We were driving back to the hotel from the WHO office the other evening, when I saw an older man walking up the street. He was probably in his late sixties. I realized how few people of that age I had seen here. The life expectancy in SL is around 45 years. It is unjust that the chances of a Sierra Leonian reaching my age are small.

As I have written before, there are many other threats to health in SL besides Ebola. In December, the government will undertake a mass drug administration for malaria in the areas of intense transmission. It is assumed that an increased mortality in children has probably resulted from closure of many peripheral health units during the Ebola outbreak. It is hoped that the government action may also reduce the risk of admitting a person with malaria only into an Ebola isolation ward during this period. With the diversion of the meagre public health resources to Ebola, there is also concern about people not getting their TB and HIV medication. On Dec 1, there will be announcements by UNMEER and the National Ebola Response Centre about progress toward the 70-70-60 targets (isolate at least 70% of EVD cases and safely bury at least 70% of patients who die from EVD by 1 December 2014 – 60-days). I trust that World AIDS Day, also on Dec 1 will not be eclipsed.

Targets are useful as long as the information used for assessments is reliable. Last Saturday and the following Tuesday, I went out into the Western Area (Freetown and rural), with UNICEF and the District Medical Officer looking at possible sites for CCCs. At one village, we were told by a schoolteacher that 60 people had died from Ebola, the last one being 4 days before. He reported that the system for picking up sick people just does not work. In another community, where, with the help of an NGO they have started building their own CCC, they had seen 40 deaths from Ebola, the last one that morning. In addition, there were 12 people sick in their homes with nowhere to go. The official data appears to show a better picture, but anecdotes seem to contradict this.

I have often mentioned the daily ritual of hand-washing on entering public and UN buildings. The common implement is a bucket with a lid and a tap. To my surprise, these are called “Veronica” buckets. I discovered why. It was a smart, low tech, invention by a Ghanaian, and was borne of necessity.

Other threats to health here are roads and traffic. Some of us got an unsettling reminder of this on Friday, when our car skidded on a dirt road, went into a ditch and flipped right over. We were all wearing seats belts and fortunately no one was hurt. The road was well maintained by a mining company, but speed and gravel do not mix well. Our mission to Moyamba and Bonthe came to an abrupt end!

We had to wait for our back-up car from Freetown and were in a large market place. This was almost totally deserted as it is in the centre of an Ebola “hot spot”. When the disease hit neighbouring districts, people came to Moyamba Junction to see the local pharmacist who was “treating” cases. He became infected and there was a large funeral where traditional practices were followed. As a consequence thirty to forty people were infected, thus starting chains of transmission which are now close to coming to an end. These “amplifying” events have been a significant driver of the outbreak. There has been a lot of effort put into “sensitization”, through messages on the radio, posters and loudspeakers on trucks broadcasting the word, but these have to be followed up by community-by-community engagement and mobilization. This is being facilitated greatly by local chiefs in the rural areas. One of the local staff was recounting that in Freetown, communities were disrupted during the war making this kind of approach very challenging in the urban area.

The CCCs that I have written about are achieving the isolation and basic care that we had planned. One of them was set up across from a peripheral health unit. WHO has just released the story behind this CCC.

A fellow Canadian and I were given a pumpkin pie by someone from UK AID, who was (happily for us) unaware that Canadian Thanksgiving and American Thanksgiving are on different dates. It was delicious! We shared it with three Canadians and one American, as well as with colleagues from Egypt, Cuba, Spain and Italy.

I was not expecting to write this blog as I had planned to be in Koinadugu and out of contact. Instead, I am working with UNICEF and the Ministry of Health to select sites for CCCs in the Western Area, which includes Freetown. We had not thought that this would be necessary, but treatment beds and other isolation beds are not coming on stream fast enough. Rapidly constructed CCCs may be the answer.

One proposed location was a soccer field about a kilometer from our hotel. Erecting temporary facilities in urban areas has many challenges, including safe waste disposal. While touring potential sites, we passed by communities beyond the main roads south of the city. In one village, a house was under quarantine guarded by an armed soldier. It is clear why Sierra Leone is considered to be one of the least developed countries in the world.

As I have mentioned previously, Ebola is affecting all aspects of life. The lack of schooling, schools and their social advantages are highlighted in this story. It is tragic, and I feel torn when we are looking at setting up another CCC in a school yard.

There are many endemic diseases here, not the least malaria and Lassa Fever. Whereas each year outbreaks of cholera are usual, this has not been the case this year. There is the suggestion that it may be related to everyone washing their hands so regularly.

