As far as we know (20th August), there have not been any cases of ebola in Hastings SL, though Sallu and his team are very worried and are doing their best to be ready, and to educate the public about what they can do. We at the Link will do our best to respond to the situation as it develops. Dr Effi Gooding has sent us the following harrowing account of the situation in the east of the country, written by a Sierra Leonean reporter:
KAILAHUN, SIERRA LEONE—The day shift at the Ebola treatment centre has barely begun when a nurse runs up to Ewenn Chenard to announce the first corpse of the day.
Chenard’s team is responsible for removing bodies from the isolation ward and the nurse stretches out her forearm, showing him the “212” she has written haphazardly on her skin. “C3. Ten years. OK?”
Such numbers and letters have become the language of death at the Médecins Sans Frontières treatment centre in Kailahun district, the epicentre of the Ebola outbreak in West Africa. “212” is the patient’s identification number; “C3” is the tent where Chenard will find the corpse; “ten years” — the patient’s age. Chenard will need a child-sized body bag.
Patient 212’s name is Jimmy and he is the 90th death at this centre since it opened seven weeks ago. He will not be buried today because there are already nine bodies in the morgue — one has been rotting for four days. “That is a problem,” says Sebastian Stein, who works with Chenard. “Not enough burial teams.”
This is the reality of fighting this Ebola outbreak. Too many patients, too many bodies, and not nearly enough money, people, chlorine or even ambulances to stop the dying. Last week, the World Health Organization declared the outbreak a global health emergency.
There is no great mystery in containing an Ebola outbreak; every flare-up since 1976 has been successfully quelled. But this time, the virus has slithered into a new part of Africa, gaining a foothold in large cities. Now more than 1,800 infections have been reported in four West African countries, including in their capitals; in Freetown, Sierra Leone’s capital, there are at least 11 cases, but a treatment centre has yet to open.
This outbreak has also been a disaster of poverty, emerging in some of the world’s poorest nations.
Forty per cent of the total reported cases in this outbreak have been in Sierra Leone. Among the affected countries, it is the worst off by nearly every development measure, ranking 183 out of 187 on the Human Development Index with more than half its population living below the poverty line.
With the arrival of Ebola, an already weak health system is now buckling. “The system’s already stretched to the limit,” said Dr. Jacob Mufunda, the country’s WHO representative. “(We need) surge capacity. Not for three weeks — six months to one year, from other countries.”
If the world hadn’t noticed Sierra Leone’s struggles before, it certainly does now. Unless Ebola is defeated in the West African villages and cities seeding the outbreak, the virus will continue to be an international threat; it has already brought patients to hospitals in Spain and the United States and caused scares as close to home as Brampton.
Millions have recently been pledged toward fighting the outbreak and reinforcements are beginning to trickle in. But it’s not coming fast enough.
In Kailahun, the district with the highest number of cases in Sierra Leone, the struggle remains lonely and exhausting. The fight has largely fallen to Sierra Leoneans like Daniel James, who volunteers his days burying infected corpses, or Ahmed Lengor, paid $10 per shift to clean vomit and diarrhea teeming with virus.
Everyone is exhausted. The day after Jimmy’s death, 10 more people died at the MSF centre, sending Chenard into the isolation ward five times, even though protocols discourage more than three daily entries to avoid fatigue and mistakes.
Only four ambulances serve this district of roughly 465,000 and one pulls up with five people crammed inside — three are confirmed to have Ebola. If the other two were not already infected, and did not have protection, chances are they probably have the virus now.
And at the treatment centre, the biggest ever built by MSF, they have reached maximum capacity. More than 150 trees had to be cut to make space for what was to be a 50-bed centre. There are now 80 beds.
MSF is refusing to expand. Without additional staff and resources, patients and staff will be put at risk, says Anja Wolz, who has been running MSF’s emergency response in Kailahun. She already served Ebola missions in Guinea and Liberia when MSF asked her to come to Sierra Leone. A few days ago, she finally went home for a much-deserved break but says she expects to spend Christmas in West Africa.
