When he arrived, Sesay was lethargic and had the glazed look typical of someone infected with the deadly disease, which by then had already claimed almost 2,800 lives in the three countries first affected by the outbreak, Guinea, Liberia and Sierra Leone (the total death toll when this article went to press was more than 5,100, including 8 deaths in Nigeria).
Over the course of two weeks, Sesay watched 11 fellow patients being taken for burial in the newly dug cemetery. In the meantime, he continued to grow stronger. “They talked to me and gave me medicine and food,” says Sesay, a junk trader by profession. “They looked after me and helped me get better.”
In late September, after two negative blood tests, Sesay became the first person at the IFRC centre to have survived Ebola. “I don’t know why I survived when others didn’t,” he says. “But I am very happy to be going home.”
That same day, an 11-year-old girl named Kadiatu, also one of the first patients to arrive at the Kenema treatment centre, was declared Ebola free. Because she had been inside the high-risk area, Kadiatu went through the required ‘happy shower’ — a chlorine bath followed by a normal soapy shower — to remove all potential remains of the virus. Her contaminated clothes were destroyed and she was given a clean new dress and new sandals.
Sesay and Kadiatu’s stories offer a sense of hope that, with treatment, people can survive Ebola. But such stories have been few and far between in the face of this pitiless virus, for which no cure exists and which attacks the organs so virulently that the infected person essentially bleeds to death from within.
The early symptoms resemble cholera — headache, fever, diarrhoea, vomiting — and might also be normal for malaria or food poisoning. But the vast majority of those who contract Ebola do not live more than a few weeks. Many never make it to a treatment centre. And for almost all of those that do, the last images of humanity they will see are strangers dressed head-to-toe in white protective gear.
Even Sesay’s story of survival cannot be said to have an entirely happy ending. “I am happy to be leaving, but my wife and 3-month-old twin sons died from Ebola,” he says. “I have one 13-year-old son left. I don’t know if he is healthy or not.”
Faces of humanity
Though shrouded by their ‘personal protective equipment’ (PPE) — the technical term for the combination of jumpsuits, boots, goggles and rubber surgical gloves that make up these strange moonsuits — the health workers here are perhaps the one true representation of humanity in the face of this very inhumane outbreak.
This other-worldly get-up allows people such as 28-year-old community health nurse Brima Momodu Jr to give patients their best chance at survival. And despite the barriers this protective clothing puts between him and his patients, he does whatever he can to ease their suffering.
“We have some patients here who are very stable,” he says. “They manage to get water for themselves and they can move from one place to another. They talk a little bit. We also have some who are very weak. They cannot do anything on their own. To eat is very difficult; even to drink water is very difficult.
“I feed my patients because I want them to get energy,” he continues. “Because some patients pass faeces, urine, vomit all over their body, I have to give them at least bed baths so they can feel refreshed and be more healthy. After that, I bring my patients some clothing to change what has been messed up.”
Pausing between stints in the ‘high-risk’ area, he is able to take off his mask, take unhindered deep breaths of fresh air and show his face, glistening with sweat after 45 minutes inside the sweltering PPE. “I’m sitting out to at least get some fresh air, to have some time to rest, so that I can be healthy enough to go back to serve my patients well,” he says.
The health of caregivers such as Momodu is critical to stopping this fast-spreading disease. But it’s an extremely risky, difficult, stressful and emotionally draining assignment. Most of the health-care workers interviewed here say that they feel safe inside their PPEs, which covers them from head to toe, and because they follow the proper protocols.
The ‘high-risk’ zone
But the dangers are very real. Ebola is not transmitted through the air, but it does spread through direct contact with the bodily fluids of an infected person. The health workers’ skin, therefore, must never be exposed to a patient’s touch, a cough, a sneeze, a drop of sweat or vomit — or even to the touch of the worker’s own gloves.
If even a small breach in the PPEs is noticed while the worker is in the high-risk zone, he or she must leave the treatment area immediately and take off the protective clothing while being sprayed numerous times with a chlorine solution.
One of the greatest dangers is posed by something they employ daily: the needles used to take blood samples. Playing on their minds as they take the patients’ blood samples, a routine task in most settings, is a fact impressed upon them during their training: the survival rate among health workers jabbed by an infected needle inside an Ebola treatment area is zero.
The slightest wrong move, therefore, could be deadly in an environment where visibility is limited, time is of the essence and patients are not always in control of their movements. All procedures must take place slowly and with extreme care.
