In Sierra Leone’s Ebola hot zone: A series of reports

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In Sierra Leone’s Ebola hot zone: A series of reports

The following account is by IRIN journalist Anna Jefferys who, together with filmmaker Ricci Shyrock, visited Sierra Leone earlier this month. It is the first of a three-part series. The second part is here. The third part is here.

KENEMA/FREETOWN, 10 October 2014 (IRIN) - We set off by jeep from the capital Freetown for Kenema, 240km away. While there are Stop Ebola posters all over the capital, we see very few en route. Every 15 minutes or so we’re stopped at an Ebola monitoring checkpoint to have our temperatures taken and to wash our hands in chlorinated water. Thirteen in all - it’s enough to make anyone paranoid.
Six Ebola-hit districts, including Kailahun, Kenema, Port Loko, Bombali, Mayambo and parts of Freetown, are “isolated” across the country, meaning locals need a special pass to leave them, and houses with confirmed Ebola cases are cordoned off, their inhabitants instructed not to leave unless they are sick. In those cases they must wait for an ambulance to take them to the nearest Ebola clinic.
The “isolation” followed a three-day government lock-down, in which all six million citizens were ordered to stay at home while contact tracers went to as many households as they could reach to identify the sick, and body collectors tried to gather up the dead: they brought in 300 corpses in total, according to the Ministry of Health. Another lock-down is being considered in coming days. Some international organizations were quietly dubious about the lock-down, fearing it would lead to mounting distrust among locals of health workers, but many say it has been a success.
Suafiatu Tunis, a volunteer community activist from Freetown, who has been travelling with a team from district to district to spread prevention and treatment messages, told IRIN: “The shift in attitude came after the three-day lockdown. That was the best idea that the Sierra Leone government initiated on its own.” The lock-down was accompanied by intensive radio messaging - the primary source of information for 75 percent of Sierra Leoneans - and she said it helped to raise consciousness of the disease. “Before, when I went to villages, people said “no thanks”. Now it’s changing. People are listening. They are Ebola-aware.”
She is one of the few women to go house and house and it makes a difference as women open up to her. They converse in local languages - Mende, Temne, Fular and Kriol - and people ask questions. In a village in Blama District that day a woman asked if survivors could transmit the disease (no), and how to disinfect the house if someone has it. Often it is as simple as showing a map of how Ebola is spreading across the region for them to put it into context.

The lock-down, of course, had an economic impact. Families trapped at home with little warning were unable to stock up on sufficient food to last three weeks, and in a country where over half of the population lives under the national poverty line, they could not afford to buy that quantity of food anyway. (The World Food Programme has been delivering food to quarantined neighbourhoods in the capital Freetown, Bombali District and Port Loko, and will begin in Kenema and Kailahun this week.)
Motorbike taxi drivers (known as Okada drivers) complain that the reduced trade means they bring in 25 percent per day of what they used to, now amounting to US$3 on average. The streets of Mayumbo are deserted as no one has been able to practice petty trade. Lavennta Konneh, a contact tracer working with the UN Population Fund (UNFPA) and the government, is one of the few individuals permitted to leave her house. “There is no business now. Our parents usually sell. Now vehicles can’t even stop. Soldiers don’t allow anyone out.” As she was talking, a military officer positioned nearby asked us to drive on.
UNICEF’s water, sanitation and hygiene manager, Patrick Okorth, said it is particularly difficult for communities that do not have ready access to clean water: which is the case for 60 percent of rural residents and most of Freetown’s slum areas. In some areas people have to wrangle with police to pass through the barrier in order to reach a safe water source. Behaviour change messaging calling on people to wash hands with soap or chlorinated water as often as possible only works if soap and water is available.
Anyone with a temperature at a checkpoint is held there and told to wait for an ambulance, but these can take all day to arrive. IRIN came across a woman at a checkpoint at the entrance to Western District, who had been lying all day with a fever, waiting. The Ministry of Health currently has 31 ambulances to serve the whole country, estimated its spokesperson Sidi Yahya Tunis.
Arrival in Kenema
After a five-hour drive we arrive in Kenema, a small town surrounded by verdant mountains. It is bustling with activity. Okado drivers fill the streets, most of them wearing wind-breakers in the boiling hot sun to prevent their passengers from touching them. The no touch message which has transformed human interaction across most of the country is less in evidence in the crowded marketplace where shoppers jostle past each other, and school-aged girls, currently out of school, hug and high five.
After settling into our deserted hotel we head to Kenema District Government Hospital, which was one of the hardest-hit health structures during the sudden spike in case numbers in June and July, which led it to lose 38 of its health workers including one of the country’s top epidemiologists, Sheikh Umar Khan.
Incoming patients are screened in a cordoned off tent to the left of the main gate. The rules: a fever of 38 or over and answering positively to Ebola risk indicator questions (Have you touched a dead body recently, vomited, helped someone confirmed with Ebola?) is given an Ebola blood test and sent to the probable and suspected case ward to await results. Those with lower fevers are tested for malaria in an instant test: the hospital treats about 90 people a day for malaria, said a nurse.
The next day we see a woman released who had been put in the probable ward but tested negative for Ebola. Her risk surely had upped while in there - hardly a promising prospect. “We track them for the 21 days to come,” said the health worker explaining there is simply as of now, no better way.
I meet an older gentleman who had a low fever but had tested negative for malaria. “I don’t feel so bright,” he tells me. It’s probably not Lassa fever, which is endemic in Sierra Leone, as it is not the season. What then? A mystery. He disappears into a consultation room.
Once Dr Bratt, the hospital’s administration head, has given us permission to film, we are more or less left to our own devices, which seemed liberating at the time but scarier later when we went over any lapses, any risks we might have inadvertently taken over the course of the day.