With Ebola, you need to be a step ahead, she says. In Sierra Leone, they have been “two steps behind, four steps behind.”
“It’s frustrating. I’m really frustrated,” she says. “We know what to do but we don’t have the capacity to do it.”
At the MSF centre, everyone’s nightmare is what happened at the Kenema government hospital.
No MSF worker has ever died from Ebola. But in Kenema, five hours from Kailahun along a pothole-infested road, more than 20 hospital workers have died from Ebola since May 25, when the Sierra Leone outbreak was declared. Among them was Dr. Sheik Humarr Khan, the country’s top expert on viral hemorrhagic fevers.
Chenard went to Kenema to help identify what went wrong. “It’s the worst place I’ve seen as an Ebola treatment centre,” says the 32-year-old Frenchman, a logistician who specializes in water and sanitation. “Take everything that you want to avoid in a treatment centre — and you are in Kenema.”
There was blood on the walls, starving patients and hygienists using water that was “brown like mud.” Health workers moved from high-risk to low-risk areas without changing clothes; “you never knew who was next to you,” Chenard says. “It could be a patient, suspected or confirmed … it could be hospital personnel.”
He recommended the hospital hire at least 46 more staff to support infection control and sanitation in its isolation ward. When he visited, there were only three.
“They don’t have the means to work properly,” he says. “It’s not like they do not try. They really try their best. But there are not enough numbers and there are not enough skills.”
There are now plans to open an isolation ward outside of Kenema, which the Red Cross will run.
At the MSF centre, built on years of experience, the rules are fastidious. There is no touching, even at the compound where staff stay, and when a visitor briefly leans against a pole, she is quickly admonished not to touch anything.
The personal protective equipment, or PPE, is your lifeline in the isolation ward and it takes 15 to 20 minutes to put on, a slow, precise process that requires a supervising hygienist who checks for gaps, tears and oversights. But when you leave the ward, it becomes your greatest threat if you don’t disrobe properly, ensuring the contaminated suit does not brush against your skin or clothes.
Since nothing leaves isolation, doctors shout their medical notes to a nurse standing on the other side of the fence. “Abdominal pain,” a doctor calls out, as a nurse scribbles. “Needs diapers.” Twice a day, waste from the contaminated area gets burned in a large pit, including the 150 Tyvek suits used daily.
The 92 hygienists — all locals — perform one of the centre’s most gruelling jobs. Among them is Ahmed Lengor, a 46-year-old who since June has walked 20 minutes from his home to the treatment centre where he is paid a daily rate of 42,000 leones, about $10. His days are filled with vomit, stool, blood and bodies — which he must clean then dispose of.
Before he started this job, Lengor enjoyed sitting in the town centre and chatting with friends and neighbours. These days, people whisper when he comes near and move away.
“I just let it go,” he says. “Whatever you think about me, I don’t care. All I know is I’m doing something for my people, to save them.”
In sleepy Kailahun town, life continues; women sell grilled corn roadside; children play in the fields; motorcycles zoom along the dusty roads, sometimes with two or three on a bike.
But all is not normal. Plastic buckets filled with chlorine water are everywhere and the local economy all but stopped after the market and only bank closed. Sierra Leoneans, prone to hugging, handholding and handshaking, keep their distance.
Last Thursday, both Kailahun and Kenema were quarantined by the military — no moving in or out. The next day, there were no admissions at the MSF centre.
“I feel more insecure when there’s zero,” Wolz said at the district health office Saturday morning, where daily Ebola meetings are being held. “Like, going from seven to zero. We need to find out why there are no new admissions.”
These daily meetings are attended every day by some 50 people — NGO workers, government officials, local chiefs — who gather to discuss the latest numbers and problems: villages that initially refused chlorine are now complaining they have none; another patient who has gone into hiding; a new rumour spreading from Nigeria that saltwater washes will ward off Ebola.
They also talk about the contact tracers, who have been charged with the most important job in stemming this outbreak — identifying every person who has contacted a patient and following them for 21 days, the maximum incubation time for the virus.
