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.
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Sierra Leone’s troubled history is written into its landscape. If you walk the roads around Kono, you’ll see shelled structures that were once beautiful homes. A brutal 11-year civil war ended 12 years ago, displacing hundreds of thousands of Sierra Leoneans. The war’s legacy is everywhere: in the bullet shells buried in dusty roads, in the thousands of ex-rebels who now drive motorbikes for the extra cash, and in the amputees populating cities and towns. Almost everyone carries a war story, and has lost loved ones in the conflict. The war and post-war period have left a legacy of lasting fear and suspicion of the government and of humanitarian aid organizations, which often leave communities to make do when funding runs out.
This distrust is amplified by a history of the government falling short on its promises. For example, in 2010 the Ministry of Health launched the Free Health Care Initiative to provide free health care for pregnant and lactating mothers and children under five. Four years later the reality, at least in Kono, is that these people are often still asked to pay for care at public hospitals. Drugs are in short supply, and health workers implement fees to maintain their inventory. Often, health workers cannot offer essential care because the necessary equipment, drugs, and trained professionals are not, or never were, available.
When a crisis like Ebola strikes in this context it is not surprising that aggressive, opaque public health measures are met with suspicion, resistance, and anger. The Ebola task force meetings I continued to attend increasingly focused on these community level challenges. The hour long task force meetings turned into four hours, circling around and around one issue: “the lack of understanding.” Funding began pouring in from the large NGOs for door-to-door sensitization. Pickup trucks with large speakers drove slowly through the market each day, blasting: “It feels like malaria, but it’s not! If you want to survive, go quickly to a facility!” One day, my motorbike taxi was halted as a several-thousand-person “Ebola protest” marched through town, families vehemently chanting as if to scare the disease away.
As public health authorities in Freetown and Kono—as well as the international media—increasingly complained of how people in Kailahun “did not understand,” the situation was spiraling out of control. Several times, patients were forcibly removed by their relatives from isolation wards and disappeared into the rural provinces. This, too, was interpreted as a result of ignorance, and inspired a new round of educational initiatives arguing against the use of local healers and traditional medicine in Kono and elsewhere.
“Many people in Sierra Leone, where an Ebola epidemic has gripped the country for the first time, refuse to accept that the disease can be tackled by Western medicine,” a writer for The Economist’s Baobab Blog explained. As the outbreak continued to spread, so too did a shallow discourse of socio-cultural explanations. Health authorities, experts, and the media increasingly blamed communities for the continued spread of the disease.
In public health, the emphasis on “harmful behaviors” arising from ignorance fails to acknowledge the complex socioeconomic factors and structural conditions that can lead to poor health. In the wake of the first Ebola cases in Guinea, the Guinean government and later the Sierra Leonean government launched a massive campaign to persuade people not to hunt and consume bushmeat, which is thought to carry Ebola. Though well-intentioned, these campaigns did not adequately consider that malnutrition is widespread in rural West Africa, and villages in which the population heavily relies on bushmeat are often healthier—in our experience, they even have significantly lower rates of malnourishment. It wasn’t just an issue of people “not knowing” not to eat fruit bats and gorillas—bushmeat was their only source of protein. Continuing to eat it can be understood as a rational decision based on a risk assessment—malnutrition will likely always lead to more deaths in West Africa than an Ebola outbreak.
But I’ve also observed through four years of fieldwork in Sierra Leone that public health interventions that rely on the passive reception of “medical facts” by target communities and that hinge on getting "them" to think like "us," are simply ineffective. To health workers, taking patients home to die in surrounded by their families, to be collectively buried and remembered in their villages might be considered “irrational” or “contributing to the spread of the disease.” But these practices also allow for a kind of solidarity and resilience in the face of capricious, cruel disease.