Numerous health workers, both local and international, have contracted Ebola while working under such conditions and many have succumbed. With the threat of the virus ever present, health workers monitor their own health constantly with even the slightest fever or headache creating considerable anxiety in their minds.
Facing the fear
For those working with dead bodies, a task absolutely critical to halting the spread of Ebola, the danger is equally real. As a member of a safe and dignified burials team, Edward Sannoh, a 24-year-old from Kenema, collects the bodies of those who have died in the high-risk area, then prepares them to be taken to the morgue. “The hardest part of this job is when you are in the high-risk area,” he says. “What makes it hard is that you don’t have permission to sit, lie down or touch your fellow worker. You can only touch a sick person if you have to. If not, there is nothing you can do.”
With so much death all around, there is a palpable sense of fear among both the patients and the communities who have already lost so many to the disease. “Of course, people are really afraid,” says Sannoh. “And even now, people are afraid of some of us who are working at this case management centre.”
But Sannoh says he is undaunted. “I don’t mind what people might say because I have been a Red Cross volunteer, so my first fundamental principle is humanity. So I’m doing this because of humanity. I want to save the lives of our brothers and sisters. That is the number one principle of the Red Cross.”
Still, fear of Ebola has fostered strong emotions in some areas affected by the disease and the threat to health workers is very real. On 16 September, a group of armed men attacked a delegation of Ebola-control personnel, including government, medical, media and Red Cross staff, as they worked in the community of Woméï, in south-eastern Guinea. Seven members of the delegation were killed, including health workers, local officials and journalists. Two remain missing. An official from the local branch of the Red Cross Society of Guinea was seriously injured in the attack.
That same week, in the city of Forécariah, south of Guinean capital of Conakry, six volunteers with the safe and dignified burials team were attacked by the local population. One of them was injured while the others fled to seek refuge in the nearest forest.
In response, the IFRC and the Guinea Red Cross called on “governments and communities to respect and protect humanitarian and health personnel,” adding that “all actions that hamper the work of those responding to this epidemic — including attacks on staff and volunteers, and violent protests and insecurity in Liberia and Sierra Leone — prevent entire communities from getting the help they need.”
“My first week has been a surreal rollercoaster between life and death, hope, grief, pain and joy. As I arrived in Kenema at the [emergency treatment] centre, my first task was to oversee four burials.”
Anine Kongelf, a community health delegate for the Norwegian Red Cross, working in Kenema, Sierra Leone, in September and October
Liberian National Red Cross Society volunteers disinfect their protective clothing after removing the body of an Ebola victim from her home in Banjor, Liberia. Photo: ©Victor Lacken/IFRC
“I don’t mind what people might say because I have been a Red Cross volunteer, so my first fundamental principle is humanity. So I’m doing this because of humanity. I want to save the lives of our brothers and sisters.”
Edward Sannoh, 24, a volunteer for the Sierra Leone Red Cross Society from Kenema, one of the areas hardest hit by Ebola virus diseaser
By 17 November 2014, an unprecedented 14,386 people were reported to have contracted the disease, and more than 5,400 people had died from it, according to the World Health Organization (WHO). Meanwhile, the United States Centers for Disease Control estimated that if the outbreak continues at its current pace, the number of cases could swell to as many as 1.4 million by January 2015.
Despite this, mobilizing a response to keep pace with Ebola’s spread has been a challenge. Public health systems in Guinea, Liberia and Sierra Leone, weakened by years of protracted conflicts, lacked the facilities, staff and materials needed to contain the disease.
Ebola has also exposed serious weaknesses in the global system set up to deal with health emergencies. A series of budget and staff cuts within the WHO unit that deals with health emergencies didn’t help and many humanitarian organizations, including the Red Cross Red Crescent Movement, lacked the experience and systems to respond immediately to the particular requirements of this very virulent disease (although volunteers from local National Societies were among the first to respond).
The notable exception was Médécins sans Frontières (MSF), which has considerable experience with Ebola. Because it too lacked the human and financial resources to take on Ebola on its own, MSF has provided crucial training to workers from other organizations, including volunteers and staff from the IFRC and National Societies, as the Movement rapidly scaled up its own response.