I share a small office with three others and we have two desks. It is good that we get on and that we are not all there all of the time. One colleague is from the UK and another is from upper New York State. You can see from the linked stories why we have interesting conversations even beyond Ebola.

While the team thinks that we (the collective) will succeed in getting EVD under control, the task, in summary, is strengthening weak health care and public health systems and improving health governance, while fighting a devastating countrywide outbreak. I will not provide any epidemiologic analyses but only to say that despite an influx of public health experts and training of community investigation teams, estimates of numbers of cases and deaths are far from accurate, but the trends that you read about are probably meaningful.

It is Sunday, and I had my run to the beach today without being stopped by the police. We often hear Friday prayers and, on Sunday morning, many go to worship. It would not be easy to find a driver this morning, as most are in Church. For those who have travelled, you will know that vehicles in many developing countries are adorned with religious sayings. The other day, I saw a sign on a community bus that read, “Fear judgement day”, which I thought somewhat worrying on the front of a means of public transport! I sometimes have time to watch the fishing boats from the hotel, but today got to see the other side. A shopkeeper that I just bought something from led the way to the beach.

Quarantine note for this week: Our social mobilization expert was due to be at home in the Philippines for Christmas. Now, she has to spend three weeks in Geneva to avoid being sent to an island off the coast for 21 days of enforced isolation.

It was good to welcome a colleague from UBC – an infectious disease doc who worked in Guinea for MSF. At the same time, we said goodbye to a psychiatrist from Hungary and an infection control expert who was from Ottawa, but now lives in Kentucky. A good team!

We are at a point in the SL outbreak where, in the most affected districts, there is a need to make an extra effort to isolate and treat as many cases as possible. In Port Loko, this is prompting the rapid takeover of schools, by the Ministry of Health, to house upwards of 50 patients. We all hope that these units will be able to provide care to cases and the safe environment for staff that we aim for in the smaller CCCs. There are still many infected persons in the communities who have nowhere to go and too few case investigators and contact tracers. We can only hope that, as isolation resources improve, as investigators catch up and get cases into care, and when all contacts can be followed up, the trends will improve. Liberia seems to have reached that stage, although no one here quite knows why. In the months after the outbreak finally wanes, there will be a need for rapid response teams to investigate and respond to new outbreaks – blips, as the curve goes down. In the newer outbreak in Koinadugu, the situation appears to be getting under control for now. New cases are occurring, but contacts are being followed twice daily to see who develops symptoms. I flew up there today by helicopter. (This was a great change from hours and hours on the road.) From today’s mission, a base camp for staff will be set up. Oxfam and Medicos del Mundo were along and they will take over the facilities from WHO very soon. We will then be ready to respond, as necessary, to outbreaks of Ebola in new locations. A possible flare up in another district was being investigated this weekend.

Whereas the international community has been criticized for its response to the events, it is interesting to see an influential Nigerian virologist not mincing his words in an analysis of Africa’s readiness and reaction to the epidemic.

Meanwhile, the over-reaction continues. A colleague was due to return to teach at Columbia University in NY State. He will not be allowed into the institution for three weeks. Another is returning to New York to spend US Thanksgiving with her family. Two of her relatives and their families are not attending the celebrations because she will be there.

I know that the security forces (army and police) do not like public gatherings and had heard that the massing of runners on the beach at weekends is sometimes stopped. This morning I could not get to the seaside. I was told that running alone was OK, but running with others was definitely not! I found an alternate route through the very varied neighbourhood of Aberdeen.

On a lighter note, last Saturday evening, during yet another raging thunderstorm, I heard bagpipes playing, or I thought I did. I decided that this must be on a TV somewhere. I later discovered that one of the WHO staff brings his pipes with him on missions and he was playing outside under a canopy facing the bay. The fishers who go out at that time had stopped in their boats to listen.

I had heard that avocados were coming into season. One of the field epidemiologists bought two off the street on her way home. She tried to eat them later but they were obviously not ripe. Two days later, someone else was buying oranges from the same seller who remarked that she had realized later that the avocados that she had sold to “his friend” were not ready to eat and insisted that he take a ripe one back for her.

One of my colleagues is from France. On Thursday, he walked into the office and asked “When is next Sunday?” I replied, November 23. He then asked, “Well, what is Nov 16?” I said, this Sunday. He was visibly rattled. He had been trying to book a flight for next Sunday, assuming that was in 3 days time. Such is the English language.

Normally, I cannot abide thinking of Christmas before December 1. This year, I am definitely looking forward to it as it means I will be with Lois and the rest of the family.

