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.

The Western Surge began the day that I left. I hear that there has been an increase in calls for ambulances to pick up suspect cases. The “push” will continue into the New Year and will be accompanied by restrictions on gatherings, festivities and travel over the holidays.


On my last evening, the “surge” team met over dinner to review the day’s work and I handed over my responsibilities. I had finished my mission report, which was a very useful exercise in reviewing achievements and lessons learned and in making recommendations for future teams.

The trip back across the estuary to the airport was uneventful and the health questions, temperature check and baggage search straightforward. Waiting on the tarmac was the last experience of a warm African evening.

Lois and I were reunited when I arrived in Geneva early on Thursday morning. I hope to be reunited with my bag soon as it will be leaving Freetown 4 days late, due to a “technical problem”!

Thursday was taken up by technical debriefs and a mandatory visit to the WHO health services and psychologist. I handed over my UN certificate, which marked the end of my mission. Later, Lois and I celebrated with fondue at the Café du Soleil, our old haunt.

The efforts to control the outbreak will continue in the months to come and I will be watching closely, but for now, from afar.

It is Harmattan season. It is noticeably cooler in the mornings (low 20s), but still gets hot later. On sunny days, the bright light has been replaced by a haze. Yesterday, I saw cars covered with a fine layer of red dust brought in by the north winds.

Fridays are a day of colour. Everyone wears traditional clothing to work, which for both men and women can be very “sharp”. I passed smartly dressed men pouring out of a mosque after Friday prayers. The women were emerging from another entrance. I also saw many brightly attired people going into a large church and was told that services were held on Friday and Saturday, as well as Sunday, due to the pressure for space.

We have been building up for the surge, which will now start on Wednesday. The timing was dependent on a last minute decision by the President. The campaign is really a concerted effort to encourage sick people to present themselves and to get help. The level of trust in government is not high and even the proportion of people in the Western Area that believe that safe burials are important is surprisingly low. I gave two presentations to groups of district councillors and tribal heads. They were really engaged, demanded more involvement and asked many questions. I presented in English (of course), others in Krio. The questions were also answered predominantly in Krio. When the debate was animated and in Krio, I still got the sense of the concerns by catching the occasional word.

The new outbreak in Kono has received a lot of attention as a result of a WHO press release. I missed going out on the mission because of commitments to the Surge. You will see in the BBC story reference to the phrase used by the MOH Director of surveillance when he said that we were only seeing the ears of the hippo! The tip of the iceberg analogy would not have worked. Kono is the centre of diamond mining, but it seems that little of the profits accrue to the people. I hear that it is not unusual to see families walking down the street with pans to look for gems in the local river. The roads are bad and the support for the district health management team is minimal. If the outbreak is to to be controlled, there is a need for basics like cars and fuel for surveillance and contact tracing teams. The cars take a real beating on rural “roads” and even to reach one affected village can take hours. IFRC is setting up a holding centre which will be staffed by Canadians. They are on site already and supplies are coming in. The outbreak was going on for a time but not admitted to. As a consequence, at least three nurses and 2 sprayers working in the local hospital died. One of the drivers saw an illegal night time burial last week in the district capital. More social mobilization and community involvement in any action is absolutely necessary.

I am writing my mission report, which is a requirement for everyone before they leave. I have seen many staff busily composing their final words of wisdom in the days before departure. It is a great way of analysing what one has achieved and a way to make recommendations. Before she left last week, I had a long conversation with Eilish Cleary (Chief MOH for New Brunswick) who spent a month in Nigeria and one month here in Port Loko. She wrote this story for the Irish Times. It contrasts with the attention that is given to treatment centres and PPE-clad health care workers. They are, of course, “on the front line” but there are so many others involved in the “fight” – health workers, community workers, as well as the patients, families and friends.

Eilish and I are, of course, in favour of bringing in more public health expertise. This is echoed by John Kim, the President of the World Bank in a commentary for the New York Times. You may have seen Eilish’s other work reported in the Globe and Mail. We do need something to balance the negatives. We want to promote health, but what we have to say, i.e., do not hug, do not touch a sick person, keep your distance from those who you would naturally want to comfort, be proud of not caring in the way that you are used to. I expect that more and more people here will want to forget the outbreak soon enough, and then there is the danger that it will become endemic and just smoulder away for months.

I will depart on Brussels Airlines on Wednesday evening. This will mean catching a boat early in the afternoon to get over to the airport. At least it will not be in the middle of the night as when I arrived. I will be in Geneva early Thursday morning. I might just publish another post next week, but, in the meantime, thank you again for all of your comments and support!

What I have missed (not who I have missed!):
Terra Breads and a good espresso
Regular exercise outside
Salads
Good roads
Consistent WiFi
Drinking water from a tap

What I will miss:
The warm weather
The warmth of the people
The fresh fish
The WHO team

What I will not miss:
The smell of chlorine on my hands

The battle against Ebola will be fought and won in the Western Area. This sounds like a headline. Port Loko is still highly “active” but, with more isolation and treatment beds and better surveillance, the situation will improve there soon.

In and around Freetown (Western Area), with its crowded communities stretching out on both sides of the peninsula, the outbreak is increasing, as shown in the graph below. Ebola has been seen before in larger communities, but not in such a dense urban area. It is daunting. From December 14-31, there will be a “surge” of effort to find people  who are sick with Ebola-like symptoms and to promptly isolate and treat them. This will involve an increase in the number of beds available – for example, MSF Spain, MSF Switzerland, Emergency, MedAir and the Ministry of Health will all be opening new holding centres and treatment centres before the end of the year.There will also be four CCC-like units created in the sites that we scouted out last week. Until I leave in 11 days, I will be in charge of the WHO response in the Western Area. On top of this, there is now a new outbreak in Kono, at the far eastern end of the country.

I understand that there is a fairly harmonious relationship between religions in SL, to the extent, for example, that, where, at the opening of a meeting, the Moslem representative is not there, the Christian representative will say both sets of prayers. Despite the mix of 50% Christian, 50% Moslem, there is little evidence of the approach of the Christmas season, unlike the images of holiday preparation, trees and lights, I see in news from Canada. Early one morning, I did see one flashing star and, on my walk to seek espresso this morning, I heard an African version of the 12 days of Christmas. The Radisson Hotel has a (fake) Christmas tree, but that does not really count! Of course, the climate and relative equal length of day and night emphasize the distance from northern climes, where days are becoming shorter and colder. It is constantly between 25 and 30 degrees, with a humidity of around 80%. The rains seem to be almost over and then it will become even hotter.

I heard on a car radio the other day the kind of African beat and rhythm that Lois and I remember from our time in Zambia. On being asked how he would describe this type of music, the driver responded, “60’s”. He said that his generation refer to it as music for the “old man set”! I smiled….music obviously does evolve. For an alternative to the “Band Aid” Ebola appeal tune, listen to the song by Steady Bongo who is a Sierra Leonean institution.

I have been in touch with a few journalists here. This is a piece by a Canadian, now based in DC.

On the interesting people file, I recently chatted with someone from UK AID with whom I have been working regularly here. I discovered that he was in Zambia in the 1990’s, where, with his partner, he cycled (and canoed) the route of Livingstone’s last journey. This would have included the Bangweulu swamps, which Lois and I both know. The book of the trek is still available. He is now based in Dhaka and plans to cycle around Bangladesh, having constructed a rickshaw for his children attached to two bikes up front for himself and his partner!