Under cover of darkness, a few burial workers pried open the steel doors of a hospital morgue and stole the corpses of two adults and one child. They carried the bodies confidently, with hands that carted cadavers daily. They took the bodies to the hospital's front gates, and tossed them beside a paved road that bisects downtown Kenema, the third largest city in Sierra Leone.
It was 25 November, 2014 and hospitals were collapsing under the weight of the deadliest Ebola outbreak in history. The men and women on the frontlines of the crisis, who risked their lives to save the dying and protect the healthy from infection, had begun to feel duped. While millions of dollars had been donated to Sierra Leone from all over the world to help them tackle the crisis, their pleas for pay had been overlooked. But the burial workers knew that the corpses wouldn't be.
As the sun rose, a crowd gathered around the bodies. No one admitted to dumping them, but members of the hospital's burial team, the 23 men tasked with carrying and cleaning Ebola-infected corpses, told local journalists that the cadavers had been displayed as a form of protest. The team had not received the €100 ($115) weekly in "hazard pay" they had been promised for nearly two months. And they were not alone. All over the country, doctors, nurses, hospital cleaners, lab technicians and burial workers were missing paychecks.
Meanwhile, donations flooded into Sierra Leone, and the two other countries affected by Ebola, Guinea and Liberia. Local staff watched land cruisers rumble through towns, transporting international aid workers, many of whom did not work directly with Ebola patients. Overhead a United Nations helicopter flew Western humanitarians and officials across the country at an estimated €4,390 ($5,000) per trip. Time magazine declared Ebola workers the persons of the year, but here they were, haunted and hungry.
Hundreds, if not thousands, of nurses and other frontline staff fighting Ebola have been underpaid throughout the outbreak – and many remain so today. The lack of pay is not simply a matter of corrupt officials stealing donor money, because so-called "hazard pay" was issued through direct payments to frontline workers starting in November, then electronic payments to bank accounts and mobile phones beginning in December. The problems appear to be twofold: first, Sierra Leone's national health system has been so underfunded for so long, that it was a monumental challenge to document all of the country's care workers and set up payment distribution channels to them. Second, it turns out that relatively little money was set aside for local frontline staff within Sierra Leone's health system in the first place. In fact, less than 2% of €2.9bn ($3.3bn) in donations to fight Ebola in West Africa were earmarked for them. Instead, the vast majority of money, donated from the taxpayers of the UK, the US and two-dozen other countries, went directly to Western agencies, more than 100 non-governmental organisations (NGOs), and to the UN.
Strikes drew attention to staff frustrations throughout the outbreak, but many health workers suppressed their anger and pressed on with their jobs. They did not want to risk their prospects of eventual pay. Indeed, at Kenema Government Hospital, the entire burial team was fired after the demonstration last November.
On the day of the demonstration, Elizabeth Kabba, a nurse in her late thirties, ignored the crowd gathered at the hospital gates. She slid into her protective uniform, and entered a makeshift structure constructed out of plywood and tarp, with the words "High Risk Area" scrawled across the doorway in permanent marker. Kabba had volunteered to work in the Ebola ward when the outbreak began in May 2014. West Africa's leading virologist, Dr Sheik Umar Khan, had recruited her and a dozen other nurses to the ward from the general hospital – one of the largest in the country. Back then, no one could have predicted how horrific the outbreak would be. They did not know that Ebola would kill Dr Khan and 36 other health workers at Kenema Hospital. Across the three affected countries in West Africa, 507 health workers have died of the disease, as of 6 May, according to the World Health Organization.
When I visited Kenema Hospital in February, graffiti on one wall of the Ebola isolation area read: "Please pay us." By then, nurse Kabba had cared for more than 420 Ebola patients, and had lost several friends. She had not received most of the €80 ($92) weekly allowance she'd been promised since September. Nurses around the country were in similar positions. "We hear about money pouring in, but it is not getting to us," Kabba said. "People are eating the money, people who do not come here. We are pleading nationwide, we have sacrificed our lives."
When I spoke with Kabba's boss, District Medical Officer Mohamed Vandi, he acknowledged that his health force had been sorely neglected. "I am not hopeful for the future," he said. As Ebola ebbed, world leaders had begun to make promises about improving fragile African health systems. Vandi looked on sceptically. "If we could not get support when the virus was here, I wonder how we could get it when the virus is gone?"