I have been “in the field” all week and was glad to get back to my hotel in Freetown.  Electricity at all hours, air conditioning and a hot shower should not be taken for granted!  Our first CCC opened on Monday and had ten patients yesterday. At least one person has died of Ebola after admission to the CCC. The second CCC opened today.

I was in Port Loko for the CCC opening, and traveled to Koinadugu district on Thursday, to the centre of a new outbreak. The roads are bad, as can be seen in one of the photos. The truck that is stuck is from WFP and is supplying food. Our staff have set up a temporary CCC in one of the villages, to be replaced by something better in the village school next week. One of the blackboards has the remains of a lesson from June 20 – the last day of classes. There are many confirmed cases in this chiefdom.

I am becoming more expert on things like the need for motorcycles for surveillance staff, ambulances, packaging for lab specimens and satellite internet equipment. At first, the only way to keep in touch was for someone to climb a nearby hill where there was a cell phone signal.

On journeys through the villages, it is common  to see rice and chillies drying, and oranges, plantain, melon, mango and other fruit and vegetables for sale. Behind this, there is another story. In affected areas, many families are unable to harvest their crops due to illness or the loss of relatives, so food is in short supply. In addition, the price of rice, the staple, has doubled while, in areas of intense transmission, markets have been closed down in a bid to stop large gatherings. At the same time, iron mines are still operating, but with workers who are kept totally apart from the outside world for weeks at a time, so that Ebola is not introduced.

In Kabala, a WHO person responsible for social mobilization spoke with religious leaders this week. Most leaders, Moslem and protestant, attributed Ebola to divine punishment.  Fortunately, they can accept how it is transmitted and do support prevention messages. Despite this, and the support of Chiefs in spreading the word, people in the villages are still carrying out traditional burials with close contact with their dead relatives. I asked a nurse why people might not come to the CCC if they were sick. She said that they were traditional people who prefer herbs for treatment. Others have recounted that they believe that Ebola has been brought in by nurses who poisoned the wells. Most leaders are working very hard to encourage changes in burial practices and beliefs, but these are deeply engrained and understandably very difficult to influence.

I passed a girl of around four years cleaning up the front “step” of her hut, using the omnipresent short reed broom. In the country, I have regularly seen children, not much older than Jade, carrying bundles of wood, washing and plastic jerry cans of water on their heads. Ebola attacks all ages, but the mortality is slightly less in the young and the plight of orphans is mentioned often in meetings with NGOs and government. For those who survive, a certificate of discharge is an important piece of paper that helps them to be accepted back in their community, if they can find a relative left to look after them.

On a lighter note, I do get to run at weekends and this morning at dawn, took a road past large bushes of bougainvillia to the long sandy Lumley Beach. This would be a good place to come as a tourist in better times…

I really appreciate all the comments on the blog and your continued good wishes. If you feel like supporting the effort, you could consider donating to MSF or Plan International. I have been really impressed by Plan’s support for the CCCs.

From outside of Sierra Leone it may be hard to understand why it takes so long to get our initiatives launched. However small the operation, such as our CCCs, it needs a constellation of stars to align: Ministry of Health and community agreement and support, a water supply, payment for staff, ORS, staff trained in PPE, tents, latrines, showers, beds, mattresses, expert oversight and lots more. I admire agencies like WFP and UNHCR who can set up small towns in isolated regions of the globe to assist refugees and migrants, seemingly overnight. I now know how complex this can be!

Today, at the dry run for our first CCC, which opens on Monday, there was a large cast of interested parties: WHO,
UK Aid, Plan International, Republic of Sierra Leone Armed Forces (who will supply medics at first, for mentorship and assessment), Partners in Health, The Kings Partnership (UK), the African Development Bank, the Paramount Chief and the BBC. I will be back for the launch. It has to go well.

More support has arrived from the UK, including a ship anchored offshore with armed forces personnel and helicopters. How can the British National Health Service send in 160 medical and nursing staff while other countries, apart from Cuba, China and the USA, are only represented by volunteers? NGOs abound, while countries are few.

Certain states seem to actively cutting themselves off. Australia and Canada’s actions to not offer visas to nationals from affected countries is being interpreted as not adhering to the International Health Regulations. A colleague from the UK working in Geneva had a long standing teaching commitment in Australia and has to leave here early to fit in three weeks in Geneva before traveling to Melbourne, in order to avoid quarantine.

Quarantine has been attempted here, as well as in the US. But in Sierra Leone, while police may guard a house during the day, they may not be there at night. In villages that are quarantined in rural areas, WFP has had to bring in food.

