Introduction

The 2013–2016 Ebola virus disease (EVD) epidemic caused widespread health system and socioeconomic disruptions in Sierra Leone, Guinea, and Liberia, resulting in food insecurity. The failure of governments to mount an adequate response early in the epidemic promoted distrust in the healthcare system because of the potential for EVD transmission within facilities [1, 2]. In the absence of a functioning health system, health providers could not assess food insecurity, which has been associated with poor mental health and worse clinical outcomes, including Human Immunodeficiency Virus (HIV) and EVD [3–7]. Widespread socioeconomic disruption in the affected countries compounded issues drastically increasing food insecurity because of increased unemployment, business closures, and other challenges [8–12].

The current EVD literature largely prioritizes containment strategies during an outbreak and disease transmission and outcomes, with few studies focused on the long-term socioeconomic impacts of outbreaks [13, 14]. The few studies that have been conducted in the Democratic Republic of Congo (DRC) and Liberia on the long-term socioeconomic impact of EVD are more broad focusing on agricultural production, lost wages, and economic stability [9, 15–17]. We chose to focus on food insecurity due to its high prevalence in Sierra Leone prior to the epidemic, and because food insecurity is a specific marker of poverty that can be widely assessed across various groups [18]. The other markers of socioeconomic stability, such as occupation, education, and income levels, vary among communities so these were not used as the primary measure of the socioeconomic impact of Ebola; however, they were still incorporated into the study.

Food insecurity, defined as an inability to obtain food in a socially acceptable manner, impacted approximately 45% of Sierra Leone’s population of 7.3 million prior to the epidemic [18, 19]. Policies to reduce the spread of EVD such as market closures and trade restrictions further pushed an additional 750,000 people into food insecurity, including farmers, unskilled workers, fishermen and rural community members [9, 20–22]. Given the 2018–2020 EVD outbreak in the DRC and the 2020 COVID-19 pandemic, populations in West and Central Africa were highly susceptible to the economic effects of viral outbreaks, with food insecurity as a potential downstream effect of such health crises [16, 23, 24]. The few studies on the long-term socioeconomic effects of an EVD outbreak on food security largely focused on survivors [9], leaving out the social well-being of the entire household unit including households without EVD survivors [25].

EVD affected the social relationships of infected individuals, particularly their household unit. Out of 1.2 million households in Sierra Leone, EVD affected 6,951 households across the country, with EVD clinical outcomes ranging from one or more household members dying, all household members surviving the infection, and some households experiencing a combination of the two [26]. In a setting where EVD case fatality rates were high (approx. 50%) [27], many affected households lost family members who were critical to their financial stability [25]. When a working parent died, the loss of income and poverty levels left children vulnerable to food insecurity.

The outbreak affected the socioeconomic stability of households in various ways. Firstly, some households with EVD survivors experienced exacerbating effects of financial instability because survivors may have suffered physical sequelae resulting in an inability to work [28–32]. Although EVD survivors received a range of support services (ie. one-time food provision, employment, education) from governmental or nongovernmental organization (NGOs) following infection for at least three months [25, 33], the heterogenous distribution of support led to differences in survivors’ wellbeing in the long term. The only survivors who were food secure two years after the epidemic were those who had received at least six months of employment or education [25]. Survivors who only received food assistance without transition to independence may have suffered from food insecurity once NGOs transitioned their programs. Secondly, public health mandates resulted in substantial socioeconomic consequences for the household unit. For example, quarantined houses required decontamination, which sometimes meant destroying all household belongings [5, 9, 34]. As a result, some households lost their stored food supplies. Lastly, some households were unable to harvest their crops in a timely manner because of the quarantine period, which resulted in food insecurity [13].

Methods

Results

We interviewed the head of each household, for a total of 30 interviews. Of the 30 households, 64% had ten or fewer household members while 36% had more than ten members. The mean age of the interviewed participants was 41 years, similar to the mean age of the heads of their households in the parent study. Half (50%) were men; another half (47%) were EVD survivors. All participants interviewed were over the age of 18. Of the EVD survivors who could still work, 50% relied on agriculture as a source of income and food. Almost all interviews were completed in Krio, the primary language of the participants.

Household structure remained largely heterogenous within our cohort. After the epidemic, many families sent their children to extended relatives in other towns because they could no longer take care of them (due to reduced income), and conversely extended family members often moved into households to take care of the children of deceased parents. Both situations resulted in fragmented households and families.

Prior to EVD, participants were able to procure two meals a day, which is still less than the recommended three. Most participants described worsening food insecurity after the epidemic because they had to reduce frequency of meal consumption, quantity and or quality. In some households, food insecurity from Ebola reduced the number of daily meals from two to one meal per day. In other households, participants described worsening food insecurity based on changes in food quality in which they ate less meat, which is considered to be more expensive. We identified three major themes as drivers and/or mitigators of food insecurity: (1) financial instability, (2) health complications and (3) NGO and governmental support. Financial instability and health complications emerged as drivers of food insecurity; meanwhile NGOs or governmental agencies emerged as both a mitigator and driver of food insecurity. Below we elaborate on these major themes. We also describe the role of religion and community as coping mechanisms for households experiencing food insecurity.

Discussion

This is the first qualitative study to explore the long-term impact of the 2014 Ebola epidemic in Sierra Leone on food insecurity in EVD-affected households. The results from our study show most EVD-affected households dealt with worsened food insecurity three years after the epidemic. Using a social-ecological framework [43], we identified three main drivers of food insecurity in EVD-affected households: financial instability, long-term physical health sequalae, and lack of long-term support.

