I spent the month of July in Freetown, Sierra Leone, with West African Medical Missions, a grassroots organization that works to enhance public health awareness in local communities there. Officially, my title was Global Health Officer, and my role was to create, implement, and oversee what we call a Community Outreach Initiative (COI) for the growing Ebola problem in the region. I had an “admin” working with me, who is a local student named Paul, who would take over the COI once it was time for me to leave. 

Before I had left the US, I watched the news and listened to the radio and read all the online articles that had to do with Ebola in West Africa. Having had only a one sided perspective on the issue, it seemed to me from these reports that Ebola was as deadly as the viruses we create in the popular cellphone app Plague Inc., with a mortality rate that was consistently reported at 90%. To someone who was only loosely invested in the disease and no knowledge of Sierra Leonean culture, Ebola seemed like an impossible giant to face. 

However, upon arriving in Sierra Leone, the first impression was: life goes on. I don’t even mean that in a cheeky sense, I mean it in the sense that most people, at least in Freetown and Makeni, are not affected by it. Many are so unaffected by it, in fact, that they either do not believe Ebola is a real thing, or they are convinced that it does not exist in Sierra Leone.  

Ebola isn’t just a biomedical phenomenon. In Sierra Leone, it’s also a social, cultural, and political entity. Anthropologically, for one to successfully understand how a disease like Ebola takes hold in Sierra Leone, he/she would need to understand the full picture – the bigger picture – and possess an intimate knowledge of all the actors at play that are unique to the country. A successful epidemiologist, in this case, would recognize that tackling the disease with pure science, as good a fight as that might be, may not be the most effective method, and to reach out to the vast majority of the country’s population, a plethora of non-medical factors must necessarily be taken into account. 

I can’t speak for the other West African countries - and now even some non-West African countries – that have been fighting the Ebola virus, but at least in Sierra Leone, misconceptions run rampant among its citizens, with many people legitimately believing that Ebola is a ruse fabricated by the government or foreign NGOs for the purpose of systematic exploitation. One may think that similar misconceptions exist in the US too, from people not understanding the mode of transmission of the virus from person to person, but in Sierra Leone, misconceptions range from “only hunters can get the disease” to “it is a curse from god.” 

While it would be unfair to attribute these types of misconceptions to a general lack of good education in the country proper, the distinct absence of proper awareness and outreach initiatives does pose a severe hindrance to such a country’s ability to educate itself. In the US, a CDC notice posted on its website can easily be shared on Facebook and be viewed by thousands within minutes. In Sierra Leone, word of mouth can only travel as fast as a student is able to walk back to his village, or until the next signboard can be erected at the end of the street. 

And oftentimes these signboards display outdated or erroneous information about Ebola. 

For instance, most cases of Ebola do not feature the symptoms that the media loves to report on: bleeding from the orifices, severe hemorrhaging, bloody emesis, bloody stooling, hemorrhagic this, hemorrhagic that. However, most, if not all signboards in Sierra Leone warning people of the symptoms of Ebola all include some sort of infographic on hemorrhaging. That is not to say that those symptoms do not exist in the realm of virology: most notably, the Zaire strain of the Ebola virus (the one that has earned the 90% fatality rating in most media outlets) does, in fact, generate a mirage of hemorrhagic symptoms. However, the average Joe (or, in Sierra Leone, the average Isaac or Mohammed), will likely only experience fever, headaches, joint and muscle pains, fatigue, diarrhea, vomiting, and some abdominal pain. Sometimes, people can get a body rash and other flu like symptoms. None of that is pleasant, and, in a country like Sierra Leone, none of that is easy to deal with, but more importantly: none of these symptoms are fatal in their own right. There is no cure or vaccine for Ebola, but any measure of palliative care can increase an individual’s chances of survival, which are usually quite good to begin with. In a country like the US, anyone experiencing these symptoms should hopefully have the insight and common sense to shuttle themselves to the nearest hospital and request treatment. Or, at the very least, find a method to quickly replenish their fluids. But in Sierra Leone, fatality comes in when people don’t seek such palliative care. People get dehydrated and can’t keep up with the fluid loss from the diarrhea and vomiting, and so on and so forth.  

The fatal aspect of the disease that is detrimental to countries like Sierra Leone is that people do not have this knowledge. Ebola is not always fatal - 

EBOLA IS NOT ALWAYS FATAL

- but people there do not know it. They do not know this because the media has conditioned them to only recognize Ebola when they see symptoms that indicate things such as hemorrhaging; and, if they did indeed become infected with the strain that includes such symptoms, by that time the disease has already reached its end stages. 

