Community-driven responses to the Kush epidemic and health system resilience in Kailahun District Sierra Leone

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Sierra Leone faces an escalating public health emergency driven by “Kush,” a locally available psychoactive substance often comprising a toxic mix of cannabis and synthetic adulterants. Its variable, often toxic composition and rapid proliferation among youth amplify public health risks. In Kailahun District, a rural border region with limited mental health infrastructure, health and social systems are under immense pressure to respond to rising demand amid chronic resource constraints, centralized service delivery, and fragmented care pathways. This study examined the community-driven responses to the Kush epidemic in Kailahun, Sierra Leone. We conducted a qualitative, exploratory study in Kailahun District between July and August 2025 to examine local system resilience. Using purposive and maximum-variation sampling, we engaged 10 diverse stakeholders, including frontline health workers, district managers, police officers, chiefs, youth leaders, teachers, and faith actors. Data were collected via semi-structured key informant interviews and focus group discussions, conducted in English or Krio, and analyzed thematically using a health systems resilience framework. This approach allowed us to map local responses, barriers, and community-identified priorities across absorptive, adaptive, and transformative capacities. Ethical approval was obtained from the Sierra Leone Ethics Review Scientific Committee. Thematic analysis revealed four interlinked themes mapped to health systems resilience capacities. First, structural determinants including unemployment, poverty, and post-conflict insecurity act as cross-cutting contextual constraints that drive Kush use and strain caregiving systems. Second, reactive clinical responsiveness and frontline ingenuity reflect absorptive capacity at the point of acute crisis, despite chronic medicine stockouts and bed shortages. Third, multiple barriers to adaptive responses including limited mental health expertise, high staff turnover, geographic centralization of services, policy ambiguity, and fragmented intersectoral coordination constrain the system’s ability to evolve beyond crisis management. Fourth, community and faith-based mobilization demonstrate latent adaptive and transformative potential, currently limited by the absence of formal integration, financing, and referral linkages. Stakeholders consistently prioritized decentralized outreach, sustained multi-sector training, reliable medicine supplies, coherent drug policy, structured rehabilitation pathways, and livelihood support as actionable priorities. Tackling the Kush epidemic demands integrated, district-level strategies that merge clinical interventions with social and economic supports. A recovery-oriented system, underpinned by pragmatic governance, interoperable data systems, and formalized community engagement, offers a sustainable pathway to impact in Sierra Leone and comparable low-resource settings facing similar substance use crises.