Today, with support from the IFRC, the ICRC and Red Cross societies in Guinea, Liberia, Nigeria and Sierra Leone, more than 7,700 volunteers have been trained to engage at community level through social mobilization activities, psychosocial support, safe and dignified burials, contact tracing, transport of the sick and clinical case management. The IFRC has also expanded Ebola preparedness and response activities to 14 other countries in West Africa where the disease it most likely to spread next. Since the outbreak began, more than 169 international staff have been deployed and six emergency appeals have been launched by the IFRC.
Meanwhile, the ICRC, which has had a presence in West Africa for many years due to conflicts there, has been providing various forms of technical and material and staff support via its delegations in Liberia and Guinea (its Sierra Leone office was closed in 2013).
The ICRC also deployed 20 additional international staff to the region and has beefed up its support to National Societies and other partners in a range of areas, from health care to forensics, engineering, economic security, water and habitat, among others.
But many on the ground say so far the international response is still not adequate. “We desperately need more resources,” says Friday Kiyee, a member of one of the Liberian Red Cross Society safe and dignified burials teams in Monrovia. “Without people on the ground to organize, coordinate and educate, we will be wasting our time… Many of the hospitals here have very few health workers, and patients most in need of other medical services are not getting care.”
The local health service, he says, is overwhelmed. More treatment centres are needed, as are more beds, more equipment, more medical staff and more training. Often, when an ambulance is called to pick up a sick patient, the Ebola treatment unit is already full and the patient must return to their home.
“They will die at home,” says Kiyee. “And when the patients die at home, people keep interacting with them prior to their death. And they too become sick. So the death rate keeps increasing.”
A culture of touch
One of the sad ironies is that with Ebola, the very humanity that people have shown in caring for their sick relatives and in tending to their bodies during burial has been a leading cause of transmission. In Sierra Leone, it’s common practice to hug the dead in order to keep a connection with ancestors.
And throughout all the affected countries, physical contact (hugs, handshakes, kisses) are part of everyday interaction. One of the life-saving messages health workers give is to avoid touching each other. Guinea’s National Commission against Ebola, of which the IFRC and the National Society are both part, reinforced this information in text messages sent to many Guineans during celebrations for Eid Al-Adha in Guinea, the Muslim holy period (also known as Tabaski in many West African countries).
“The messages wished us a happy Tabaski, but told us to avoid touching each other during the traditional greetings to stop the spread of Ebola,” says Amadou, a medical student from Conakry. “I know it’s necessary, although it does feel a bit strange not to embrace my family during this time of Eid.”
From the beginning of the crisis, local culture has played an important role. Many people in West Africa suspected Ebola was the result of witchcraft, others feared voodoo was at work. And because many people turn to traditional healers, part of the health response included engaging with traditional healers such as Fallah James, from Sierra Leone’s hard-hit eastern Kailahun district.
“When I got the information that you can get it through contact, I, as the head of the traditional healers in this district, have stopped treating patients,” says James. “And I have been advising my colleagues that they should stop for now, until we get training and proper information about Ebola, so that it cannot infect so many people in our community.”
The ‘no-touch’ zone
Fear and stigma are not limited to West Africa, however. Many humanitarian organizations have had a particularly hard time mobilizing and deploying international staff and volunteers to take on this risky and difficult assignment in part because of fears at home among colleagues, friends and family. On top of that, those who deploy with the IFRC must be willing to spend at least one month in the field — followed by a three-week, stay-at-home period afterwards to monitor for symptoms.
After several international health care workers were placed in forced quarantine after their return from mission in West Africa, the Movement officially urged governments to ensure and facilitate movement of health workers to and from West Africa. “Stigma or discrimination against health workers — including isolating them with no scientific basis — will lead inevitably to a human resources crisis at a time when we need qualified people,” the statement read.
One of those who took on the challenge recently was the Norwegian Red Cross’s Anine Kongelf, who signed up for a tour in Sierra Leone because she felt her experience tracing people exposed to cholera in Haiti and working with communities would be useful in tracking Ebola.
“I was working with the cholera epidemic, but that’s very small compared to this,” says Kongelf, whose job in Sierra Leone involved coordinating with other agencies to help track those exposed, cared for, cured and buried in order to monitor all steps taken with those who have been infected. “This is unlike anything else.”
Soon after her arrival, she wrote in a blog post: “My first week has been a surreal rollercoaster between life and death, hope, grief, pain and joy. As I arrived in Kenema and at the centre, my first task was to oversee four burials.
