FREETOWN, Sierra Leone—“Sir, Mr. Lamin’s daughter was discharged this morning, God be praised,” my friend and colleague Saffa said in that strange-sounding formal, almost archaic, English syntax of Sierra Leone. Those untutored in the formality of local language and social mores would miss that he was addressing me, a close friend, as “Sir” while talking of Yama, the 13-year-old daughter of his closest childhood friend and work colleague, Seule Lamin.
Seule, a government official; his wife, a nurse treating Ebola patients; and another daughter have died from the disease in the last two weeks. Yama survives with her 15-year-old brother, the only family member not stricken by the virus. Their future is certain. They will be raised by their extended family. Such is the Sierra Leonean way, the most tolerant, compassionate, and friendly people I have found anywhere.
Such good news, like Ebola treatment spaces, is in very short supply. The death toll today was 121, the highest in one day so far. More than 700 people have died from about 2,500 cases, according to the official numbers. With under-reporting rampant, the real numbers are probably much higher. Sick people don’t come forward and locals don’t rate the competence of civil servants to do the math or—more precisely—the data gathering, which is a challenge even for epidemiologists. Also, they are overly influenced by their democratically elected political masters who want to keep the lid on potential social unrest, perhaps with good reason. Recently, when the up-country city of Kenema had a few days without new cases, these exuberant and joyous people, true to form, had a spontaneous street party and the infections picked right back up again. Ebola is spread by physical contact with bodily fluids.
The government is being roundly criticised for its response, especially early on. I’ve done it myself, but in reality the government is doing its best with a health infrastructure that, at the best of times, is a shambles. And while I don’t want to blame the victims, the situation is abetted by an incredibly misinformed, gullible, and largely illiterate rural population. The totally inadequate international response must shoulder blame as well. Until the outbreak, depending on who you ask, the country had either four or 10 ambulances serving almost 7 million people with 20 used ones on order. Ten recently arrived, but eight were good only for spare parts. There are two doctors for every 100,000 people. Cuba has more than 500, the highest in the world. The U.S. has 390 and Canada has 227 per 100,000. There are 40 hospital beds per 100,000. The U.S. has 300 and even Afghanistan has 50. Quality drugs and medical supplies are always in short supply and procuring them is a major source of corruption.
Money is not the problem even if, according to the UN secretary-general, the $1 billion sought to deal with the epidemic remains undersubscribed. Britain and the United States, among others, have pledged vast amounts. But no one is asking for the money. Getting skilled medical and support people to come and work with the sick is the real issue. The epidemic will not be under control without people on the ground to build the specialized centers to house the sick and as long as the shortage of skilled medical staff remains. Feeling good about giving the money won’t create a single Ebola bed or help keep the disease away from the U.S.
Here in Freetown there’s an increasing sense of the plague closing in around us. That’s new. When I arrived here almost three months ago, as part of an international team dealing with public financial management, Ebola barely made a ripple. It was up-country, away, nothing to worry us. And yes, of course, let’s pity the poor people, and anyway it may not be real.
Not now. Death is looking people in the face. I saw two bodies on the center island of a traffic roundabout last week—they were still there two hours later. On Tuesday, heading to the office, a road was blocked as a body had been found on the street and the Ebola burial party had failed to show. I saw a woman collapse on the street and no one, including me, raised a finger to help. We eventually learned it was not Ebola but a simple fainting spell probably brought on by hypertension, another large-scale national health problem.
In fact, the burial teams were on strike. So, on the day following the single largest death toll no bodies were buried. The strike of burial teams has now been resolved. Apparently, a one-week backlog for hazard pay, which was deposited in the bank but never reached the burial teams, was behind the dispute. Such bureaucratic bungling is commonplace. The burial teams are composed of 600 workers organized in groups of 12, and there are now unconfirmed allegations of “rent seeking” against them. “Rent seeking” is a euphemism for corruption whereby the teams accept money to provide families access to the bodies who are at their most infectious immediately after death. If this is true, it represents a significant and dangerous leak in the quarantine system.
In July, warnings of huge infection numbers coming down the pipe from Médecins Sans Frontières (MSF) were felt by many, including me, to be over the top, alarmist, and probably motivated somehow by money. The local mind-set is, with good reason, to see corruption everywhere. But no longer seen as alarmist, MSF are the heroes with GOAL, an Irish NGO, and the International Medical Corps among others. They are seen to walk the walk. When they scream for more help, people help.
CDC is here too, in Sierra Leone, Liberia, and Guinea—146 people, I’m told. The WHO and CDC are doing stalwart work focusing the government response on “sensitization”—getting the message out that Ebola is real. Why so much focus on sensitization? You tell them it’s Ebola and that they’ll die, right? Surely, that’s enough. Many did not believe it was real. Conspiracy theorists saw it variously as a political plot to wipe out those from the eastern region who largely oppose the president, or as a way of derailing the national census. Some even saw it as an American plot to export infected monkeys to Sierra Leone.
Another reason for sensitization is many people don’t trust the government. On the recent three-day lockdown for sensitization, or the “ose-to-ose” (house to house) as it became known, some said the bars of soap given out by the teams were tainted with Ebola and that the teams were bringing the infection with them. Rather than going to government-run clinics, many chose traditional herbalists, some of whom claimed to know the cure.
Tracing has suggested that patient zero in the current outbreak may have been a young child in Guinea who had eaten fruit previously eaten by a bat. A traditional herbalist, who later crossed into Sierra Leone, treated the child. They both died. I have since discovered that in some regions “batmouth” fruit—fruit, frequently mangos, dropped by bats—is the fruit of choice among kids who pick it up in the bush. This also explains why, on my last trip here, I received a curious email from a British government source suggesting I refrain from eating fruit bats and bush meat (monkey and other primates) near the Guinea border.
One day in late July, there was pandemonium in the early hours as people all over the country were woken by calls and text messages telling them to take a saltwater bath, it would prevent Ebola. Millions did and, frankly, I would have done the same, but nobody phoned. Before the arrival of help from overseas, treatment protocols were inadequate. Suspected cases were placed together in locked holding areas. Testing, which could be hours or days later, resulted in “positives” being isolated for treatment and “negatives,” many now infected, being released, subject to an even now largely nonexistent public-health contact-tracking system.
So where does it all go from here? I’m no expert but my best guess, based on what I have seen develop in Sierra Leone, is that it’s coming your way soon unless the vaccines are developed, deployed, and we get boots on the ground, hopefully without guns this time. Of the 3,000 U.S. Marines heading to Liberia, why not send 300 doctors instead?