Day 34

19.2.2015

Safe burial procedures are crucial to stopping the Ebola epidemic. Corpses are sealed in body bags by workers in full personal protective equipment (PPE) and buried in secure graves. The current official policy from the Sierra Leone Ministry of Health is that every corpse, regardless of cause of death, should be given a safe “medical” burial. Here, the interests of public health, guarding the public against possible Ebola transmission from infected corpses, often collides with that of mourning friends and family, who typically desire a traditional burial in the family plot.

Connaught Hospital, the tertiary referral health center where I’ve been volunteering in Freetown, is positioned next door to the Connaught Mortuary.  I had heard recent rumors that several bodies had been taken out of the Connaught Mortuary by family members to be buried.  It was unclear whether this was being done with the mortuary’s permission or knowledge. I decided to investigate. 

Through a contact who worked with the non-governmental organization Concern, the group responsible for overseeing burials in the greater Freetown area, I linked up with the burial team that was scheduled to come to the Connaught Ebola Holding Unit on Thursday, my day off.  We had two corpses in the unit’s morgue that morning.  The burial team donned full PPE and brought out the two bodies, placing them in the back of an open pick-up truck.  They then decontaminated, put their used PPE in garbage bags, tossed the open bags on top of the bodies and drove around the block to the Connaught Mortuary to see if there were any bodies there to pick up. I followed the truck in a separate car. I couldn’t help but notice that the garbage bags of used PPE were jostling precariously on the rough roads.  Pedestrians weaved in and out of the slow moving traffic, oblivious to the nature of the unsecured cargo.

Following the burial team, in heavy traffic with pedestrians brushing against the vehicles.  Two bodies in body bags lie underneath the open yellow bag of used PPE in the back of the open pick-up truck.

At the mortuary, I introduced myself to the manager, explaining that I was interested to learn more about the burial process during the Ebola outbreak.  I was graciously offered a chair in his cramped office. That’s when things got a bit bizarre.  The manager was in conversation with family representatives of several people who had just died in a motor vehicle accident. The families were petitioning for the bodies to be released for a private funeral.  During the discussion, a woman walked into the office to decant some formaldehyde from a large container in the back of the room.  Possibly seeing my puzzlement, the mortuary director explained it was for ‘body preservation’ happening in the next room.  Odd, given current policy dictates that all bodies be buried immediately. The conversation between the mortuary manager and the family representative dragged on.  Ultimately the family was told that they would need to go the next day to the command center to obtain the results from the oral swab sample for Ebola.  If the result was negative, they would have the option of bringing an official negative Ebola death certificate back to the mortuary in order to collect the body. The unspoken, but clear, implication was that this service would require a hefty fee. 

From this brief exchange, it was made very clear that not all bodies in Freetown are being given safe ‘Ebola burials’.  One might argue that this policy is not necessary – people continue to die from many causes, not just Ebola.  However, it is impossible to know what most people die of – the oral swabs to detect Ebola in corpses are notoriously insensitive and autopsies are strictly forbidden.  The potential public health consequences of a traditional funeral of a person infected with Ebola are enormous: One funeral where traditional burial practices are performed can spread the virus to hundreds.  Each week, the Ebola Situation Report by the World Health Organization reports tens of known unsafe burials in Sierra Leone, a number that is almost certainly a vast underestimate.

The burial team picked up one more body at the mortuary, and then we got back in the trucks for the short drive to cemetery. 

King Tom cemetery is a very old graveyard located in the heart of Freetown, which borders the city dump.  When the Ebola epidemic hit, city officials offered a small area in the cemetery for the Safe Burials.  Soon, the plot was full.  The rational next step was to make more space by plowing into the city dump. 

When we arrived that afternoon an enormous Caterpillar excavator was moving soil to carve out more usable land in the western corner of the cemetery. About 10 bodies in white body bags were already lined up by ready graves, awaiting burial.  The team that I had been following drove down into the area of the open graves. The team again donned full PPE and unloaded the bodies, placing each one by a single grave. 

King Tom cemetery, pushing up against the the rubbish of the city dump.

A small crowd of onlookers had gathered at the mound at the end of the road. I recognized the brother-in-law of one of our patients that had died the evening before, when I was on call.  The oral swab had come back negative for Ebola, which was small comfort to the family. I could hear their wails of grief. 

Each body bag was placed into a single grave that had been draped with a clean white sheet.  The burial team pulled the sheet over the body, placed a number of short sticks in an orderly fashion over it and then began the physical labor of shoveling in the earth.  An imam standing with the family raised his hands, chanting a melodic prayer.

Just beyond the fresh graves, the rubbish heaps of King Tom city dump are visible, pushing against the flimsy barrier between cemetery and landfill.  On this side of the fence, separated by mere inches, the small mounds that mark full graves stretch for hundreds of meters in all directions.

Freshly dug graves, soon to be filled, in King Tom cemetery, Freetown, Sierra Leone