The walking dead
When Ebola crept through Guinea's porous border, and into eastern Sierra Leone by May 2014, it was the national health workers who responded. By July, the Ebola ward at Kenema Hospital had swelled with more than 100 patients.
With a 70% chance of a swift, painful death, people perished in their beds and on the floor; nurses climbed over corpses to reach other patients crying out for help. Invalids died while the nurses rehydrated them, and while cleaners wiped every variety of infectious fluid from their bodies. Nurses described how patients stricken with fear would fight them, or flee to the latrines. "When I'd find them in the toilet, I'd wash them and return them to bed," one nurse told me. "I'd stay by the bed and pray for their lives to help them to cope. I'd lie and tell them I was once an Ebola patient, and that I survived."
On 29 July, Dr Khan, the head of the ward, died of Ebola. His death sent chills throughout West Africa, but most of all Kenema's hospital. "He was the captain of the ship, and when he died, everything changed," said James Massally, the laboratory director at Kenema hospital. "The attitude of workers, nurses, technicians, everyone was terrified."
To keep the hospitals staffed, the government promised hazard pay to health workers who continued to work. Prior to the outbreak, nurses who were lucky enough to find paying jobs in the national health system earned about €115 ($130) per month – less than guys who drove motorcycle taxis. Those who weren't yet on the payroll worked for free until a job opened. To get by, nurses confessed they sold goods on the side or charged patients for care under the table. So when the bonuses for frontline workers were announced, thousands of nurses and other staff across the country volunteered. Those treating Ebola patients directly were to get about €100 ($115) per week on top of their meagre (and often non-existent) salaries; those in Ebola triage units, €80 ($92); and nurses in general wards, €40 ($46).
Yet with a budget less than Mississippi's – the poorest state in the United States – the government of Sierra Leone could not afford to pay the increasing number of staff it needed to tackle Ebola. In Kenema, the WHO contributed to hazard pay funds for a couple of weeks. In addition, it recruited a handful of international health workers to help. William Pooley, the 29-year old British nurse who later caught the disease, was among them. So was Nahid Bhadelia, an infectious disease physician from Boston University. Bhadelia arrived in August to find fliers commemorating dead nurses and lab technicians hung on hospital walls – and a facility lacking rubber gloves, plastic Tyvek suits and other safeguards. "So you're not getting paid, your friends are dying, and you have nothing to protect yourself. We couldn't get anything into the country because commercial shippers stopped flying," she says. "At one point, we created aprons out of tarps."
By August, Ebola had spread to the capital. Marta Lado, a Spanish infectious disease doctor, was there when it hit. She had been working on HIV in Connaught Hospital in Freetown, as part of a team from King's College London, which has partnered with Connaught since 2011. She and the director of that partnership, Oliver Johnson, converted one of the hospital wards into an isolation unit, and recruited a couple of local nurses and cleaners. "We'd finish at 9pm, go home to sleep, and then a soldier or a security guard would call and say someone is banging on the door of the unit, or there is a dead body," Lado says. "It was completely crazy."
In August, after nearly 1,000 people had died of Ebola, the WHO declared a world health emergency and the process of organising and funding an international campaign to fight the contagion began. The world's largest donors searched for organisations to deliver their help – and that took time. Few NGOs specialised in emergency clinical care, and a rare one that did, Médecins sans Frontières, was stretched to capacity. In the meantime, the death toll in the three hard-hit countries tripled. By 1 October, it included 3,330 people. Dedicated local nurses and support staff struggled to care for patients. Desperation drove them too – in the form of the hazard pay they had been promised.
In November, the hazard pay process was altered after the World Bank (along with the African Development Bank) offered funds to cover it. Almost immediately, the World Bank noticed signs of corruption in Sierra Leone's health system. When they looked at the lists of frontline staff created by officials in the Ministry of Health, they discovered "ghostworkers" – aliases, family members, and mistakes in enumeration – that meant certain people might collect more money than they deserved. "The lists were bloated and it pointed to some maleficence," said Sheriff Mahmud Ismail, a communications officer with the World Bank in Sierra Leone.
