Blue

Updates from Ebola-affected Sierra Leone – November / December 2014: Brian Starken C.S.Sp.

Chapters:
I Return to Sierra Leone – 11th November
II A very fine line between life and death – 18th November
III The Ebola Burial Ground – 24th November
IV Reflecting on Health in Sierra Leone in the wake of Ebola


Chapter I  Return to Sierra Leone – 11th November

Photo for Ebola updateHaving been out of Sierra Leone since July this year, I returned to our Kenema base in early November. Given that the town was the initial epicentre of the current Ebola outbreak and as the constant and harrowing media coverage at home was greater than was ever given to the brutal civil war which raged in the West African country from 1991, I was a little apprehensive. 

Flying back via Brussels, I was one of about 100 passengers who got off in Lungi airport which is some distance from Freetown, the Sierra Leonean capital. 

There was no sense of panic at the airport. We were very politely asked to wash our hands in chlorinated water before entering Arrivals.  Apart from the usual landing card, we also had to fill out a medical form stating such things as where we boarded the airplane – some had got on at either Dakar or Conakry.  After the regular immigration checks, we formed another line for the ‘health desk’.  My medical form was quickly checked and my temperature taken with a pistol-like, small thermometer held close to the head. 

As there is a nightly curfew from 7pm, my first night back was in the retreat house of the Clarissian Sisters in Lungi. Interestingly, Lungi town has to date had no reported case of Ebola; people seemed to be moving around the town quite normally, traders were sitting at their stalls, and a few bars even appeared to be open for business. 

Next morning, after breakfast, I set off with two others for Kenema, usually a five and a half-hour trip. The first health check we met was just outside Port Loko town which has been badly hit and is quarantined. At the next check the medical attendant came to the vehicle and took our temperatures while we were still inside. The two police / army checkpoints along this stretch of road waved us through. With fewer vehicles on the road and no delays at any of the five additional health checks before Bo town, we moved quickly. 

On the road to Bo we had passed by Moyamba Junction – a lively market place along the main road and a place where public transport stops for refreshments or to buy goods. It is always bustling, and market women, armed with trays of food and fruit, usually surround any vehicle that stops. This town has been quarantined for the past month or so. The market was deserted and only a few people were strolling around.  Because of the quarantine, vehicles can’t now stop here.

It was getting close to 1.00 p.m. when we reached Bo. We stopped for a lunch of groundnut stew. The town looked unbelievably normal.  Ebola cases have been confirmed here but not in sufficient numbers to warrant a lockdown. The okadas (motorcycle taxis) seem to be thriving and people were going about their daily chores.  Shops, petrol stations, bars, restaurants and even some barbershops and hairdressing salons were open!

The forty-mile onward journey from Bo had seven check-points. The authorities remain very strict on people moving into and out of Kenema; the most demanding checkpoint was just outside the town where we were asked for our travel passes. We finally arrived at the Pastoral Centre; this was built in the 1970s – its first director was Ray Barry C.S.Sp. 

A thirty-strong team from the International Federation of Red Cross and Red Crescent Societies (IFRC)*is currently staying at the Pastoral Centre.  Team-members come from Australia, Belgium, Canada, Finland, Germany, New Zealand, Norway, Spain, Sierra Leone, Switzerland and the UK.  A field hospital has been set up at Mano Junction, about 15 miles to the east, while the IFRC also works at Kenema’s government-run hospital.  

With Freetown still very badly affected by Ebola and agencies struggling to cope with the large numbers of new cases, some patients are transferred from the capital to one of the two facilities here. The medical camp is divided into three sections: one section for new arrivals and those suspected of having Ebola; a treatment centre for confirmed cases; a section for recovering patients who have to remain under observation for three weeks. An ‘Ebola kindergarten’ was recently opened for the children of patients.

While no one can give an accurate indication of when the current Ebola crisis might end, the IFRC’s presence is having an obvious impact and no new cases have been diagnosed across Kenema district for the past four days. 