There are currently 1,264 contacts being traced across the country. In Kailahun, there are 270, currently being traced by 314 volunteers equipped with a day’s worth of training and a cellphone.
But it is obvious that contacts are being missed. There are still new cases, new deaths in the villages.
“Only yesterday, there were three community deaths; today about four to six,” Wolz said last week. “This means we are not following up. It’s not functional at all.”
Alpha Sesay is a volunteer contact tracer with the Red Cross. He is 20, polite and wears a seemingly permanent smile and a T-shirt that says, “Spread the word and not the disease. Kick Ebola out of Sierra Leone.”
Sesay’s job is to follow up on a teenage boy he has been tracking who came to Kailahun after his father died in another village. Sesay walks to the teenager’s home and asks if anyone has seen him today. A boy, maybe 6, shakes his head; the teenager’s mother also shakes her head. Everyone gathered around the home shake their heads.
Sesay has only just received the contact tracing form. He starts to fill it out but scraps it when someone points out he has written the wrong name; he pulls out another one and finally enters the answers from his previous two visits.
Did the teen have nausea or vomiting? Muscle pain? Fever? No to all of these. Sesay could only take the boy’s word. He does not use a thermometer to check for fever.
After 15 minutes, the boy still hasn’t showed. Sesay shrugs and leaves but returns later that evening, catching him this time. Any symptoms? Still no, no, no. The boy has now made it through day nine of being traced by Sesay and has 12 more to go — unless he gets sick or runs away.
Sesay doesn’t get paid for this work, which has exposed him to potential Ebola patients as well as threats from nervous townspeople.
But he won’t quit, even though his brother told him to. “I want to help,” he says brightly, with that wide smile. “So soon we can kick this Ebola virus out of this country.”
A group of glum-looking young men are sweating in a dusty lot near the centre of Kailahun, listening to a stern 20-minute lecture.
“Whatever you do today will reflect on you tomorrow,” says Eric Moosa, the district health superintendent. “If you are a hard worker, it will reflect on you in the future.” The boys stare at him in silence.
“We know it’s a risky job,” says Daniel James, a Red Cross volunteer. “But please, let’s do it from our heart.” More stares, more silence.
These boys are in their late teens and early 20s, dressed in soccer jerseys and dirty flip flops. They are the burial team and theirs is one of the most dangerous jobs in any Ebola outbreak.
Ebola is relentless. Even after it dispatches its victim, the virus will shed from the corpse, making funerals super-spreading events. Mourners often wash, touch or even embrace the bodies of their dead. Two or three weeks ago, two unsafe burials were performed in a nearby village “and then more than 30 to 35 people got infected,” says MSF’s Wolz.
Today’s lecture is in response to last week’s strike by some of the gravediggers. The boys wanted more than the monthly “incentive” of 350,000 leones, or $88, paid by the Ministry of Health. Hardly enough to make such grim and dangerous work appealing. But there are simply no other jobs in Kailahun due to the outbreak.
These boys labour in the heat in full PPEs. Sweat pours out of their boots and glasses when they take them off. The slightest mistake — a slip of the glove, a snag on a nail — could cost their life.
Their days are spent with corpses, some found lying in pools of blood. Sometimes, rigor mortis has seized the bodies and they have to wrestle with stiff limbs to fit them in the body bags.
One man told James he has nightmares of an Ebola corpse chasing him or sitting on his bed. “It was the first dead body he had seen,” James says. “Sometimes I worry when I see them doing the job because I can see they are frightened.”
James’s team heads to a village deep in the bush called Sambalu, where a death has been reported. Another team will take care of the 12 bodies waiting at the MSF morgue.
Like most days, the morning is filled with frustrating delays — the car needs fuel, they need to fetch more PPEs. Jimmy Kapetshi, a doctor from the Democratic Republic of Congo who samples suspected Ebola corpses, has yet to arrive.
At 12:30, the team finally hits a road so bumpy and treacherous that two cars wind up in a fender bender. When they reach Sambalu, Manjo Lamin is already there, a health official with the Ebola surveillance team as well as the 46th patient at the MSF centre — he was infected after poking his finger with a needle while taking a specimen.