There are only two airlines flying into Freetown now. A colleague from Nairobi arrived this week and had to fly to Brussels and south to Sierra Leone to get here; another way of isolating affected, countries.

Today is Sunday but I will get an espresso before heading out again. Last evening, I had a lovely meal with colleagues at a Lebanese Restaurant. It was a good break!

The first news story on the BBC world Service radio here was, for once, not Ebola but the shootings in our national capital. Everyone expressed concern and great surprise. I have not been able to view the videos but got a good sense of events. It must have been really worrying for those in Ottawa and the country.

Meanwhile, we all keep fighting the threat or perceived threat of Ebola. I think that the response in the US is becoming disproportionate e.g., quarantining of returnees to NY State. Workers here are wondering what we will have to face by the time we return to our home countries. One US NGO staffer I talked to wanted to be away for just two weeks to move her belongings from DC to Geneva. At present, she will have to try to avoid landing in New York, but still has to stay in the US for three weeks, taking her temperature twice daily and reporting to CDC.

There is still a lot of denial here, which is, perhaps, not surprising. The stigma for infected families is high, and sometimes survivors and orphans are shunned. If Western countries had to face the same, would we be any different, even given our greater acceptance of how infection is spread? Sierra Leonians who travel are also suffering discrimination. On the radio I heard one person state that “we may not be infected but we are all affected”.

I have talked about the influx of assistance. This can put a strain on UN organizations and NGOs who work here permanently, with new and constantly rotating staff, as well as disruption of long standing programs. In addition, offers of help, like the well publicized Cuban contingent, are not as straightforward to take up as might appear at first sight.

Our first Community Care Unit (previously called ECUs) should open this week, with three more to follow soon after. We are having to train workers to be safe and will have to ensure tight oversight. At a training session last week, the local Paramount Chief showed his leadership by encouraging the workers, but also by ordering all village chiefs to turn up. He then proceeded to take them through the facility to show them how it would function; an influential, impressive and powerful man.

The UN system does look after its staff here, with medical services, security assessments of hotels, limitation of transport to UN vehicles, and requirements to get permission to travel outside of Freetown. The creation of an outpost in a remote village in Koinadugu Dstrict, to investigate a new outbreak and build an isolation unit, will create particular headaches for the organization’s security arm. I just wanted to re-assure you that our well being is a high priority!

I may be able to report more on the outbreak investigation and plans soon, but can say that last week an advance team took 8 hours to travel 300km to the district and then another 8 hours to travel 40km into the mountains to access the affected village.

Meanwhile, features of daily life continue to fascinate; trucks and cars on the road laden with charcoal, wood, rice, palm oil and plantains bound for Freetown. I had forgotten how delicious fried plantain is! The buyers can charge double in the city for what they pay picking up supplies put out on the roadside. One can often see small scale furniture makers who produce beds chairs and dressers. I asked what kind of wood was being used to make shelves and stands for chlorine buckets in our CCC and the answer was “forest wood”. I was shown such a tree, but was none the wiser.

We are protected somewhat in the city as, when the power goes off, which is not infrequently, a generator comes on in the hotel and WHO offices. In Port Loko the power is only on from 7pm to 7am. Power meant a fan and being able to sleep with a breeze blowing into my mosquito net when I stayed there on Wednesday night. The next night I was able to get a room with AC and hot water! It is always very hot and sticky and more so inland. 30 degrees during the day is usual but the humidity is also high. Thunderstorms and heavy rain will continue for a while longer.

Finally, while Canada is well into the hockey season, soccer is on every TV screen here. I have seen many cars sporting Manchester United colours and yesterday, people were glued to a match between Real Madrid and Barcelona. I have been out running twice and am not alone. I suspect that most of the young men who are exercising as well are budding soccer players.

I very much appreciate your notes of support and am very lucky to have the ability to see and talk to Lois on most days! The occasional sight of Jade and Rhys and chats with Mish, Steve, Chris and Shiny are precious.

A good piece of advice here, is to try to achieve something that will hopefully have some influence on stopping the epidemic. That might seem obvious, but inevitably we do spend a lot of time responding to “fires”, planning for the short-term, coordinating, travelling between meetings and trying to get a sense of what is really going on. The latter is really difficult to assess, but it seems that the epidemic is still entrenched in Freetown, the Western Area, Port Loko and Bombali.

