In early April, as the first reports of Ebola began to emerge from Western Guinea, I was invited to attend the first meeting of the Kono District Ebola Response Task Force. Kono is a remote and impoverished diamond-mining district in Sierra Leone, bordering the then-epicenter of the outbreak, Gueckedou. We had just received bad news. One week earlier, the Guinean Ministry of Health had contacted the Sierra Leonean Ministry of Health, explaining that a potential Ebola victim had been carried across the border for burial. In interviewing family members in Guinea, they learned that a 15-year-old boy had died, and his family had brought his body to Boidu Village, Sierra Leone for burial.
The authorities in Freetown, Sierra Leone’s capital, guessed that the village was in Kailahun District, a region south of Kono that also bordered Guinea’s highly-affected areas. But on their list of village and town names, Kailahun’s health authorities saw nothing that resembled the word “Boidu.” Confused, they called Kono’s health officials who looked on their own list of villages—and found a “Buedu” village close to the border with Guinea. They sent a Land Cruiser to the distant community and officials sat down with the chiefs and elders. Indeed, they had buried a boy from the village who had been living with family in Guinea. Before he died, he had been bleeding out of his eyes. Everyone in the household in which he had been staying had since died too.
We sat listening to the story of the boy buried in Boidu village in the dusty office of Kono’s District Medical Officer—one of only three physicians in the public healthcare system for 500,000 people (and he himself does not practice). In the room were local staff from the major nongovernmental organizations working in Kono, as well as representatives from the media and three Paramount Chiefs, the highest of Sierra Leone’s traditional authorities. I was there as the executive director of Wellbody Alliance, a healthcare NGO that operates a medical center in Kono. Each of us had been provided with a print-out of the Wikipedia article on Ebola and a mandate to come up with possibilities for the district’s response.
“I want to see hundreds of volunteers going door to door to get the word out,” suggested one person.
“We should make every Guinean in the district register with local government, and be ready to expel them if the disease spreads,” said another.
The mood was tense in the room. The messages filtering in from Guinea were extreme: “a killer disease,” “bleeding out of every orifice,” “ravaging border villages in Guinea.” Radio broadcasts implored people not to eat bat meat, or touch people who exhibited symptoms.
We needed to develop a preventative response. With nothing to cling to but past experience, the group fell back on procedures that had become familiar in Sierra Leone through interventions that targeted HIV, maternal health, malaria, and tuberculosis. The majority of these programs emphasized education and “behavior change” as primary methods to improve health outcomes—people must be taught by health workers, volunteers, and community members to take better care of their own health. Women should be directed to deliver in clinics; mothers should be told to make their children sleep under mosquito nets; locals must learn rudimentary hygienic practices, stop eating bushmeat, and cooperate with local health regulations to slow the spread of Ebola. Few would deny that education plays a role in global public health, but the task force that day was reiterating an unquestioned assumption: that somehow, communities and patients’ choices would be to blame if Ebola came to Sierra Leone.
At the meeting we also learned the national protocol for isolating and referring patients to the treatment center. Lassa fever, a disease similar to Ebola, albeit less deadly and more treatable, has long been endemic in the south of Sierra Leone. In Kenema District, around 80 miles from Kono, the public hospital had an equipped isolation ward supported by international partners such as Tulane University in New Orleans. With this basic infrastructure for handling hemorrhagic fever patients in place, as soon as a patient met the criteria—fever, vomiting, and a history of travel to an affected area—the patient was to be immediately isolated where he was while blood tests were rushed to Kenema for diagnosis. If positive, one of a small fleet of Ebola-specific ambulances located in strategic regions of the country would rush to the presenting clinic and whisk the patient immediately to Kenema Hospital. The Ministry of Health created a national hotline to request testing and ambulances, and had distributed the protocol to all facilities in the country. With such a system in place, many healthworkers—including myself—felt relieved that Sierra Leone was well-prepared to use existing healthcare infrastructure to contain the disease.
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For two months Ebola swept through Guinean villages bordering Kono, but Sierra Leone remained almost unbelievably spared. On May 25, the first cases of Ebola were diagnosed in Sierra Leone in a remote village south of Kono called Koindu, in Kailahun District. All of the initial patients had attended the funeral of a local healer in Guinea who had been treating Ebola patients in her home; as is customary, they had likely washed her corpse before burial and contracted the disease. Cases were isolated at the public clinic in Koindu Village where they had presented, and preparations were underway for transferring them to Kenema’s Lassa fever ward.
This is when the rumors started spreading to Kono. Outside of our clinic, a woman yelled “Ebola is a lie! They’re sending people to Kenema to die!” I heard patients waiting at a food shack near our facility talking about how the government was trying to rapidly eliminate the Kissi Tribe—the inhabitants of the remote region where the outbreak began—in order to shift the census for the upcoming election. In Kailahun, a family barged into the Koindu clinic, demanding that they take patients waiting for transfer to Kenema back home.
Patients had presented at the Koindu clinic with diarrhea, fever, and vomiting, typical signs of tropical illnesses that are common in Sierra Leone, but were immediately separated and sent off to the Kenema hospital. Most of them did not return, and even their bodies were lost in the process—many were buried in mass graves in Kenema. Our nurse spoke to a friend in Kailahun who complained that she had absolutely no idea what had happened to her relative after he was taken away by the men in white plastic suits. The two fundamental components of the national response—rapid isolation and quick transfers to Kenema hospital—had unexpectedly induced a panic that ultimately contributed to the disease spiraling out of control.
The rumors proliferated. In Kono, in early July, I received a call from one of our staff in town that I shouldn’t meet him for lunch as we had planned. A rumor had spread through town that two children had died after receiving routine vaccines during a national in-school vaccination campaign. The entire city descended into panic. In the waiting area of our women’s center, a woman yelled into her cellphone. “Go pick up Kumba! They’re injecting Ebola and killing patients!” In Kailahun, Ebola continued to spread as villagers reportedly stoned health workers. Ambulance drivers described youth building ditches to prevent them from entering into communities where the nurses had reported Ebola patients, and in another village a medical store was burned to the ground.