Lamin has already done a preliminary investigation and says three men have washed the dead body. But he does not think the man died of Ebola — he was more than 100 years old and had not left the village in 20 years.
Moses Msellu, a villager, says there have been no Ebola cases in Sambalu, even though the village is a short paddle across the Mua River to Guinea, where the outbreak originated as early as December of last year.
The team gathers. Should they spend precious time burying the old man the “Ebola way”? Or appease the villagers by allowing a traditional burial?
But in this “era of Ebola,” the question “What if?” lingers. They suit up.
As they walk toward the dead man’s home, the villagers watch in silence, some snapping pictures. The team sprays everything with chlorine from tanks worn on their backs; the dirt floor outside the door, the rickety wooden bench.
In the dead man’s tiny room, goggles immediately fog up from the heat. The mood is tense and James’ voice takes on a hint of urgency. “Spray,” he commands, pointing to the walls. “Spray,” he says, pointing to a bucket. “Spray,” he says, pointing to the dead man, lying in bed beneath a thin blanket.
Kapetshi enters and carefully swabs inside the man’s mouth and nose. He takes a needle — slowly, slowly — and draws unpumped blood from the man’s heart.
The body is wrapped in a white sheet and body bagged — twice. Chlorine is sprayed after every step. They heave the corpse onto a stretcher and lay it on the ground outside so the villagers can gather and pray.
Kapetshi has seen Ebola many times and is not worried. “This is not Ebola,” he says. But even so, his entire body is disinfected before he carefully removes the suit, demanding again and again to be sprayed. His sample tubes are in a plastic bag that is sprayed, bagged again, and sprayed one more time.
The blood tests come back negative but no one feels the day was wasted. For one day, at least, there is one less “what if.”
The latest blood results have been posted: Negative, negative, negative, negative, negative, negative, negative.
A commotion suddenly erupts among the staff at the MSF centre.
“Seven people cured in one day,” nurse Géraldine Bégué exclaims. “I’ve never seen it.”
Everyone is especially excited about patient “65.” Dr. Sameh Kirollos, a 30-year-old doctor from Egypt, recognizes the number immediately — Isata, a 22-month-old girl admitted on the same day Kirollos started working here two months ago.
When Isata first arrived, she was terrified, says Stein, a water and sanitation specialist. She had been confirmed positive and was supposed to stay in the high-risk isolation area, accessible only to workers clad in PPE. But the area is fenced off with only plastic orange mesh — easily escaped by a toddler crawling underneath, which is exactly what Isata did.
“She’s so small and tiny and she can hardly walk, but everyone was freaking out,” Stein says. “It was this terrible situation where they were forming a circle around her, trying to keep her there, while people were very quickly trying to put on their PPE so they could put her back.”
Such is the savagery of Ebola — even a crying toddler becomes a source of terror and cannot be comforted.
MSF staff say babies never survive Ebola but last week, Isata became the youngest patient to be discharged from the centre. Staffers stayed late and came in on their day off to watch her leave. After she was doused in chlorine, she tottered out of the isolation ward and into the open arms of the joyful nurse. Everyone cheered.
But Isata’s struggle is only just beginning. She has survived Ebola but her parents did not. Across the district, workers are looking for other children orphaned or left vulnerable by Ebola; at last count there were 82.
The consequences of this outbreak will ripple for years, says Dr. James Sylvester Squire, Kailahun’s district medical officer. There has been no school or economic activity for months and for survivors like Mamie Lebbie — the country’s first laboratory-confirmed patient and survivor — her illness prevented her from farming and she is only now ploughing her fields, while others are already growing their rice; she worries about where she will get food or money in the coming months.
“The impact is huge,” Squire says. “Even in the next two years you’ll see the effects. People have lost entire families.”
Right now, the outbreak shows no signs of slowing. The staff at the MSF centre were still celebrating Isata and the other six discharges when Wolz received some news that ambulances were on the way.
“Twelve more are coming,” she tells a staffer. He grimaces and sighs deeply, shrugs and gets back to work.
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