For people who are freaked out about Ebola coming to America: Ebola would never work in the US because the majority of the American population trust medicine, and would rather go to hospitals than stay at home and die. However, in Sierra Leone, there is a systemic and deep seeded mistrust of healthcare officials – especially ones from foreign countries – due to a history of exploitation that historically dates back to as far as the era of slavery. Socially, having Ebola and going to the hospital for Ebola is a huge stigma, and people would rather not put themselves and their family through the shame. Instead, they would rather stay home and, if they were to die, die with their loved ones. 

There is also somehow the misconception that people who are discovered to have Ebola will be taken and shot. At checkpoints in and out of Kenema, people are examined for fevers before they are granted exit. If found to be febrile, they get sent to a healthcare facility and tested for Ebola. But to many families, those loved ones who disappear into treatment centers seem to always die there. Though the government has now made it illegal for people to harbor a known Ebola patient, the notion of a family is still a very strong and cohesive source of solidarity in the country. 

Aside from an unhealthy distrust of medicine and the healthcare system, many Sierra Leoneans also fear that Ebola, and the subsequent hospital visit, is a death sentence. In the beginning stages of fighting the virus, many patients were taken to hospitals and quarantined, and never seen again. Families would rather risk infection than to let a loved one disappear into a hospital ward. There’s also the very real danger of quarantiningsuspected cases of Ebola together in one space: out of four people, if only one actually had Ebola and the other three only had similar symptoms because they had cholera, they may very well have just caught Ebola just by virtue of the health center’s decision to keep them in close proximity to that mysterious Ebola patient. While this is only a logistics issue, Sierra Leone doesn’t have the ability to sustain full quarantine wards like the US; from what I understand, many healthcare centers do not even have quarantine protocols.  

The strain of Ebola most present in Sierra Leone has a relatively constant fatality rate, holding at approximately 33%. It is not airborne. It can’t be absorbed through the skin. You can’t get it from contaminated water or bushmeat. Actually, the source of the current Ebola outbreak is still unidentified. The disease is transmitted by fluid contact, but that means the family members cleaning up the vomit of the sick uncle and the niece wiping his sweat have all been put in danger of exposure.

There are also many aspects of the Sierra Leonean culture that make the transmission of a contact-precaution virus not only easy, but downright inevitable. Infectivity is highest when a patient is nearing death, because that’s when the release of body fluids peak. Traditional burial practices, for instance, puts family members in close proximity to the infected corpse and all its body fluids. Furthermore, upwards of 90% of the country is either Muslim of Christian, both of which feature mass gatherings for worship and prayer. I’ve had the pleasure of attending a Sunday mass with a good friend myself, and the sheer closeness at which people sit and stand, coupled with the amount of movement (dancing, singing, jumping around) and the heat, produce so much sweat that a swing of the arm could land a few droplets onto the person next to you. Any careless person – myself included – would not think twice about touching my own sweaty arm, which now unknowingly has someone else’s sweat on it, and perhaps touching my own mouth. 

Transportation in Sierra Leone is another huge venue for transmission. Only a small percentage of the population own individual vehicles. The majority of people utilize taxis (which is usually shared among 2-4 passengers), or okadas (motorbikes that seat one driver and one, at most two, passengers), podapodas (vans that have been modified with benches to squeeze in as many people as possible before there is no oxygen in the car), or buses (which often turn out to be just as cramped and stuffy as podapodas). When the Ebola outbreak was reported to have reached Freetown, I, along with other members of WAMM were discouraged from taking buses and podapodas to avoid unnecessary exposure in such cramped spaces. But for the average Sierra Leonean, this isn’t always an option, because taxis are more expensive by comparison. 

The majority of Ebola cases have so far been confined to the southeast region, particularly in the cities of Kenema, Kailahun, and the province of Bo. The first outbreak was discovered in Kailahun, which is located very close to the border with Guinea, and the patients were transported and hospitalized in Kenema. Due to the geography of the outbreak, many people also hold the belief that Ebola was invented by the government as a mechanism to depopulize certain regions where political dissidence is heaviest. A party war still exists in Sierra Leone between the All People’s Congress (APC) and Sierra Leone People’s Party (SLPP). Currently, the APC dominates the Sierra Leonean government, but many people suspect that Ebola has been “unleashed” on the southeastern regions because provinces there such as Kenema possess a chairman and a council that are affiliated with the SLPP. Basically, people think that the APC is using Ebola has a weapon to take down the opposition. Or at least a distraction tactic from focusing on the other political questions the country faces. 

