Courage, death and survival: On the front lines of the Ebola outbreak
STEPHEN DOUGLAS
KENEMA, SIERRA LEONE — Special to The Globe and Mail
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The man everyone calls “Shawarma” looks tired and weak sitting in his rickety wheelchair. I’m immediately worried as I enter the Ebola Treatment Center at the Kenema Government Hospital. Shawarma, in his early 30s, is an Egyptian national who was transported to the center from eastern Freetown after being discovered in a private “mushroom” health clinic – one that popped up outside the network of licensed clinics. He tested positive and spent two months in isolation. Shawarma’s hair is uncombed and he hasn’t shaved, for risk of nicking himself, in two months. Beside Shawarma is Mustapha, a very lean looking man in a tight blue T-shirt. He too was in isolation for the past six weeks. Mariama wears a head tie and looks dazed and confused. Fatmata, standing off to the side, is young but her gaunt cheeks and hollowed eyes tell a different story. Today these four are being discharged from the Ebola Treatment Centre. They have survived the virus and can now return to their homes.
People walk by a billboard in Freetown, Sierra Leone. (AP Photo/ Michael Duff)
Two days earlier two nurses passed away in the same clinic, Josephine, the hospital matron, tells me. My friend, Hawa Rebecca, was one. When I tell Josephine that Rebecca was a friend of mine, we exchange condolences and Josephine tells me what a fine nurse and friend Rebecca was to her. More than 20 nurses and healthcare workers including Sierra Leone’s top virologist who was leading the Ebola effort, the Dr. Sheik Umar Khan, have died from contact with the Ebola virus.
Josephine moves from the sadness of death to the joy of discharge very quickly as she introduces me to the survivors. “We have very bad days here and today we’re celebrating a good day,” she says as she gathers the nurses and doctors around her. We’re standing in the entrance way to the clinic, behind the white plastic walls that separate the triage area and the isolation unit, and as we talk more and more people in scrubs and gloves join the group. We all stand apart and no one touches anyone. Josephine makes a compelling speech full of motivation and praise for “the team” and wishes the four survivors well. “You are well now but you still need to heal,” she says, and the staff applaud. But I’m struck by the thought that these survivors have to go home, continue to get well, deal with the negative stigma of being an Ebola patient and also mourn the loss of members of their families who didn’t survive.
There’s a short lull in the proceedings as nurses adjust their goggles and wander back to their stations and doctors turn to each other to discuss specific patients. I’m pulling at my plastic hood and trying to get some air down the front of my slippery overalls. It’s hot standing under the sun and it’s very hot under my plastic coverings. My feet ache in the rubber boots that are two sizes too small. My shirt, under the gown, is soaked in sweat and my goggles have fogged up. I’m thankful for an auto-focus lens on my camera.
Following the brief ceremony and posing for pictures, each survivor is called into the office to receive a small allowance of 60,000 Leones (approximately $13 U.S.) and a letter stating they are now healthy. The letter, on A4 paper, is signed by a doctor. It carries an official hospital stamp and has the date in the top right-hand corner. Two of the former patients have to ink their thumbs and provide a thumbprint in a large ledger to acknowledge receipt of the money because they can’t read. I’m not sure what they’ll do with their letters.
Scrub with chlorine, and scrub again
Nurses at Kenema Hospital are sprayed down before being ungowned. (Stephen Douglas for The Globe and Mail)
The security personnel, just inside the metal gates are from a private agency. As I leave, behind the former patients, I greet the older guard with, “Ya Pa. Ow de bodi?” – without shaking hands but with a slight bow. He responds with a smile and ushers me forward. Most of the new “white folk” don’t speak Krio so he was a little flummoxed by my salutation.
On my way out, I pass by the triage area again, a white plastic tarpaulin tent with the logo of Médecins Sans Frontières (Doctors Without Borders) pasted on the side. I’m told to wash my hands, again, in a chlorine mixture by a nurse dressed in full protective gear. She wore her plastic goggles, mask, two pairs of gloves, full body covering and rubber boots proudly. She watched me, from a safe distance, wash my hands and then instructed me to pull each finger from base to tip. She then proceeded to give me a detailed lesson in hand washing making sure I scrubbed my thumbs and fingernails. Upon inspection, she then said my fingernails were a bit long and I should cut them down to help prevent the spread of any disease. “One millimetre, only!” she instructed.