My task is to coordinate the roll-out of Ebola Care Units. WHO is responsible for the technical aspect and training, but we are in charge of setting up the first four as a proof of concept. Then NGOs, probably funded by the UK, will set up many more. These will be small, 8 bed facilities, in tents, built by local labour with a lot of local material. The objective is to provide isolation for cases close to their homes, when there are no treatment beds or beds in holding centres or where transportation is not available. Hopefully, we will have 4 operating next week.

A miniscule number of health workers across the world has ever worn the personal protective gear required for Ebola, so it is hardly surprising that there have been problems in the US and Spain, with apparently hasty training. We have the task of training health care workers in rural SL to perform at the same level, for their protection and the protection of others, in the ECUs. This is a tall order.

I visited Port Loko and saw ECUs under construction. I heard from a local MP about his task of dispelling myths about Ebola. This included fears that a person went into a centre for treatment, had a needle in their arm (for a specimen) and were sprayed with chlorine and then died. It is not hard to understand how some would think that the first was injecting the virus and the second caused death.

It is probable that there are many uncounted cases in villages and that when new beds, such as ECUs are open, sick people will emerge. We shall soon see.

There are posters everywhere about “kicking out Ebola”, and encouraging people with symptoms to call the 117 hotline. On the way out of the hotel the other morning, we saw two men with loud hailers walking up the road broadcasting prevention messages. Meanwhile, life goes on as it has to, where people live from day to day on meagre earnings, but there are no schools open for children. Large businesses are suffering; our hotel only has WHO staff as guests.

In the villages, rice and palm kernals are laid out to dry, but the disease is not far away. Opposite one the ECU sites, I saw a burial team at the local health centre. Another health centre that we stopped at did have Ebola cases, but there were no warning signs at the entrance. I was told that it was a “dangerous place”.

I am working from my hotel today, trying to write SOPs for the ECUs, but also fielding calls and meeting with others staying here.

More next week!

Click on the pictures for the captions!

I had to hit the ground running after arriving in Freetown at 0630 on Thursday morning. The plane arrived at 0330, but the airport is a long way across the river from the city.
Thursday was spent getting a security briefing, phone, cash from the bank and initial meetings. Commerce and street trading are busy, but Ebola warning signs are everywhere and all the bars are closed. I did see a woman, who I presumed to be a local resident, wearing an “I love Ottawa” t-shirt!

Handshakes are out and chlorine handwashes and temperature checks are in.

I am spending most of my waking hours working, and that includes Saturday and Sunday. The situation is not very good in many areas and the impression that I get is that this is still an uphill battle. As I said in my first posting, there are numerous partners, but the great majority are collaborative and highly motivated to succeed. I am working with dedicated people.

I am staying at a hotel on the ocean with many other WHO staff. So far, the food has been good and I ate barracuda for the first time last night. On Saturday, the person whom I am replacing had a farewell party, which hopefully the police do not decide is a mass gathering. It also celebrated the Spanish National Day when Christopher Columbus landed in the “New World”. I almost declined the invitation!

I spent this morning with UK AID and a large group of British soldiers. This was a new experience!

I am off for a site visit to Port Loko tomorrow.

Happy Thanksgiving!

My time in Geneva was short. I saw the mountains flying in, but did not have much time to look up after that. I was rapidly re-immersed into the WHO culture and all of the activities around Ebola. Many old friends and colleagues are working on the outbreak and it was good to meet up with them again. They remain dedicated and resilient despite external as well as internal pressures.

Even though I have not yet landed in Sierra Leone I have a number of working hypotheses. Lois will recognize, but not agree with, this approach!

In West Africa, and beyond, the response to Ebola is not chaotic but is certainly very complex. My public health pragmatism with be essential. Countries outside those affected, the UN system, and international governmental and non-governmental organizations are engaging on their own terms. They all have mandates and are making choices as to how, when and where to be involved depending on their interests, expertise, and willingness to become embroiled in the response. This makes coordination and adherence to a strategic plan very difficult. Also, in an affected country it may be seemingly well directed at the national level, but it is not straightforward to translate programmatic decisions into local action where community buy-in may not be present. I will let you know how well this analysis holds up!

There is good news from some areas of Sierra Leone but then not so good news from newly affected districts. I will be responsible for rolling out Ebola Care Units throughout Sierra Leone. These will be community based and are sorely needed where there are no treatment centres and where communities need local facilities for isolation and basic care. The person whom I am taking over from leaves on Saturday, so that we will be talking a lot over the next couple of days. I will be based in Freetown but will undoubtedly be travelling all over.

The training in Geneva was very much about personal safety and security and I have had to add a large medical kit as well as a mosquito net to my luggage. That, as well as a few more bottles of hand sanitizer! So, I will be looking after myself.
More to come…