In a less conspiracy theory-like conviction, many also believe that Ebola is another way for the government to draw foreign aid.  According to Transparency International Sierra Leone’s corruption score is a 30/100, with the lowest meaning the most corrupt. To put it in perspective, even China has a score of 40/100. One can assume that of the millions of dollars being thrown at Sierra Leone right now towards the Ebola response, at least a good portion is being syphoned away into the pockets of top level officials without anyone ever being the wiser. You think the top 1% in America is bad, in Sierra Leone it can be the difference between life and death. People in Sierra Leone are not oblivious to this, least of all the cynical ones. This, among all other factors, help entrench a sentiment that Ebola is a farce, a tactic, something evil, but not something to be concerned about because it’s politics, and for the average man, politics is still a faraway thing that happens behind the closed doors of fancy office buildings. 

Let’s talk a little bit about the healthcare centers in Sierra Leone. In online photos and news articles we often see workers in full hazmat suits, spraying down tents with water or chlorine or whatever. Sadly, the majority of Sierra Leonean health centers do not look like that. In fact, most do not even have basic PPE. Forget even the yellow contact precaution gowns that I often have to wear working as an EMT – many of these places do not even have gloves. Nurses and doctors, though trained as they are, knowingly place themselves in risk attempting to treat suspected Ebola patients without proper protection because, well, they don’t exist. And in fact, the majority of the current case count has been healthcare workers. The first cases in Freetown were caretakers. 

And, there are the communities. These could be a group living in the Kroo Bay area of Freetown, or they could be a conglomeration of villages out in the suburbs, away from the cities, where families live in huts and stone houses, where there is no electricity and water must be fetched from the well in the next village. These communities are high risk targets for Ebola because they not only lack access to healthcare and treatment, they also lack access to information. They are not sensitized to the Ebola situation, its symptoms, prognosis, etc. More than once health aid workers have gone out to a village and their vehicle was stoned because the residents there distrusted the country’s health system so much. In another instance, a village had sent away all its women and children so the men could stay and fight the healthcare workers who showed up. These are the most difficult people to reach, but they are also the most important, because educating one chief could easily mean educating his entire chiefdom. 

Lastly, I want to talk about the influx of NGOs and foreign aid workers. It’s nice, I get it, and yeah, arguably I can be categorized as one such person. But when I was doing disaster relief after Typhoon Haiyan in the Philippines I learned that there is always a chokepoint when it comes to response. And for Sierra Leone, that chokepoint has become a destabilizing force in the country. The top officials from all the ministries are getting pulled out to do work with or consult for these big international companies on salaries that outshine their domestic earnings. This is a brain drain from the Sierra Leonean ministries, and their best people are being thrown into these large international machines and getting lost among all the politics. This is highly disruptive to the already fragile healthcare infrastructure there. 

I’ve had the pleasure of attention a major meeting hosted by the Ministry of Health and Sanitation. It was a response coordination meeting that included people from the EU, UNICEF, WHO, among many others. I sat there for two consecutive days, listening to how the meeting progressed. It was held in one of the fancier hotels in Freetown, and lunch was complementary for everyone in attendance. The discussions, however, was what enraged me. There was no sense of urgency, and most of all, no sense of any kind of structure. People were broken up into groups to discuss response protocols for respective regions in the country, but lacking a central leader, people were shouting random things, or simply not participating at all. Honestly, the whole picture reminded me of group projects in high school. A laptop was connected to a projector, and one guy was typing away, but he seemed more preoccupied with making the excel margins neat than the content of what was inside them. On the second day, the group I sat with spent an hour discussing fuel costs for the transport these workers would need. It was both sobering and disappointing to see the leaders of the country and foreign aid workers all gathered in a conference that seemed so unproductive. If all the people who have the ability to make a difference were stuck in meeting such as this one, who is out there actually making decisions and responding? 

Anyway, these thoughts are a few weeks old now. I follow the news, but I don’t know what’s happened on the ground since I left. 

But for any of my friends who are getting stupid over the whole Ebola in the US thing: Ebola is not the end all be all. It may seem that way in West Africa – though it really shouldn’t be. But in the US, it doesn’t even have a chance of ever even becoming that. And if it does, I swear on all things holy, I will volunteer to do medical transport for that patient.