Lockdown ordered, emergency teams move in
The Kenema Government Hospital and Ebola Treatment Center is on a main thoroughfare in Kenema but still well within the town’s limits. There’s a police post opposite one of the two entrance gates where constables in blue coveralls lounge and chat with passersby. There’s a booth selling T-shirts next to the gate and a collection of motorcycle taxis, called okadas, parked to the other side. Behind the okadas is a shop selling plates of rice and sauce for 5,000 Leones. Other street traders have abandoned their stalls, thrown-together affairs of scrap wood and tarps and bits of corrugated metal. Business is slow for those who’ve stayed.
On Thursday, President Ernest Bai Koroma, addressed the nation over radio and television. In Kenema, there are few people with TVs so residents gathered around battery-operated radios. I stood listening with a group of people, all standing at least a meter apart from one another in front of a ramshackle stall selling flashlights and batteries. The President had already declared a state of emergency. Now all bars, cinemas, video parlours and nightclubs were told to stop their activities. All “mushroom” and private health clinics must stop their operations. The Sierra Leone Police will organize regular patrols to prevent illegal activities including unauthorized movement of Ebola-infected persons. Non-essential travel will be restricted between the Ebola epicentres of Kenema and Kailahun and the rest of the country. People seemed bewildered, not sure what all these measures will really mean for them.
Admittedly, Sierra Leone got a slow start on preventing the spread of the disease even though the outbreak was ravaging neighbouring Guinea. But forces are now mobilized here and “all hands are on deck,” according to government spokespersons. The President chairs a task force and the WHO has set up an emergency operations centre. Since the “stay-at-home” day last Monday, there’s been a flurry of activity around the country.
Health workers carry the body of an Ebola victim to the Kenema Hospital morgue. (Tommy Trenchard/The New York Times)
Here in Kenema, Red Cross doctors and nurses have converged from Spain, Australia, Scotland, Norway and Sweden. They are a very impressive group and are now being oriented and trained by WHO and MSF field staff. I meet the Red Cross team every morning for breakfast at the place I’m staying, the National Pastoral, Social and Development Centre, run by the Diocese of Kenema under the Catholic Mission. We break bread and share fresh eggs from the poultry farm nearby with Father Paddy and a Sierra Leonean seminarian named Augustine. Fr. Paddy is an Irish priest in his 60s and has been in Sierra Leone for years. His relaxed attitude and welcoming hospitality are reassuring to the team. Aunty Mariama, who’s worked at the Pastoral Centre for 21 years, is everyone’s mother and beams as she carefully sets out the plates, cutlery and hand sanitizers for the team.
The emergency response unit of the International Federation of Red Cross and Red Crescent Societies has brought a ton of experience and know-how to help the government of Sierra Leone fight the disease outbreak. They’ve also brought much-needed equipment and will be setting up a 60-bed hospital 40 kilometres outside of Kenema in the middle of a deserted area near the small village of Hangha. The logistical requirements are huge and costly but not overwhelming. The ERU team is a well-oiled machine and I’m amazed at what they’re able to accomplish in such a short period of time, especially in this place where it’s “not easy,” as so many people say.
Suspicion of a foreign “miracle cure”
As I approached Binta’s cookery shop located in a newly constructed and basically empty plaza that also hosts a private bus company, I overhear a conversation about a miracle cure from the U.S. The rumour mill is a powerful and pervasive source of community and international news. Word-of-mouth spreads gossip and rumour faster than any disease will ever spread. My lunch of groundnut stew, fish and rice is interrupted by a fierce argument from the adjoining table. Two middle-aged men are thrashing out the ethical dilemma of using experimental drugs on Sierra Leoneans. One man, bald and shining with perspiration, states that if he were sick or his family were sick, he’d choose to be a test subject. The other, a greying man with what they call a “government belly” is fiercely against such experimentation.
Word-of-mouth spreads gossip and rumour faster than any disease will ever spread.
The drug in question is ZMapp, although I’m sure they don’t know its name, is an experimental serum that was recently used on two U.S. Ebola disease patients. The patients, one a missionary, are said to be recovering. And so the debate rages here on the front line of the Ebola crisis. Should the experimental serum be used here? Like so many other things, you’re almost damned if you do and damned if you don’t. As I listened to the debate and finish my plastic bag of water, I thought: If they somehow manage to get the drug here, some people will accuse the U.S. and medical world of experimenting on suffering Africans. And, if they don’t use the drug here some will say, “See? The Western world and those white people don’t care about us poor Africans.”
