to develop a healthcare network to support the most underserved communities. (13) Ultimately, many public health crises grow and persist due to a lack of effective infrastructure. By working to improve existing infrastructure, national legislators and public health officials might more effectively understand and resolve existing health crises and safeguard communities in the future.