Ebola: Fighting Back in Sierra Leone

Like Londoners during the Blitz, Sierra Leoneans are fighting back against Ebola, with surprising results. This report was written for DDI by Lansana Gberie, author of A Dirty War in West Africa and member of the UN Security Council Expert Panel on Liberia. For a statement on Ebola from DDI’s Executive Director, click here.

Sierra Leone Map
(Photo courtesy of WorldAtlas.com)

On 5 November, the World Health Organization (WHO) issued its eleventh situation report on Ebola. It was a mixture of good and bad news. A total of 13,042 Ebola cases had been confirmed, resulting in 4,818 deaths. This is an appalling figure, but far short of the 20,000 fatalities that WHO and Imperial College London had predicted in September. More encouraging still, the outbreaks in Senegal and Nigeria were declared over in October, indicating that with robust measures taken early, West African countries can contain and eliminate the deadly virus.

The report also noted that the weekly incidence appeared to be stable in Guinea, while in Liberia – the worst hit by the Ebola outbreak so far – it seemed to be declining. In Sierra Leone, which seemed to have been managing the crisis better than Liberia, the weekly incidence appeared to have spiked in October, and continues to rise. Much of this, the report said, “was driven by intense transmission in the capital of Freetown, which… remains one of the worst affected cities in this outbreak.”

There were bright spots even in this bleak picture: “There is more evidence of a recent decline in the number of cases reported weekly in Kenema and Kailahun,” the report noted cautiously. These two districts were the original locus for the outbreak, between them recording close to 700 deaths. Now, they reported only 14 new confirmed cases in a week. In fact, the declining trend had been evident for over four weeks.

So what accounts for this turnaround in Kenema and Kailahun districts, formerly epicenters of Ebola?

There is, of course, the heroic work of aid agencies, in particular Médecins sans Frontières (Doctors without Borders), which set up a 64-bed emergency clinic in Kailahun in June and which has expended enormous resources in the area.

Doctors without Borders
An MSF/ Doctors Without Borders Hygienist in Kailahun; Photo courtesy of: doctorswithoutborders.org

The government also revamped its facilities in Kenema under the leadership of Dr. Sheik Umar Khan, the country’s leading virologist. Dr. Khan himself is credited with saving the lives of more than a hundred Ebola patients. He died in Kailahun at the MSF facility on 29 July of Ebola-related complications. More medical assistance, from the government and international health agencies, poured into the area after this widely publicized death.

The real turning point, however, may have resulted from the containment efforts of local authorities. This includes social mobilization, education, proscriptions around burial procedures, and the imposition of fines for breaking new bylaws focussing on the reporting of sickness and the movement of people in the area.

There has been much debate about the role of traditional rulers in the context of the modern state in Africa, and the activities of chiefs in Ebola-wracked eastern Sierra Leone are likely to give the debate new texture. In the absence of governmental infrastructure in many of the stricken areas, chiefs have played the critical role in the containment effort, and have demonstrated that they can be more relevant to ordinary village people than the modern state.

In July, at the height of the outbreak, Paramount Chiefs and representatives from all 14 Chiefdoms in Kailahun District met to develop a common strategy to contain and eradicate Ebola from their chiefdoms. At the end of the meeting, they issued a communiqué which contained a uniform set of bylaws that were immediately adopted in every chiefdom.

In addition to measures already in place, such as the closure of schools and other venues where people normally congregate, the bylaws impose stiff fines on anyone concealing an illness, refusing an Ebola test or interfering with contact tracers, community mobilizers, Ebola burial teams, or any other healthcare personnel. Any new arrival in a town or village, whether known or not, is treated as a possible carrier, and must be reported and assigned a contact tracer for three weeks. Heavy fines are imposed on anyone found negligent in enforcing the new bylaws, including people in positions of authority. And finally, anyone stigmatizing a recovered Ebola patient is also subject to a fine.

“The bylaws impose stiff fines on anyone concealing an illness, refusing an Ebola test or interfering with (…) healthcare personnel”

Chief Mandu Farley Keili-Coomber wrote in an email on 6 November 2014: “We felt that only chiefs enjoyed the moral and legitimate authority of our people to get them to willingly comply with behaviour-changing regulations, which central government organs, with all their resources had failed to achieve. This was at a time when nobody wanted to send their sick people to hospitals, people were still burying their dead in the traditional ways and, government Ebola intervention units were routinely attacked because of our people’s historic mistrust of central government.”

Within weeks, the results were palpable. By August, infection rates began dropping dramatically in Kailahun District. Chiefs in the adjacent Kenema District adopted the bylaws in August, and there, too, infection rates began to drop significantly in September.

“The checkpoints manned by the police and army to quarantine our district (…) now serve to keep others from coming in from areas that are less resolute in fighting the disease.” – Chief Mandu Farley Keili-Coomber

By October, the quarantine measures that the Government of Sierra Leone had adopted—deploying 1,500 troops to cordon off Kenema and Kailahun districts from the rest of country to prevent Ebola spreading to other parts of the country – were now working in reverse. In addition, perhaps, to keeping Ebola in, the cordon was keeping new cases out. As Chief Keili-Coomber explains: “There are some interesting ironies. The checkpoints manned by the police and army to quarantine our district, have indeed had a very bad effect on our local economies. However, these same checkpoints now serve to keep others from coming in from areas that are less resolute in fighting the disease.”

Still, much remains to be done. A recent Yale study suggests that if transmission via burial practices were eliminated, the secondary infection rate would drop by close 70 percent. Burial practices in which mourners handle bodies, “are effectively serving as super-spreader events.” Recent reports state that safe burials are now taking place in over 90% of Ebola deaths in Sierra Leone. And initiative like that shown in Kailahun and Kenema holds huge promise.

To quote Churchill at the end of the worst of the Blitz, “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

London Blitz
London during the Blitz (Wikipedia)

Editor’s note:
This is the second perspective on Ebola presented by the Diamond Development Initiative. To read the first, a statement from DDI’s Executive Director, Dorothée Gizenga, click here.