In response, the World Bank assessed the situation and suggested a radical idea: frontline staff could be paid using an e-pay system, in which a health worker would receive money directly to their bank accounts or via a text message instructing them to go to a pay station to pick up cash. With e-payments, money could not be stolen by government officials on the way.
According to the World Bank, the UN Development Program (UNDP) were brought in to manage the hazard pay database and co-ordinate the payment system: hospital supervisors passed new lists of frontline staff to co-ordinators in each district, who examined, signed and sent them off to Freetown. There, a small team in Freetown, staffed from both the UN and the National Ebola Response Centre (Sierra Leonean government officials), corresponded with a US-based accounting firm, BDO, to be sure the appropriate signatures were in place. If everything looked correct, the World Bank asked BDO release the funds.
Ultimately, this small team in Freetown was responsible for overseeing $23.7m (€20.8m) worth of hazard payments to a fluctuating workforce of about 23,000 nurses, lab technicians, and support staff throughout Sierra Leone's health system.
It was a monumental challenge in a country with a cash economy, no digital human resources database, a dearth of accountants, and a history of corruption.
When e-payments launched in November, Rupert Simons felt concerned that the effort was drastically underpowered. He was then a senior adviser to Tony Blair's Africa Governance Initiative in Sierra Leone, and asked officials at the National Ebola Response Centre in Freetown, whether they wanted assistance with hazard pay. "They said, 'We have a plan'," Simons says. "And when people say, 'We have a plan,' you have to let them get on with it."
Each month, from November until today, complaints of missing hazard pay persisted. Doctors at the renowned 34th Military Hospital in Freetown, who had treated hundreds of Ebola patients, showed me copies of signed letters describing missing hazard payments, which they had handed to the pay team to no avail. And the international doctors from King's College London said they had advocated on behalf of their local partners for months.
"Since the beginning [of the Ebola response], the most consistent problem has been the failure to pay risk allowances," said Johnson, when we spoke in February. "We have given the pay team records of who needs to be paid, which have been verified by the District Medical Officer, us at King's, stamped, signed and the lot, and yet still a lot of people have not been paid and we have been fighting this since August," he said. "It's inexcusable with all of this money lying around that nobody has invested in a big team that can sort it out."
'I am deleted'
By the time I met Faith Sisay in February, she spoke bitterly of promises to support the "angels" of the response. She had worked at the Ebola ward at Kenema hospital since June, and continued to do so after she realised she was pregnant in August. Sisay, in her twenties, having just completed her nursing degree, had looked forward to the weekly stipends, as well as a pledge of post-Ebola employment, guaranteed by Sierra Leone's President Ernest Bai Koroma.
Once her womb swelled, the head nurses asked her to remain outside the ward, to prepare medications and fetch supplies. Initially she received her hazard allowance, but then paydays in October, November, December, January, and February came and went, and Sisay didn't receive a cent.
Beads of sweat collected on her nose as we spoke on her back porch; Sisay's huge belly seemed to burst out of her tiny frame. When she complained to her supervisors about missing hazard pay, they told her to be patient. But nothing changed. "They don't even know about Faith. I am deleted."
Back at Kenema Hospital, I watched young men from the former burial team don their protective gear. Ebola was no longer prevalent, but people continued to die of various causes and their corpses needed to be handled safely, just in case they were infected. Although the workers had been fired after the corpse-dumping demonstration in November, they continued to work for occasional tips. The men emerged from the morgue carrying a casket, and slid it into a truck. Then in the dry grass nearby, they shook off the gear, tossed it in a pit of burning trash, and, wet with sweat, one of them – Abdul Sam – invited me to see where he'd lived during the peak of the outbreak in Kenema.
Sam motioned to the morgue, and I stepped inside. A thin white sheet covered a corpse in a corner, near a rusted steel cabinet. At the opposite end was a narrow sectioned-off corridor, where Sam said he'd rested. By sleeping beside a pile of bodies, he was able to prepare Ebola's victims around the clock. Then he was discarded. "No pay!" he gasped in a voice that climbed towards a falsetto, palms raised to the sky.
At Kenema Hospital, Massally supported Sam and a few others with his own pocket money after they were laid off without pay in November. He worked with the UN in East Timor in 1999, he said, and had a sense of how much money flows through people who tackle a crisis via laptop. "I feel pathetic for the local staff. They do everything but the returns go to the internationals who do not go into the red zone," he said. "Some do, but it's a relative few."