Strangers, uniforms and even nurses evoke fear
This strange “good and bad/no win” combination hit me again as I talked to Patrick, who’s a young guy working for the Kenema District Medical Office. He was helping at a community volunteer “sensitization training” supported by the International Rescue Committee. As we whispered outside the crowded meeting room, I asked how the new awareness-raising teams were going to work. Apparently, the IRC, supported by WHO through the District Health Office, were going to send teams of “sensitizers” into the community to preach the word of Ebola. The young people would receive a day of training and some posters and then be sent into all chiefdoms and neighbourhoods within the district. I asked how the “sensitizers” would be identified because there have been instances of violence when healthcare workers entered communities. Patrick said maybe they would get T-shirts.
Identifying those “sensitizers” – or being labelled a healthcare worker – is risky. Nurses are associated with the sick, and most people don’t want to be around anyone involved with Ebola. Many people have seen the transport teams as they retrieve sick people or dead bodies, and they seem frighteningly alien. Some communities want nothing to do with anyone in a uniform or matching shirts. But not identifying “sensitizers” or community awareness teams is also risky. And if the young sensitizers don’t wear identifying clothing, they’ll be shunned as newcomers, something else neighbourhoods are wary of. Once again, you’re damned if you do and damned if you don’t.
Preaching Jesus as the Ebola solution
Stephen Douglas for The Globe and Mail
There are other groups who aren’t afraid of being identified along the dirt track roads. These are the evangelists with loud speakers, matching T-shirts and hand-drawn signs. As I wove my way through one of the tightly packed markets, I heard the commotion. I also heard the booming voice of a young man telling people to pray – and that Jesus was the answer to Ebola. All around me the market women, fish sellers and small children would shout, “Amen” in unison whenever the strolling pastor bellowed out: “In Jesus’s name.” The Kenema Council of Pentecostal Churches came rallying through town parading around an SUV that had “No new Ebola infections – in Jesus’s name” printed on the side of the vehicle. Followers were enthusiastic and the market sellers had something to gawk at for a few minutes.
I climbed behind Amadu on his okada motorcycle taxi, careful to avoid any skin contact, and sped away. Amadu is a former child soldier and now rides a motorbike to make ends meet. He turned to me and said, “Crazy Christians” and we shared a good laugh.
A child’s smile, and enduring hope
Amadu dropped me along a rutted and pot-holed dirt road so I could look for the Kamara compound. I was greeted by a swarm of children who’d obviously been told repeatedly not to touch anyone. Normally, I’m peppered by little hands and upturned smiles. On this visit, the children merely gathered around and I kept my hands to myself, which was a bit difficult given my propensity to grab, tickle or rub heads of anyone under a metre tall. I met Pa Kamara, who’s almost 80 but doesn’t know for sure, and his second wife, Mary. We sat under the overhanging branches of a mango tree and were discussing the rising price of food at the market since the quarantine began. A cup of rice, two months ago, was 750 Leones. The rice I bought for the family was 1,200 Leones per cup – and not because I was paying the “white man price.” I’m a shrewd negotiator and quick with “me sabi Salone money,” which means I understand the value of a Leone and can’t be tricked into paying exorbitantly inflated prices.
Mary turned abruptly and shouted in Mende, her tribal tongue, at a small child who’d climbed a small stump and was balanced against a dull yellow house. The little girl climbed down and disappeared behind the lean-to cooking shed. Mary told me that the girl shouldn’t touch the house. Medical personnel had sprayed the house down the day before. Someone in the house had died of Ebola earlier in the week. The house was deserted.
I visited the Kenema Hospital again and demonstrated my hand-washing technique to the triage nurses, who were suitably impressed. The MSF tent was empty, for a change, and nursing staff had lowered their hoods and taken off their goggles. They looked relieved to be bored. I had my shoes sprayed down and donned gloves avoiding the full gowning because I wasn’t going anywhere near the Ebola treatment side of the compound. I visited Josephine, the hospital matron, and handed a bundle of photographs to Joseph, the general secretary. These were the prints of the pictures I took during the discharge ceremony the previous day. After giving the survivors their photos, Joseph thought it would be good to post the remaining pictures on the treatment room notice board for all the nurses and doctors to see. “It will make them feel so good to see the success of their work,” Joseph said to Josephine. “And,,” Josephine added, “it will help give our patients some encouragement and hope.” Perhaps I should learn something from the parading Christians. There may be no cure for the Ebola virus disease but there’s always hope.
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