In our study, death of a breadwinner or loss of their resulted in major changes to the structure and support system of households and the annual income of these households. While the outbreak had a direct influence on the financial stability in many households, the systemic impact of the disease also drove our participants into financial instability. Prior to the Ebola epidemic, many of the households in our study struggled financially due to Sierra Leone’s economic situation, as the nation was still recovering from the perils of the civil war [44]. When the epidemic began, Sierra Leone was finally making great strides in economic growth, with the country’s GDP ranked amongst the fastest growing in 2014 [45]. However, during the outbreak, there was a substantial loss in productivity, and an increase in food prices [46] pushing an additional 750,000 people into food insecurity [5]. Sierra Leone lost an estimated $1.9B from the Ebola epidemic [47]. There was a decrease in revenue generated from the mining and farming sectors, which disproportionately impacted Kono district. All of these systemic and structural factors worsened the financial stability of many households. Consequentially, breadwinners of EVD-affected households, who needed new sources of income, struggled to find jobs in the declining economy. Households that lost business due to the EVD quarantine protocol were not able to recover from their financial losses. Therefore, the effects of the systemic and structural factors in combination with the major changes that were happening at the household level in EVD-affected households amplified financial instability, which made level of food insecurity in EVD-affected households more profound than non-EVD affected households. Similar to our findings that financial instability serves as a driver of food insecurity, a study conducted by Josephson and colleagues showed that the COVID-19 pandemic has resulted in food insecurity in many households in Ethiopia, Malawi, Nigeria and Uganda because of the pandemic’s direct impact on financial instability [16, 23, 24].

In many EVD-affected households, survivors experienced debilitating sequelae that prevented employment involving physical labor (i.e., mining, farming). Because many of the households in our cohort and in Kono district relied on blue collar jobs for their income, the debilitating post-EVD sequalae had a direct impact on food security. These households also experienced a loss in productivity and reduction in household income. Similar to financial instability, systemic and structural factors also influenced the role of long term sequalae on food insecurity. The poor healthcare infrastructure in Kono district and other parts of Sierra Leone made it difficult for survivors to access care. Prior to Ebola, Sierra Leone had a shortage of healthcare providers. The epidemic made this shortage worse as the country lost 7% of its healthcare workers [48]. As a result, the healthcare system was not prepared to handle the novel medical needs of EVD survivors who presented with post-EVD sequalae. Many of the participants in our study reported that they struggled to make ends meets as their health deteriorated, which further exacerbated financial instability and food insecurity in their households. Additionally, because of the financial instability inflicted on the households by Ebola, many of the survivors could not afford to seek care from profit, private healthcare institutions.

During and immediately after the epidemic in Sierra Leone, there was a national government effort to provide support through a Comprehensive Programme for Ebola Survivors (CPES) [49]. These services included access to healthcare through the Free Health Care Initiative program, access to free medications, and transportation support for referrals to sub-specialty care. NGOs provided food and additional support to households with EVD survivors [33], enabling them to meet their dietary needs during that time period. While the provision of services was important to the health and well-being of EVD survivors, they did not adequately target the pathways of food insecurity identified in our study (e.g., financial instability, work-related disability) because of their breadth, duration, and scope. In terms of breadth, CPES and other programs were focused on the EVD survivor and not the household unit. Most households consisted of a large, extended family with one or two primary breadwinners, highlighting the point that even though the Ebola virus infects individuals, the impact of the disease is felt by everyone in the household unit.

In terms of duration and scope, most EVD survivors received NGO support for less than a year, which was further limited in scope of health services. Few survivors received employment opportunities. Studies have shown that when EVD-survivors received job security, educational opportunities and monetary support for at least six months, these survivors experienced a better quality of life [25, 50–52]. Depending on how long support was continued by organizations in our study, some households with EVD survivors remained food secure after support was removed. These findings extend evidence that when survivors received comprehensive, long-enough socioeconomic support through job security and education, it allowed households to increase their income, eventually leading to long-term food security and improved social well-being [25]. While long-term socioeconomic support is critical to ensuring affected communities can be financially secure once NGOs transition their support out of the area, these investments often take time before individuals can accrue the benefits of such programs [53, 54]. We found that for most NGOs, the removal of support was too early to sustain the gains needed for long-term food security and stability, pointing to the need for more comprehensive approaches (e.g., cash transfers, continuous food provision) in supporting households directly impacted by EVD, not only survivors, over a longer period.

The provision of support was not equal among households. Households that only had EVD deaths and no survivors were not prioritized in the humanitarian response and did not receive substantial food supplies or socioeconomic support from the NGO community. We identified these affected households without EVD survivors as food insecure in our study, serving as a reminder for the NGO/governmental community to consider them in future EVD support programs. For affected households with and without EVD survivors to achieve long-term economic stability, programs such as CPES should continue for a longer period and shift the focus from health and well-being to educational and employment opportunities over time as part of a long-term commitment to transition households and communities to sustainability and independence.

Our study has several limitations and strengths. This study was done in Kono District, where there is a higher proportion of famers and miners compared to other communities. Thus, it is difficult to generalize our findings to the general population of Sierra Leone or, indeed, of West Africa. However, these findings still highlight major concerns and themes on the socioeconomic impact of the Ebola in low-resource, rural settings. One of the strengths of this study was that in using an open-ended, semi structured interview format with probing, we were able to get a better glimpse of the complexity of food insecurity in EVD-affected households and minimize bias [55]. This allowed us to unravel a range of topics, including quality and quantity of food, short term and long-term humanitarian support, and physical health sequalae.

Supporting information

Acknowledgments

We are grateful to the communities in Kono District, Sierra Leone, that participated in this study. We thank the staffs of Wellbody Alliance and Partners In Health for their dedication to health equity. We would also like to thank Amy J. Markowitz and the Harold Varmus Global Health Scholars fund for supporting this work.