On the outskirts of Kenema is an Ebola treatment centre operated by the International Federation of Red Cross and Red Crescent Societies. It opened gradually during September, after the worst of the outbreak had passed through the district. By November, patients diagnosed with Ebola at Kenema Hospital were transferred there for care. When I visited in February, there were no patients at the unit. A silent swathe of granite and pristine, white tents beneath a blue sky, the compound looked like a mirage. Two dozen local nurses sat in the shade of a tent. They felt their salaries were fair and their hazard payments were reliably being processed by the NGO.
An unpaid ambulance driver picked me up from the centre. On the drive, we came across a throng of kids standing around a UN helicopter. With a requested budget of $96.3m (€84.5m) for UN air services, humanitarians flew around the country constantly. I decided to figure out why, when so much money had been hurled at Ebola, so many at the frontline were not being paid.
While we were sweating
I found nurse Miriam Conteh outside Kenema Hospital's Ebola unit the following morning. Her faded maroon scrubs darkened with sweat. She had been at the hospital until 3am the night before with a patient she now suspected of Lassa fever, a highly-infectious viral disease that, like Ebola, is characterised by high fevers and bleeding. Conteh said she could help create an employee list, but it had to be kept secret because the nurses had been warned not to complain to outsiders. Already, a nurse who had told a local journalist about his pay problems had been transferred without warning to another district. Nurses around the country echoed the concern. For these reasons, the names and some distinguishing features of the nurses and burial workers have been changed in this story.
Conteh arrived at my guesthouse a few days later, carrying a backpack heavy with documents. The loose papers formed a rough diary. A page from 23 July read: "29 confirmed Ebola patients, 3 in critical condition, 1 lactating mother, 6 orphans, 8 in need of psychosocial support, 2 dead, 41 nurses on duty for all shifts."
A set of papers from the lab showed that technicians in Kenema had tested 3,083 patients for Ebola, in addition to 742 corpses between May through November. Log books listed staff in the Ebola ward over time. For every name, Conteh described the person: he was a diligent cleaner, she was a fat nurse, and so on. Conteh said several had not received hazard pay for months, and many of the others – including her – had been paid only half.
I converted the staff lists to an excel file, and emailed it to the UNDP in Sierra Leone, the agency involved with hazard pay. Sudipto Mukerjee, the UNDP country director, met me in his office in Freetown. Just before we spoke, someone on his team searched in their system for some of the nurses on my list and replied with a subset of names they found. Mukerjee said everyone on that list received the 400,000 leones (€80 ) weekly pay, (though later, he told me to verify that with the pay team member from the National Ebola Response Centre). I told him about nurses not on the UN's list who had not been paid, and I said that those who were named insisted they had received half the promised amount. To this, he suggested their complaints referred only to October, the period preceding the World Bank's involvement. "November payments have been paid, as far as I am concerned," he told me. "And if they say they aren't [paid], they should lodge this complaint through a proper system and not through you." I replied that they are threatened if they complain. "If you have a situation where people are being threatened they should report it to Anti-Corruption [agencies]," Mukerjee countered. "They should report it to the police, to the traditional chief, there are so many means of getting your voice heard."
When I left his office, I called a senior nurse in Kenema to be sure I hadn't misunderstood. She sounded shocked. "They should see what we went through on the frontline while these people sat in the A/C, in their own vehicles, while we were sweating," she said. I decided not to tell her that the UN's international staff earn $1,600 (€1,400) in danger pay every month on top of their significant annual salaries; country directors in Sierra Leone, for example, take home $153,825 to $187,904 (about €135,000 to €165,000) per year. The gross national income per capita in the country, meanwhile, is just $660 (€580).
You, the taxpayers
At Connaught Hospital in Freetown, a nurse in the Ebola unit recognised me from a few weeks earlier. He asked if I'd heard anything about the hazard pay he was owed from December, January and February, and pointed to a "useless" list of phone numbers for the hazard pay help desk. All three lines led to a recording that said the phones were shut off.