Talking to the doctors and nurses, they will quickly say that they find the work very difficult and stressful. While the Ebola suits that they must wear are very light, they are extremely hot – especially in tropical climates – and staff can only work in them for some 45 minutes at a time. The medical staff generally work a 10-hour day, 7 days a week, ending with a daily team meeting before supper. Medical personnel, who have regular contact with Ebola patients, are typically on assignment for about a month at a time.  Not all doctors complete their stint; recently one doctor took ill and had a very high temperature. Fortunately, it was quickly diagnosed as ‘only’ heat stroke and the doctor went home on the next flight.

Kenema itself looks very normal. Life has not come to a standstill. I was able to get my internet connection up and running and to get my mobile phone re-registered. Supermarkets are open.  Food seems to be available though, of course, prices have gone up. 

It does seem to me that there are fewer people on the streets of the town but then all the schools and educational institutions are closed until further notice. One interesting consequence of the spread of Ebola is that football is now banned. As a result, the two playing pitches on the Pastoral Centre compound, which were used until recently by local children every afternoon, are becoming overgrown!

* See http://www.ifrc.org/en/news-and-media/news-stories/africa/sierra-leone/in-pictures-ebola-virus-disease---kenema-treatment-center/ 


II  A very fine line between life and death – 18th November 

The dry season is fast approaching and it is getting considerably hotter here in Kenema. Many of the IFRC workers are not used to such tropical heat, and today they brought a new large electricity-generator to the compound. The ‘town supply’ of electricity is inconsistent and unreliable while our own two much smaller generators have been around for some time and we only use them for two hours in the morning to pump water and for four hours at night both to pump water and provide light. The IFRC will operate the new generator and provide electricity allowing for rooms to be ventilated. The hope is that the generator will remain here even after their workers have been able to move on. 

With my fellow Irish Spiritan Paddy Ryan C.S.Sp. away in Bo for a few days, I took on responsibility for his ministry last weekend. While public places where people gather, such as cinemas, discos and video centres are closed until the present state of emergency has been lifted and football games are off, churches and mosques remain open to the public and services / prayers are held as normal. 

Fr. Paddy’s main station is at Burma, by the old airfield outside Kenema. Where there had been just one Sunday Mass now there are two in order to avoid overcrowding during the Ebola crisis. Both Masses were very well attended.

Outside the building there was the compulsory container of chlorinated water. Of course, there is no handshake for the sign of peace – everybody just waves. Communion is taken only in the hand.

After each Mass in Burma there was a role-play presented by the local ‘Ebola Committee’. It began with the ‘Chief’ announcing that Ebola in the area is now finished. The people start celebrating and hugging each other. A nurse arrives and tells the people to be vigilant even if there are no new cases of Ebola locally. Nobody pays any attention and the celebrations continue until a woman arrives with a very sick child and crying ‘Ebola’. The celebrations stop and the people scatter immediately. A simple but effective message: ‘Do not let your guard down’.

My third Mass was in the very rural Bandawo village, a few miles off the main road. It was also well attended and there was plenty of fruit and newly-harvested rice at the offertory.

On Monday morning I noticed about 40 pairs of wellingtons on the veranda outside the IFRC office with the word ‘Ebola’ being painted on each one. I enquired as to why this was necessary. It transpires that, after each use, the wellingtons are treated with disinfectant and can be re-used but a number of pairs were stolen when left out to dry. The hope is that, with ‘Ebola’ written on them, these boots won’t walk away!

Tomorrow we have to get firewood for the kitchen. All cooking is done on wood-burning earthen ovens.  We will get a large vehicle from the bishop’s office and we also have to get a pass for the vehicle and workers to travel.

To obtain a pass from the government office in town to travel outside Kenema, we have to apply and present all information – registration, destination and the names of driver and passengers.  With the reduction of confirmed cases here in the district, it is now a little easier to get travel passes but the restriction on travel outside – and into – Kenema remains in place. I believe that this travel restriction has helped greatly in curtailing the spread of Ebola in this eastern region of the country.

