Day 17

03.02.2015

When Ebola cases first showed up in Sierra Leone, it was late May 2014.  Initially, cases presented only in a small part of the country, near an eastern township called Kenema.  By early July, Connaught Hospital had its first case – a businessman who had had been visiting family in Kenema.  Since his return to Freetown, he had been sleeping in close quarters with several other people, despite mounting fever and gastrointestinal symptoms.  One of his housemates brought him to Connaught Hospital for evaluation.

At that time, the only laboratory in the country to run Ebola PCR testing was in Kenema, a 5 hour drive from Freetown on a bumpy road.  King’s Sierra Leone Partnership staff obtained a patient’s blood sample, packaged it securely, and arranged for a courier to deliver the sample to the Kenema lab by taxi.  Two days later, the Kenema lab had still not received the sample.  The courier was tracked down, and ultimately confessed that to save some money he had opted against taking a taxi and instead had taken a boda-boda (popular form of public transportation usually in the form of a crowded mini-bus) – and had lost the blood sample somehow on the way. 

Another blood sample was drawn and sent to Kenema by another courier.  At the time, it took on average over 5 days to get results back on an Ebola PCR blood test.  The patient had died by the time the positive result was reported.  One of his housemates had also fallen ill.

Early in the epidemic, several esteemed Sierra Leonese doctors, including Dr. Kahn, head of the Lassa Fever clinic and national expert on viral hemorrhagic fever, had died.  Fearing for their lives, doctors across Sierra Leone went on strike.   

King's staff scrambled to rapidly expand their capacity to accommodate the flood of Ebola cases. The two bed isolation unit at Connaught Hospital expanded to a 16 bed unit, sometimes with as many as 20 patients.  Patient mortality was over 60%.  It still took many days to get lab results back, and when a result was positive (the vast majority), almost invariably there were no beds available in the few operational Ebola Treatment Units.  As a result, the positive cases were not isolated from the suspect cases in the holding unit, increasing risk of transmission within the unit.   

With no open beds in the Connaught Hospital holding unit, patients with Ebola were often left outside the hospital gate in the triage tent, sometimes waiting for days.  Patients often opted to return to their homes rather than wait in the tent's oppressive heat with other sick and dying patients.  King’s volunteers informally referred to the triage tent as the Tent of Horror.

It would have been easy to get mired down in the weeds of patient care given the huge and pressing needs at the small isolation unit in Connaught Hospital.  But the real issue was the public health disaster occurring at the regional level. Only two ambulances were functioning in the entire country.  Traditional funeral practices with high risk of Ebola transmission were still being performed. Ebola cases were not being isolated quickly.   People with known Ebola exposures were not being quarantined. Dead bodies were not being buried safely or quickly.

Meanwhile, almost all routine healthcare operations in the country had shut down.  Prenatal care was not available, childhood vaccines were not being administered, hospitals and clinics were shuttered, and patients with HIV and TB did not have access to treatment.  Mortality from treatable diseases sharply increased. 

The need for region-wide coordination was obvious.  The concept of an Ebola Command Center, with centralized information and coordination, was born.  King’s S/L Partnership volunteers were the brains and brawn of the center's creation. One of these early champions, Amar, recently took me through the Center and described some of the struggles and challenges of that critical time.

The first step was to understand the magnitude of the problem – making the numbers of the epidemic known - numbers of patients (suspected, probable, confirmed), numbers of case contacts, numbers of ambulances, number of beds at Ebola holding units and treatment centers, numbers of burial teams.  The idea was to put up white boards in the Command Center, initially a dank cramped and windowless office, with these numbers in real-time.

Almost immediately, the idea was met with local resistance.  There is incredible power in numbers; public health interventions and outcomes hinge on good data. But real, hard numbers can be frightening; there is a false security in ignorance.

It was a hard-fought battle, but at the Command Center, these numbers were finally made public – and they were shocking.  So many cases.  So few beds. 

Gradually, incrementally, the two or three volunteers who had founded the Command Center garnered support.  Over the next few weeks to months, the Royal Sierra Leone Armed Forces and the British military joined the efforts.  The Centers for Disease Control and World Health Organization came on board.  NGOs rallied.  The Command Center moved from the cramped office to a large conference room with vaulted ceilings, with integrated computer system and official signage designating the three pillars of Case Management, Safe Burials, and Surveillance.  A call center was created and social media churned out billboards and posters encouraging people to dial 117 with any suspect cases.  It may have been a bit premature – the call center was completely overwhelmed for weeks, but it was a start.  Slowly, Ebola Treatment Units were built and beds opened up.  Finally in November, the epi curve (number of new Ebola cases) started decreasing.  By mid-January, when I arrived in country, the numbers of new cases were falling precipitously.

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Having arrived late on the scene of this Ebola epidemic, I keenly feel the guilt of someone who came too late to be of much help.  Yes, the Ebola holding unit at the hospital is still usually full of patients, but few now have Ebola. 

This is a time of transition – scaling down disaster relief, and turning attention to the chronic, systematic needs of a country whose healthcare infrastructure has been shattered.

For me, a tiny cog in the wheel, it is hard to know where I fit in this time of transition.  I’m not seeing the loads of Ebola patients that I expected, although working in the Ebola holding unit is still intense.  The needs are now greater on the general hospital wards; patients with HIV and TB who need treatment and care.  Public health systems are beginning to grind to a start.  Other hospitals and healthcare facilities need support as they open slowly, cautiously.

I have three weeks left in Sierra Leone.  Three weeks can be a lifetime in the timescale of disaster relief, but it is only an instant in the timescale of effecting real healthcare system change. 

I am starting to wonder if I shouldn't ask to go home a few weeks earlier than planned, given that the Ebola crisis seems to be largely over.