“The sad fact is that there will be many graves as the centre will admit more patients, and some of them will lose the battle against the virus. One of the bodies that day was an 8-year-old boy.”
And it’s not just people who work directly with patients who are exposed to the dangers. Another recent international recruit was Garth Tohms, a volunteer with the Canadian Red Cross Society. A plumber by trade, Tohms felt his experience and training working with hazardous materials for the Canadian military would be useful in his work as a water and sanitation expert supporting the emergency treatment centre in Kenema. He says even the most basic tasks, such as replacing a valve, can become a painstaking task inside the high-risk zone.
“The goggles are the worst, they fog up quickly, reducing our time inside,” he says. “I put extra anti-fog liquid on my lens from the inside of the goggles. I don’t wipe away the excess, I prefer there to be so much anti-fog that it is actually in drops on the lens. It is a bit blurry, but I can see for a longer period of time.”
‘How de body?’
To bring an element of humanity to his work, Tohms tells the patients from the outside that he’s coming in and, when possible, makes a joke or two. “That way, they will know who is walking past them and talking to them from behind the mask,” he writes. “I can’t imagine what it must be like for them, to be brought here and be corralled into fenced areas surrounded by alien-like people walking around.”
Tohms and others here say they are also struck by the level of humanity they see every day among people who are ill or highly stressed and afraid. Despite the reports of violence against health workers, he says many here do appreciate their work and they are often met by locals with friendly smiles and the traditional greeting: “How de body?”
Sue Ellen Kovack, a Canadian who recently returned to Cairns, Australia after a month in the Kenema treatment centre says she was struck by the resilience of people living through this unprecedented outbreak.
“We had a lovely lady Lucy in the hospital, who lost her husband and all her children to this disease, yet she greets me with a massive smile each morning to ask me how I am, if I slept well. ‘How de body?’ she asks. Wow! The ravaging illness on the bodies I was expecting, but not this resilience. It breaks my heart to see what people like Lucy are going through.”
That same resilience can be seen in the survivors. One of the first to survive the disease in Guinea, Saa Sabas caught Ebola while taking care of his sick father. After being transferred to the Ebola treatment centre set up by MSF in Guéckédou, Guinea, he recovered and returned home, only to be stigmatized by his neighbours. “People avoided me even when I showed them my certificate of discharge,” he says.
Now a volunteer with the Red Cross Society of Guinea, Saa Sabas visits communities, raising awareness among his fellow Guineans of how to prevent the spread of the disease and to allay some common fear and rumours. “I am one of them and I can talk to them in a language they understand,” he says. “Who else is better placed than me to tell them about Ebola?”
These survivors are living proof that Ebola can be defeated. As one of the health workers who cared for 11-year-old Kadiatu recalls: “When she came out she was clean, uncontaminated and safe. She turned around to wave to Haja — another Ebola patient who had been taking care of her inside — and walked out past the double orange fencing.
“She gave one last wave to the other patients before walking away from the centre for the final time and someone asked her: ‘How de body?’
“‘Fine,’ she replied, and for the first time in weeks, she meant it.”
By Cristina Estrada, Katherine Mueller and Malcolm Lucard
Katherine Mueller is communications manager for the IFRC’s Africa Zone. Cristina Estrada is IFRC senior officer, operations quality assurance. Malcolm Lucard is editor of Red Cross Red Crescent magazine.
Here in the low-risk area of the IFRC’s Ebola treatment centre in Kenema, Sierra Leone, workers discuss the day’s work. In the high-risk area, there are separate areas for suspected, probable and confirmed cases and workers must perform their tasks fully covered from head to toe in personal protective equipment.
Photo: ©Katherine Mueller/IFRC
“I can’t imagine what it must be like for them, to be brought here and be corralled into fenced areas surrounded by alien-like people walking around.”
Garth Tohms, a volunteer water and sanitation specialist with the Canadian Red Cross, working in Sierra Leone
To help stop the spread of Ebola, volunteers with the Red Cross Society of Guinea visited communities and met with residents face-to-face in order to change attitudes and practices that could help spread the virus.
Photo: ©Moustapha Diallo/IFRC
11-year-old Kadiatu was the third confirmed Ebola patient to arrive at the newly opened treatment centre operated by the IFRC in Kenema, Sierra Leone. In late September, she was one of the first patients at the Kenema centre to be declared Ebola free. Photo: ©Katherine Mueller/IFRC