Given that the number of confirmed new cases and deaths has reduced so much, I enquired as to what factors contributed to this. In addition to the travel restrictions, it is believed that the 48-hour ‘lockdown’ of the country in September and the accompanying sensitisation programmes helped focus people’s minds. The deaths of two well-known and well-liked local doctors here in Kenema, and of many nurses and paramedics, really scared people into taking protective action. 

But Ebola is far from over. Today the IFRC had no fewer than 16 burials at the cemetery which is beside their field hospital.

 __________________________________________________________

Why did so many people die and I survive?

Let me thank God that I can return to my family.”

___________________________________________________________

One of the doctors just asked me if our chapel was open. It was closed but I offered to open it for him. On the way, he told me that he wanted to say a prayer of thanksgiving. Three weeks earlier he was working in the camp with Ebola patients. As he was removing his protective clothing, he noticed that he had somehow managed to cut his finger through the plastic glove and it was bleeding. 

His first reaction was ‘I am going to die’. He was horrified and lived the following three weeks in terror of getting a fever and of being diagnosed with the deadly disease. Today was the twenty-second day since the cut and, as three weeks is the maximum incubation period for the virus, he is now clear. He said that in those three weeks he had seen so many others die from Ebola. 

As I opened the door of the chapel, he said, ‘Brian, when you are working with Ebola, you realise that there is really a very fine line between life and death. Why did so many people die and I survive? Let me thank God that I can return to my family’. 


 III   The Ebola Burial Ground – 24th November

Andrew, a quietly-spoken New Zealander, is one of the IFRC team in Kenema.  His role as the Discharge Officer for Ebola patients has two very different aspects. As he puts it himself, ‘there is only one entrance to the field hospital but there are two exits’. 

One exit is to the main road, to continuing life and to a return to family and community.  Patients who no longer test positive for Ebola are moved to the recovery ward and, after three weeks, if still clear, are discharged. This is an occasion of much celebration, happiness and well-wishing – it is a victory for the staff and a ray of hope for other patients. The other exit, sadly, leads to the cemetery. 

For Andrew, who is assisted by a very well-trained burial team, the most difficult and dangerous aspect of work is the preparation for burial of those who have died from Ebola.  The virus does not die with the victim. In fact, it becomes more virulent in the dead body. 

To date 120 victims of Ebola – male and female, Christian and Muslim – ranging in age from 50 years old to a mere 3 months are buried in the new cemetery. The IFRC makes a great effort to contact the families of those who have died. If the deceased is from the local area, some family may attend the burial. But the majority of those who have died here are from far away and are buried with no family or friends present.  Each burial is an occasion of sadness. While mass graves have been used elsewhere to bury victims, the cemetery here is very well laid out with each individual grave marked with the deceased’s name, age, place of origin and date of death. A photograph of the grave is sent to the family.  As the IFRC does not always know the religion of a victim, Andrew recites the Our Father and one of the Muslim workers recites a passage from the Koran at each burial. 

Earlier this week Andrew informed me that his ‘tour of duty’ was soon coming to an end and he would dearly love to have the ‘Ebola cemetery’ consecrated before his departure.  We discussed the idea of a blessing for the cemetery with his team-leader; he was very supportive of the idea saying that ‘it is our duty to treat all our patients with dignity and respect. If a patient dies, we must offer the same dignity and respect to the deceased’. 

Having consulted with our local bishop, it was decided to have an inter-religious service. The local authorities, the District Ebola Task Force, the City Council, the Imams of the different Muslim communities as well as the Anglican and Methodist churches all agreed that they wished to be present and to take an active part in the ceremony. I asked Andrew to provide a small bottle of gin, a bottle of water and two glasses for the ceremony as ‘pouring libation’ is integral to all cultural ceremonies in Sierra Leone. Usually performed by a respected community elder, the purpose is to share with, and appease, the ancestors who have not been forgotten. The person designated to pour the libation addresses the ancestors and then pours a little gin and a little water on the ground, and also takes a little himself. 

