Les Roberts – Makeni, Sierra Leone – April 9 2015
As an outsider, with only a couple of months experience in Sierra Leone back in 2001 and 2002, it is really hard to digest the nuances of the culture here. For example, when people lie to you or to the record, it is hard to know if you should be ticked-off.
About two weeks ago, I was with a couple of colleagues investigating a case involving a woman who had died in the District hospital; almost everything went wrong. She died just before the three days lockdown so it took four days for the District health officials to start investigating and then:
- She had arrived with clear symptoms of Ebola but she was related to the head nurse, so when a nurse wanted to call the “Ebola Alert” line to take her as a suspect case to a treatment center (in the next District over), the head nurse said “no”, she was fine.
- She died around 36 hours after arriving but it then took 12 hours for the body to be picked up by the safe burial team with her lying dead in the full ward for that period.
- None of the nurses were practicing any of the minimal infection control practices (wearing gloves, washing hands between patients…).
- When the safe burial team sprayed chlorine around the bed, they did not spray the mattress and instead set it outside in the sun. When a new patient arrived some hours later, she was put on that mattress.
- When during the inquiry four days later, my colleague saw a women vomit and brought it to the attention of the staff, they realized she had a temperature of 38 degrees Celsius, they said it was not an issue because she had been fine before. They could not be talked into calling the 117 Ebola Alert line… nor could the hospital safety officer… it just goes on and on.
So when I heard the chief nurse yelling at someone, mad as hell because she was now quarantined with nine other nurses, claiming that her nurses on the women’s ward always wash their hands between patients when I had just witnessed the opposite 20 times, I felt a little miffed! Many of my Sierra Leonean counterparts have had their lives ruined. The schools have been closed for a year. Selfishly, it has been weeks since I woke-up next to my wife. I have students that have waited two months to get papers back – that has never happened before. And hundreds of others and I are here now because of a systematic series of sanitary catastrophes, still happening 12 months into this outbreak. I later learned that four of the seven deaths logged in that women’s ward were never registered as a death within the District. Our local co-workers insist that this is because the families bribe the burial teams to give them the body so they can have a traditional burial… which if true, only increases my miffedness.
On the other hand, I have visited about a dozen Public Health Units (PHUs) in the past days and all of them are ignoring the rules about screening febrile patients. The government insists that anyone with fever and three symptoms must be turned away from the PHU and sent to be tested for Ebola at a Community Care Center (CCC) or Ebola Treatment Unit (ETU) for further screening, and when appropriate, testing. Often this involves travelling great distances. Even when the CCC is nearby, it means having your blood drawn and staying for a day or two before getting the results back. In the rural district with the highest attack rate this week, they had one positive blood sample out of around 880 taken at the screening centers in March, so almost all people tested experience two days of fear and loneliness for no benefit. Most people will just not go to these treatment centers. They are scary. There are human-like figures in PPE. It is hot and away from people, which is unnatural here. Thus, the nurses at the PHUs just do not enforce the screening requirement. They see a woman walking in with her child, the child is 1,000 or 10,000 times more likely to have malaria than Ebola. If they enforce the screening rules, that woman and child will not come to the clinic and that child will not be treated. The nurse knows the rules, she knows the risks, and she is choosing to do what is best for that mother and child while ignoring what is best for catching those last couple cases of Ebola in the country, which is my agenda. When I arrive in my nice WHO vehicle and she lies to me about having no patients that matched the suspect Ebola case definition, and I see dozens of malaria and typhoid cases diagnosed in the past weeks which mostly had to fit the suspect Ebola definition, I feel nothing but affection for her. My agenda and the Government Ebola agenda are not well aligned with her life-saving agenda.
Thus, I am not sure what to think and how to feel when I catch Chiefs in a bold-faced lie. For example, three out of five villages in Kambia District where the Chiefs told me they had no deaths this year had fresh graves in the cemetery. Not fresh like no vegetative cover, fresh like in recent days where the soil is not yet dried out and sun-bleached. I know they fear quarantine. I know they have broken the law by hiding deaths. But, what I cannot fully understand is their motives and how much these lying, Chief hiding deaths are markers for those populations that practice unsafe burials, and how much they are inducing risks for the collective good. The wounds of the war are fresh. Many tribes don’t trust their District leaders. I don’t fully understand the implications of their deception.
There are a lot of deaths still hidden in the rural areas. But I take great comfort that two weeks to the day after the debacle with the dead woman in the hospital ward, no secondary infections have arisen from her nurses or fellow patients. Last week we only had nine cases nation-wide in spite of all these widespread appalling practices. Thank goodness Ebola is only an intermittently infectious disease.