I visited Awul Wurie, the manager from the National Ebola Response Centre on the pay team. He greeted me outside of the Situation Room at the UN Special Court, where the leaders of every major organisation involved in the response met daily. I asked him for the specifics about who had received what and when. "You have the nerve to ask me for private information," he said. "I'm done with this. We're done." In a follow-up email, Mukerjee clarified that UNDP is assisting the government in ensuring that the right people are paid appropriately and on time, but that they are not responsible if nurses get less than they deserve because their names are missing from lists, or if they've been misclassified.
A 2015 report on the Ebola Response from the UN claims that 100% of Ebola response workers registered in the system have been paid. It does not mention those not in the system. The head of the District Ebola Response Centre in Kenema, Abdul Wahab, reiterated this success, just after I spoke with several unpaid staff. In an email response, a World Bank spokesperson wrote: "The majority of workers who have earned hazard pay are receiving it." Perhaps, she suggested later on the phone, the nurses misspoke.
This lack of accountability is a common characteristic of UN agencies, says Simons, who is now CEO of Publish What You Fund, a London-based organisation. "UN agencies will say the local government is in charge, but they have responsibilities — in this case for making sure that the World Bank's funds for hazard pay get out there. So they need to be held accountable to the World Bank, and the World Bank is accountable to its board of governance, who are governments, i.e., you the taxpayers." That's true for the World Bank, which is essentially owned by the governments of 188 member countries, the UN by 193 member countries, and for each bilateral donor – such as the US and the UN – who act on behalf of their citizens and with their citizens' money.
However, to their credit, the World Bank and the African Development Bank, with the UN's support, offered money to frontline workers in Sierra Leone's health system in the first place, and to do it they launched a radical means of payment through mobile phone networks. Vastly greater donations avoided staff in the national health system altogether, precisely because the system is chaotic.
Instead of aiding the process, the world's largest donors to the Ebola response gave their funds to NGOs, Western and UN agencies. After each organisation absorbed a piece, the remains trickled down to the local and international staff working with patients (generally outside of the national health system) and with communities affected by Ebola. Some of the expenditures were undoubtedly effective, and some were wasteful, but it's difficult to discern between the two because budgets are opaque.
For example, the US gave $423m (€373m) of its taxpayers' Ebola response money to the US Centres for Disease Control and Prevention. The agency has run more than 12,000 diagnostic tests for Ebola, monitored more than 150,000 travellers exiting West Africa, kept a large team of press officers rotating through Sierra Leone, and more. But when I asked these officers how much money went to each of these services, I didn't get numbers. Several NGOs directed my budgetary queries to the donors that gave them money. Donors linked to websites with incomplete information. The totals don't match up. Grants for many thousands of dollars are described vaguely as "health," "Ebola support," and "Ebola response". Other common phrases, "social mobilisation" and "sensitisation" apply to any activity involving communication, such as Twitter posts, posters of smiling nurses, and billboards painted with slogans like "Kick Ebola out!" and "Getting Ebola to zero!" In a solitary account with detail, the Dutch government lists one sensitisation item: a Stop Ebola Memory card game that cost them €18,421.
After the 2010 Haiti earthquake, an economist at the Centre for Global Development in Washington, DC, Vijaya Ramachandran, attempted to track $6bn (€5bn) in taxpayer donations to the crisis, and concluded it could not be done. "A question worth asking is why we rely on this model of going through expensive NGOs rather than relying on domestic systems," Ramachandran says. "Corruption is often used as an excuse to not build up the local system."
Business suites and 4x4s
What is obvious to anyone in Sierra Leone – before or during the Ebola crisis – is that much of the aid money returns to people from donating countries. Dozens of international NGOs have settled in Sierra Leone since the "blood diamond" civil war ended in 2002. Their overhead is relatively high because international staff expect living wages, internet, health insurance, and flushing toilets. During the outbreak, it was even higher because they required expensive security measures, such as private 4x4s, and hotels with ATMs and surveillance cameras. Every standard room in the Radisson Blu, which typically cost $270 (€230) per night, was booked by the US Agency for International Development for six months. Business suites went for ($350) €310 a night, while less pricey hotels remained nearly vacant.
The most diplomatic explanation for the flow of aid to Western organisations is that extremely poor countries like Sierra Leone do not possess the infrastructure to implement programmes and handle grants with accountability. Yet at a December hearing on funds for the Ebola response, the chair of the British public accounts committee, Margaret Hodge, noted that skirting the government's system costs quite a lot. She cited one Ebola intervention in Liberia in which "only €3.4m out of a €53m EU programme reached the frontline. That is less than 7%, and it is shocking".