The ceremony itself, on the morning of Friday 21st November, was a very simple one with Christian and Muslim prayers, readings from Scripture and from the Koran, short statements from the various religions and organisations present, interspersed with appropriate hymns and songs sung by an ad hoc choir.  

There was a very poignant moment during the ceremony when the bodies of the two latest victims of Ebola were brought by the burial team, all of whom were dressed in their protective clothing. The bodies, placed in ‘extra-secure’ body bags, were quietly and respectfully laid to rest under Andrew’s watchful eye. 

Bishop Patrick Koroma gave the final Prayer of Blessing and, after a few wreaths were laid, we departed in silence to the sound of workers filling in the two latest graves.  


IV   Reflecting on Health in Sierra Leone in the wake of Ebola 

Of all the factors that contributed to the spread of Ebola throughout Sierra Leone, lack of preparedness by government is surely top. Alarm bells should have rung when the first case was diagnosed in March just across the porous border with Guinea. When the first cases were diagnosed in Kailahun, there was still time to act by quarantining the infected people and the affected areas and by restricting the movement of people. Instead, panic was caused when suspected cases were moved to hospital in Kenema.  Fear and mistrust were soon rife.

The lack of any national information campaign allowed the rapid spread of mis-information such as ‘they are taking our people to the hospital to inject them and kill them’ and ‘the Ebola virus was imported so that health agencies and the government could make more money.’ Sick people would not go to hospital and in those early months of the outbreak, families removed relatives with Ebola from hospital making it extremely difficult for health workers to track down and control new infections. It also gave rise to very unsafe burials – a practice which may have caused up to 70% of new infections, as people who have died from Ebola are particularly contagious and must be buried without washing or touching the body.

The health system in Sierra Leone has always been very weak and it must be remembered that the civil war (1991-2002) had a further devastating effect, especially in rural areas. While a number of hospitals and clinics have been rehabilitated since the war they are still under- resourced, under-funded and under-staffed, and totally ill-equipped to deal with the current epidemic. Before the outbreak the country had just 180 doctors to serve a population of over five million people. At least ten of those doctors have since died from the virus. A four-month delay by government in introducing health checks and restrictions for people entering or leaving Kenema allowed the virus to spread easily to many other parts of the country while even health workers were unaware of the devastating effects of the virus or the precautions that were needed. 

The international response was also very slow in coming. Only Médecins Sans Frontières (MSF), which moved quickly in June to set up a field hospital serving the area first affected by the virus, had both previous experience of working with Ebola patients elsewhere in Africa and a long-standing presence on the ground in Sierra Leone. It has done a splendid job. (See http://www.msf.ie/

The International Federation of Red Cross and Red Crescent Societies (IFRC) came to Kenema in late August setting up its 60-bed facility. The IFRC too has made a real impact and the number of ‘new’ cases in Kenema has been reduced to almost zero. This shows that the outbreak can be contained. However, containment demands the co-operation of medical agencies, the government and the local population. 

One major fallout of the crisis is that people with other illnesses are now reluctant to go to hospital at all, including hospitals that are not designated for Ebola treatment, and people are even fearful of getting injections. 

Panguma Hospital, for example, is run by the Catholic Diocese of Kenema and is typical of those health facilities which, though not ‘Ebola-designated’, must be constantly on the alert for people infected by the virus. Suspected cases are immediately transferred to Kenema. The number of ‘regular’ patients at Panguma Hospital has decreased significantly. Expectant mothers will come for pre-natal checks and to receive their nutritional feeding supplements but, when it comes to delivery, they are unwilling to check-in to the hospital and opt to stay at home and call the Traditional Birth Attendants.

On the positive side, regular immunisation programmes are continuing, and patients who require regular medication and treatment for a range of diseases including diabetes, epilepsy HIV and TB are being catered for. Nutrition programmes continue to be administered by the hospital.   


Brian StarkenBrian Starken C.S.Sp. (pictured) was first appointed to Sierra Leone in 1975 and has spent a total of over 25 years there.  
Having returned to Ireland in December 2014, Fr. Brian takes up an appointment in pastoral ministry in a Dublin parish in early 2015.