My flight to Brussels departs this evening, on the way to Montreal and Vancouver. I will be very glad to be home again with Lois and the family. The immediate task is not finished, and after “Zero Ebola” it will take a long time for this country to deal with the root causes of the outbreak.

The week was spent reviewing, re-visiting and refining the WHO response. I had the pleasure of orienting a number of new team members deployed from abroad and within the country. There is a lot of impressive talent coming in, which will be needed for a time yet.

I was able to talk to the BC Health Officer’s Council meeting in Victoria on Ebola, via Skype. It worked well and the questions were very thoughtful. I teamed up with a physician who had spent time working for MSF in Sierra Leone as a clinician and is back in Vancouver.

Yesterday three of us went out into the Western Area to observe what was happening during the three day  “Stay at Home”. The main streets were eerily quiet with no taxis or minibuses and few pedestrians except for those allowed to be working. In the side streets people were sitting outside of their houses passing the time. The only groups of people were at water and food distribution points.

Social mobilization teams were spreading the word as well as distributing soap as a reminder to wash hands (only possible if you have enough water of course). Scouts had been recruited to assist at the police roadblocks. Hopefully the hardship for those who cannot work during the three days is outweighed by the benefits of finding sick people or, at least, ensuring that there are none to be discovered.

The markets were deserted but we found that the local council was using this as an opportunity to clean out the storm drains before the rainy season. The workers were doing a nasty job out in the heat of the day. I met the Chief Environmental Health Officer for Freetown who was very pleased to hear of my profession and that of my father who was an EHO.

We then visited two cemeteries. The one in Freetown is full after receiving 6700 bodies. The only flat area that is not dotted with burial mounds was the site of a mass grave from the war. The great majority of deaths are not now due to Ebola but to reduce any risk of infection, every dead person is treated the same way. A swab is taken and the body is disinfected, placed in a white body bag and transported to the east of the city, and now contains 2300 graves from during the outbreak. The burial teams and gravediggers doing all of this work are still stigmatized. Some are not allowed to live at home by their families or have been deserted.

Each mound is carefully marked with a number and/ or name, so that relatives can find it. The welfare officer at the new site was visiting every family at home giving them information. Workers ensure that after being placed in the earth, bodies of those of the Moslem faith are covered in sticks and leaves, according to tradition. We watched the burial of four persons with some families in attendance. This was a moving experience and brought home the immensity of the loss of people during this outbreak.

We ended the afternoon with an expansive view of Freetown. This City and country experienced a devastating war, which ended 13 years ago, of which I heard some harrowing tales from someone who was here during the hostilities. Memories must be long, and Ebola is testing them again. I hope that with meaningful support, this country can succeed and build an equitable safe, equal and healthy society in the future.

With intense efforts to locate every case and contact, the disease is slowly receding, despite persistent problems with insufficient expertise, irregular payment of staff, a lack of fuel in outlying districts and challenges in data management. Thursday marked the first day with 0 reported cases since the start of the outbreak here last May. This is likely to change, however, as last week there were still 4449 contacts being followed, some of which can be expected to develop the disease within the 21 days of monitoring.

Guinea to the north and east is now reporting more cases than Sierra Leone. This is a concern for Sierra Leone, as most cases are occurring near the border. Liberia had reported its last case, but another appeared yesterday.

As the push toward zero is promoted, the sense of relief will turn to frustration when there is an inevitable trickle of cases at the end. The Presidents of the three affected West African countries signed the Mano River Declaration, pledging zero transmission by April 18th, 2015. I was told that political, business, and military interests are the stimulus of the national “campaign” to get to zero.

Looking forward, I represented WHO at a meeting between partners and a delegation from ECOWAS consulting on priorities for assistance to rebuild the economy and health infrastructure. WHO’s main area of concentration, however, continues to be on the outbreak.

Schools may re-open soon, but those used as Ebola isolation and treatment centres must be decontaminated. An interesting outcome of the resistance of Chiefs in the Northern Districts to colonial rule in the 19th century is the greater number of schools in the south, which, for a long time, translated into higher rates of literacy.

Non-Ebola reports: no water the other morning. I was told later to follow the edict of WWYC – wash while you can…. Power outages are common and then generators kick in. That happens regularly throughout the day. Both running water and power should never be taken for granted!

Image and sounds:
Breaking rocks into increasingly small sizes, by hand with a hammer; gravel has to come from somewhere. The product is then carried on the head as for everything else.
Celine Dion is popular and unavoidable!

I am back in Sierra Leone for a brief stint, at the request of WHO. As I was only currently available for three weeks , I was surprised to get a call on March 6^th to arrange my flights! I arrived on Thursday evening, after being in transit for 27 hrs. It was good to feel more at ease this time, which helped when I had to search for a room for the night. I knew that I would find a bed somewhere! I will be coordinating WHO’s technical activities for the next two weeks. Although there are many new faces, it was good to meet up again with colleagues from before. There are far more WHO staff here now and they are spread across the country. At the end of last year, we were scrambling to get expertise even in the hardest hit areas. Local, sustainable, disease-control, and infection prevention and control capacity is being developed as a start to (re)building a health system.

The outbreak is definitely slowing down. There are now only a limited number of Chiefdoms with transmission, with 58 cases last week. This is still a significant number, but the smallest weekly total since July 4, 2014 when the President declared Ebola as an emergency. Resistance to control measures continues for a number of reasons, including mistrust of government and a preference to be treated by traditional healers and to adhere to traditional burial practices.

The fishing community that I can see from my hotel window is very quiet just now. The normal transit of boats, morning and evening, has been interrupted by the disease. A fisherman, recently infected, returned to his village in the interior to consult a traditional healer. As a result, cases occurred there as well as in the fishing community across the bay. Although the quarantine period is now over, the fishers have yet to return. As a possible sign of a return to normality, the weekend runners were out in force again early this morning, right near the dock.

Banners announcing religious revival meetings now outnumber those promoting protection against Ebola, although there will be another door-to-door search in two weeks time for cases across the country. It will not be a “lock-down” but a “stay at home”. An exception will be made for going to Friday prayers and to church for Palm Sunday.

The desire for the country to resume “normal” life is compelling. Funders such as the UK and World Bank would also like to start cutting back. But, at the same time, communities and public health officials need to remain vigilant. I spent many hours on Saturday in a meeting discussing “right-sizing”. The tension between being positive that the end is in sight and the need to plan for the future and avoid complacency will remain until we are free of disease.

Images to remember:

A girl, about 4 years old, sitting outside a squatter’s shack enthusiastically brushing her teeth at 0730 on a Sunday morning.

A woman in stunning traditional dress with her child, getting off the back of a motorcycle taxi to enter a Mennonite Church, from which organ music could be heard.

A man getting a mango from high in a tree with a pole and sling with the customer waiting below.