Ebola - Back from the Hot Zone

 A retired ambassador I was in charge of the U.S. embassy in Freetown, Sierra Leone for several weeks in August and September.  Following is some background on the rapidly changing situation there. I have been home now for more than twenty-one days and did return before the Ebola hysteria mushroomed in the U.S. 

Last August in Sierra Leone the infection rate for Ebola was doubling every week. Hundreds were already dead and a thousand more sick with the deadly disease.  The country was in shock, the populace scared and apprehensive, the government confused and the international community ill prepared to deal with the scourge.  American authorities were slow in understanding how quickly the malady was spreading and what its impact would be.  A crisis of this sort was not something we diplomats trained for, but the first order of business was to put our house -  our embassy -  in order and to re-focus on an appropriate response.   Accordingly, Peace Corps Volunteers were sent home and embassy families were re-located to the U.S.  We advised citizens not to travel to the region and, if they were already there to leave if convenient.  However, most of the approximately four thousand Americans in Sierra Leone are dual nationals and many of them are minors. The embassy declared an “emergency,” a formality that permitted USAID to respond with disaster assistance funding.   At the chancery we began a series of educational discussions designed to insure that all employees, both American and Sierra Leonean, knew what Ebola was, how it was transmitted and how to avoid contamination.  We stressed “don’t touch sick people, don’t touch the dead.”  We also trained a team to wear protective gear and put into place visitor screenings and contingency plans should a contact or an infected person enter the premises.  We deemed that our consular operation where dozens of folks applied for visas daily to be our most vulnerable point, but judged it necessary to continue operations.  Even as we took these precautions at the chancery itself, embassy personnel engaged intensely with Sierra Leonean authorities from the President on down and the donor community with regard to strategies, policies and mechanisms designed to curb the outbreak.   Unfortunately, nobody really knew the dimensions of the problem or how to deal with it on the scale required.  Clearly human resources, i.e. health care workers, the necessary equipment  - protective gear, gloves, body bags, laboratory supplies, disinfectants, etc. - and sufficient beds in properly managed isolation and treatment centers were in short supply. 

By mid-August all were acutely aware that the situation was spiraling out of control.  The numbers of sick and dead from the hard hit eastern regions were growing astronomically and cases were beginning to popup in the densely populated capital.  The international press publicized the situation. African neighbors ostracized the three core countries. Most international flights were cancelled.  The government adopted stringent measures.  Chlorine hand washing stations were required at all buildings.   Public meetings, gatherings and sporting events were banned. Schools closed indefinitely. Travel to and from the interior was constrained.  All illnesses were to be reported to authorities, likewise all deaths.  Traditional funerals and funeral rites were banned. The dead were to be collected and buried by trained teams wearing protective gear. A nation-wide campaign was undertaken to educate the populace about the disease.  In September there was a nationwide stand down so that Ebola education teams could visit every household.  Meanwhile, the government and the World Health Organization (WHO) in conjunction with international partners invigorated the response mechanism with new leadership.  Visits by UN Ebola czar David Nabarro and CDC Director Tom Frieden underscored both the urgency of the crisis and the commitment of the international community to be supportive.   By September that support was beginning to flow in a steady manner. 

Fortunately, CDC was ahead of the curve and by early August already had a number of epidemiologists and other experts, between 20 and 30, on site. They were instrumental in helping to establish the first isolation and treatment centers. Working with the national Emergency Operation Center they helped to define policies and priorities.   They were hands on in establishing laboratories, reporting mechanisms and statistical compilations.  A CDC team worked closely with airport authorities to ensure that screening for travelers met the highest standards. A four person Disaster Assistance Response Team (DART) from USAID soon arrived and began the process of ordering and coordinating the delivery of quantities of necessary supplies.  We were also successful in getting five ambulances transferred to the Sierra Leonean army from the Department of State controlled regional peacekeeping stockpile.  We also made arrangements for specialized training for Sierra Leonean military personnel engaged in providing security in and around the isolation and treatment centers in the quarantined zone.    Subsequently all of these undertakings have expanded.  Now, even the U.S. military is deploying personnel and resources to aid in the response.  American efforts have been complimented by other donors, foremost the UN family led by the World Health Organization (WHO) and the World Bank. Additionally, the U.K. Ireland, China, the EU and others have all played a part.  A number of health professionals from elsewhere in Africa have also volunteered to serve.  Yet the anti-Ebola effort remains mostly a Sierra Leonean affair.  At least ninety percent of the crucial health care providers are locals and health care personnel have borne the brunt of the casualties.  Virtually all of the contact tracers, ambulance personnel and burial teams are local. More people are being recruited and trained for all of these tasks.  The number of treatment beds is expanding. The population is acutely aware of the reality of Ebola.  Hysteria and rumor that characterized earlier times have subsided to be replaced by stoicism while waiting for an uncertain future.   So far, although we may be gaining a little, it is still not enough. New infections continue to outpace the response. 

The cost to Sierra Leonean society is high.  People no longer touch in greeting.  No handshake is a ever present reminder of the crisis. How to reconcile the need to care for sick family with the stricture of not to touch?  How to conform to the directive of don’t wash or bury the dead, when traditional culture requires that?   With no schools families are hard pressed to monitor their children.  Imagine the disruption this generates.  Fear of Ebola has meant the collapse of the non-Ebola health care system.  Hospitals and clinics have closed because staff have no preparation or equipment to deal with feverish walk-ins.  So malaria, measles, flu are untreated not to mention heart attacks, injuries, and maternity cases.  Food is in short supply in the cities as transportation links to rural areas degrade.  Similarly, regional transportation throughout West Africa is stalled, exports affected and the economy spirals downward.  Lack of international personnel, business travelers and visitors has hit the hospitality industry hard.  Hotels and restaurants are empty.  Banks have limited hours. All of this, but especially the specter of the unknown - will I get infected? Will my family? Will I have a job? How safe am I? -  result in great apprehension.  Personal relationships are suffering and discrimination against families with known cases, survivors and even health care workers is evident. People feel victimized by God, by the devil, by fate, by government, by politicians, by the international community, and by neighbors.  So a sense of helplessness grows.  So far this has not yet resulted in social chaos, but it might.  One has to hope that the Sierra Leonean strength of character, tempered as it has been by a terrible civil war, will prevail.   However, at the end - when it comes, when Ebola is conquered - a massive undertaking will be required to heal the national psyche as well as to rebuild the economy.