The nurses here wear starched grey dresses and dainty lace doily hats perched high on their heads. Despite having lost 38 colleagues, they are upbeat, they laugh, and they are strong. Their mood is of people who have survived a war and are going to stick together. Aminata Kamara’s husband just kicked her out of the family home for the work she is doing, and the landlord from whom she is renting a room is about to do the same, she said. “I thought about stopping but I stayed to save lives. We are soldiers! We’ve been doing this since the beginning and we’ll continue until it ends,” she told IRIN.
Issa French, the deputy head nurse - the two previous ones died - says the caseload at the hospital has dropped from an average of 30 per day in June and July to just a couple of admissions per day now. The hospital refers more and more cases to the new International Federation of the Red Cross’s 30-bed facility 16km outside town, which can take 30 patients and will soon expand to 60. “Our message to people is to come to the hospital. They are still fearing,” said French. “There are still cases hidden in houses.”
Survival chances
Though the data is still being studied, some preliminary epidemiological data analysis undertaken by health specialists indicates that in the current outbreak, if the disease is treated within 1-3 days the chances of survival could be very high, lowering to 60 percent if treated within five, and after that the statistics become grim.
One of the reasons so many nurses died at first was because they were wearing protective gear to prevent Lassa fever, but which did not prove adequate to protect from Ebola. Now they have enough personal protective equipment (PPE) and they are scaling down the ward, sending patients on to the new International Federation of the Red Cross Ebola treatment centre 15km outside of  Kenema. Residents want their hospital back - and they’re going to get it. Patients for routine illnesses or child wellness clinics are staying away for fear of contracting Ebola, said several nurses.
Eight Ebola survivors: five adult men and three children, one of them a baby, are being discharged today. Several of them have been waiting 24 hours for a bus to take them home. They will likely face stigma from their neighbours. One woman told IRIN that in some cases child survivors are being rejected by their parents.
One of the survivors, Alfred Pujeh, 24, a teacher, is from one of the taped up compounds we passed in Mayambo. He relates a horror story of loss: 23 of his 30 family members living there contracted Ebola and the only ones to survive were he, his uncle and grandfather. He contracted Ebola while caring for his uncle who had it. Yet he does so with a huge bright smile. “I came here and I accepted it. I smiled. I knew I’d survive.” After 10 days of continuous battling he felt stronger and tried bathing himself but collapsed. Four days later with nurses feeding him his three meals, he got stronger.
Pujeh will return to no job for a few months as all the schools are closed. His grandfather, Saidou Lahari, looks exhausted, resigned. “The lord has fated this to be - so we have no alternative. I can say nothing about it - only the Lord can. My family is never coming back. The Lord can take my life too.”
Pujeh translates for Josephine Konneh*, a 10-year-old girl in the ward, the only child of a disabled woman in Freetown who, like so many other children, was whisked away from her mother to be sent into quarantine. She contracted Ebola by looking after her best friend when she was vomiting, and is clutching a doll. “The nurses gave her to me to give me hope,” Konneh told IRIN. “What’s her name?” We ask.  “She doesn’t have one.” “Ebola!” Pujeh suggests, and a couple of the men give a gentle laugh. 
Just then a frail older man, Hassan Tourey, comes into the low-risk area seeking help. He looks desperate, lost and tired. He tells me he brought his 14-year-old grand-daughter, Mamy Babar, to the hospital one week ago with aches and a swollen throat but no fever. She did not take an Ebola test as she had none of the symptoms. “She did not have Ebola,” he cried. He left her there saying he would return for her but since then she has disappeared. “Maybe she was sent to the Ebola camp,” said a nurse, trying to be helpful, but it makes him panicked. “She had no Ebola!” said Tourey, who had come from Panguma 40km away to find her. The nurses have no answer for him. He soon left the hospital looking afraid.
I visit the maternity block. The post-natal wards, with about 15 beds each, are clean, bright and breezy - one of the nicest wards I’ve ever seen in West Africa. About one quarter of the beds are taken. “The women they stay away,” said midwife Alice Kabbah. “They think all the nurses here have Ebola.”
Time to leave

I am starting to lose my guard. We are not allowed to touch anything - people, but also walls, doors, nothing if you can avoid it. I find myself leaning against a wall in the low-risk area, and I am starting to want to sit down and chat to people more casually. It’s time to leave. This assignment goes against all my reporting instincts: getting close to people, sitting in their houses, being open to chaos and unpredictability and absorbing myself in other people’s lives to forget about me. It is, of course, always possible to connect, and with protection we can get a lot done but I recoiled when a cleaner at the Ebola ward got too close. I conducted an interview from a car at the quarantined Mayambo village as I just wanted to stay insulated. No one is infectious unless they exhibit symptoms, so we are constantly looking into people’s eyes, trying to ascertain if they seem off, hot, dazed.
And it is mentally exhausting never being able to switch off. We are constantly disinfecting our camera equipment with chlorinated water, wash our hands at least 50 times a day, seal the tripod in three plastic bags that we then spray with chlorine, spray our rubber boots before and after we do almost everything, even spray the car doors with chlorine any time anyone leans on them, which is all the time.
Ebola survivors seem safe - perhaps the only people in the country you can touch carefree, but a couple of members of the group at the Kenema hospital - tired, hungry and cold having waited for a Ministry of Social Welfare vehicle for two days to take them to their various homes - had persuaded a nurse to let them sneak back into the high risk Ebola ward to take their blankets as they were forced to sleep on a hospital room’s dirty floor. Those blankets were contaminated and turned a low risk area into a medium-risk one. Josephine, the head nurse, assures us this happened after we had wrapped up our interview in the same room. She is a survivor among many dead. “I don’t know how I have survived," she said. "Maybe I am immune - it is only God who has kept me safe."
*not her real name