Emergency responses aren't about finding the cheapest option, I was told, they're about speed. Still, expensive doesn't equal effective. The situation with stand-alone Ebola treatment centres illustrates that point: just 28 Ebola patients have been treated at 11 Ebola centres in Liberia that cost the US hundreds of millions, according to a New York Times investigation.
What's more, stand-alone treatment centres have already begun to pull up the stakes as the outbreak ends, while the public hospitals stay busted. This model of providing assistance outside of the government's system has been the norm for aid to Sierra Leone for more than a decade. Even when the aid saves lives, the infrastructure required to deliver services in-house is not built. As a result, the country remains reliant on more aid. Sierra Leone's health system is one of the world's worst. According to the WHO, the minimum threshold of doctors, nurses and midwives required for access to basic care is 22.8 professionals per 10,000 people. The UK's ratio is 123.1. Sierra Leone's is 5.
Salaries are not sexy
In February, mobs of patients lingered at the entrance of Connaught hospital – the biggest referral hospital in Sierra Leone. Many had tested negative for Ebola at stand-alone Ebola treatment centres run by NGOs, and were sent here for care. I spoke with the head nurse of the overrun emergency ward in his office, which was in a supply closet. He was missing hazard payments, frustrated with his low salary and depressed with the lack of services for patients. If someone arrived in the throes of an epileptic seizure, he would have to ask them to go to a pharmacy and buy a needle and catheter, because the hospital didn't have its own.
Health professionals in Sierra Leone often seek out better paying jobs with NGOs, or in other countries if they're able. During the public accounts hearing in the UK, Stephen Phillips, a Conservative MP, asked why Sierra Leone's national health system was anaemic after 15 years of British aid from DFID. "When this outbreak comes along, the British taxpayer finds that there are only 120 doctors in the entirety of Sierra Leone," he said. "Isn't the magic bullet for DFID and the international community to supplement terms and conditions in a way that encourages medically trained staff to remain in their home countries?" Mark Lowcock, DFID's permanent secretary, replied that it had been tried, and failed.
A common dismissal of the idea that donations might go directly to local nurses and other health workers is that underwriting salaries is unsustainable. Another explanation is that it discourages African governments from paying civil society workers themselves. Then there are more jaded hypotheses, such as salaries are not sexy. Do-gooders prefer tangible displays of generosity – iPads for data entry, air-conditioned biohazard suits – gifts that look good on camera. Another possibility is that those in charge have little incentive to change a system of aid attractive to those on the giving end. A Sierra Leonean economist told me, on condition of anonymity for fear of jeopardising relationships with donors: "It's in their interest to make us look bad so they can hold the budget, the NGO industry is an industry."
Whatever the reason, the fragile health system that initially let Ebola become an international disaster is now in even worse shape. While Ebola raged, people sick from pregnancy complications, diabetes, measles, and myriad other maladies stayed away from hospitals for fear of the bloody disease. Now they're returning to find a staff depleted from health worker deaths, and deflated from the horrors they witnessed.
Infectious disease scientists guarantee this will not be the last outbreak in our lifetimes. To prepare for the next one, Bill Gates, the UN, and the WHO have released recommendations. Their advice includes equipment, isolation units, affordable healthcare, workshops for nurses, surveillance systems, technological solutions, and pharmaceutical products. But none that I've found mention pay for nurses in fragile health systems.
Perhaps with more time, manpower, and pressure to do the job well, the UN, the World Bank, and Sierra Leone's government might have sorted out e-payments. There were hints of improvement after I left the country. In March and April, the pay team returned to Kenema to investigate. On 9 April, nurse Elizabeth Kabba called me to say she had been paid in full for February, although she still lacked half of her hazard pay from the months prior. She suggested I call Faith Sisay, who had just given birth to a "bouncing baby boy". Sisay thanked God for her healthy child, but added that she had received no payments, and had lost hope in the system. I imagined her sitting in the dark on the back porch, babe to her breast, and a few neighbours around her. "When the next disease comes, it will be difficult to get nurses," she said, "How will you do it?"