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Story Publication logo December 24, 2014

Sierra Leone's Ebola Dragnet Has Lots of Holes

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Research during a disaster can seem frivolous when there aren’t enough resources to handle the...

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In the Command Center, the heart of the Ebola response in Freetown and the surrounding western district. Image by Amy Maxmen. Sierra Leone, 2014.

Inside the bustling Ebola "Command Center" in Sierra Leone's capital, it appears that the disease outbreak might finally be brought under control. Staff register alerts that stream in from a call center, and they dispatch surveillance officers located in each neighborhood, who decide whether an ambulance is warranted. However, a day spent with the surveillance officers—medical school students hired by the government for this response—reveals how messy the roundup can get in practice.

The dragnet is part of an operation dubbed "the surge," announced on December 17 by Sierra Leone's president, Ernest Bai Koroma. The goal is to find and quarantine people suffering from the virus, but one week in, it has dredged up hordes of people with a variety of maladies left untreated, and it is not yet clear whether the effort increases the number of Ebola patients brought in for care.

With 500 new Ebola cases in the country's western region since December 1, something more had to be done. In the past few weeks, the government has added about 600 new hospital beds to hold people who have, or may have, Ebola. And it has placed 16 additional ambulances on the road, bringing Freetown's total to three dozen.

One key to the operation has been hiring hundreds of people to monitor their own communities and to dial "117" if they see someone who might have Ebola. Other citizens have been urged to do the same. The alerts are forwarded to the command center, which contacts surveillance officers on the ground to track down the case and call for an ambulance if Ebola seems probable. If laboratory tests confirm Ebola, the individual is moved to a hospital for treatment and the command center dispatches a team to quarantine anyone who might have been in contact with that person for 21 days.

The strategy sounds efficient, but on the ground, the surge can seem bewildering. It is the country's first intensive experience with a system like the U.S.'s 911, and now that it exists, they've found plenty of reasons to call for help.

Alpha Kamara, a medical student on a surveillance team in Tembeh Town, a densely populated neighborhood in Freetown, says that since the surge began a week ago, he has been busy, but not with people who seem to have Ebola. Twice he's tracked down the same local drunk, whose neighbors dial 117 when the man stumbles into their alleyway.

Another suspect, it turned out, coughed with tuberculosis. The man quickly made his case for not being hauled into a hospital by showing Kamara his TB drugs. On Saturday, Kamara hopped on the back of a motorcycle and tracked down a vomiting teenage boy when I was not tagging along with him, after the command center received an alert from the teen's neighbor. When Kamara arrived, he says the boy's relatives screamed, "No Ebola! No Ebola!" They claimed the boy was hung over from drinking too much alcohol the night before. Other young men, seemingly drunk, added to their shouts. "They surrounded me, and threatened the bike driver, and said we should leave," Kamara says. As he departed, he watched the young men march toward the house of the neighbor who had reported their friend. Kamara says he'll check on the boy today, and if Kamara is again threatened, his supervisor says he'll alert the police.

Incredibly, Kamara, like all surveillance staff, has not been given a thermometer. He must decide to call for an ambulance based on how the person looks and how they say they feel. He asks questions like, Do you feel feverish and fatigued? Have you been vomiting? Do you have diarrhea? How is your appetite? "It would be nice to have a thermometer," Kamara admits.

I accompany Kamara on one of his trips to trace an alert from the command center. We walk off the paved road and scale down a rocky slope that ends in eroded cement steps. People rarely have street addresses in Sierra Leone, so in this case, Kamara locates the place that was reported by asking women who wash clothes in buckets along a narrow dirt path that winds between concrete tenements. Eventually, someone points to a second-floor apartment. Once we arrive at the doorstep, a woman inside says the man is not home. The man's son approaches Kamara and says his father suffers from arthritis, not Ebola. Kamara nods and says he'll return tomorrow to check again. We climb back up the hill.

When the 117 Ebola hotline launched in August, people in Freetown didn't call because they mistrusted doctors. They had heard too many stories of patients who entered clinics and never returned home. By December, as it became clear that Ebola outcomes were worse at home, people began to dial in, but they became upset when ambulances didn't arrive. There were not enough vehicles and beds to hold patients, and people died because Ebola can kill its victims within days after they show signs.

In the first half of December, about a third of the corpses picked up around Freetown tested positive for Ebola. That means Ebola victims died at home, likely infecting other people before they passed away. Burial-team workers told me that when they arrived at houses to collect dead bodies, frustrated family members who had called 117 with no response would scream at them. "People say, 'You don't come for the sick, you just come for the dead,'" explains Thomas Abu, the supervisor of several burial teams in Freetown.

Now, with additional beds and vehicles, the capacity to isolate suspected Ebola patients has increased. But how to efficiently respond to a flood of 117 alerts is daunting in a country largely without addresses or GPS tracking, and with a host of health problems beyond Ebola—many of which have been exacerbated as hospitals devote their energy to this disease alone. In this context, a lone help line becomes rapidly overwhelmed.

In Devil's Hole, a rural village on the outskirts of Freetown, I accompany two surveillance officers as they respond to an alert. A group of men standing in the shade of a mango tree direct us to an elderly woman. She perks up as we approach. Flies hover around the yellowed bandages surrounding her badly swollen foot. As she complains of pain, the officers ask if she has a fever. "Sometimes," she answers in Krio, the language spoken in this area. And vomiting? She says no but then begs us to call an ambulance. "No," the officers mutter apologetically, because ambulances are for Ebola only. She does not fit the case definition, they affirm with one another.

I offer the old woman money for a taxi to bring her to the hospital, but a crowd who had gathered to watch the scene explains that taxi drivers no longer take sick-looking people anywhere, because they're afraid of contracting Ebola.

Later, in Waterloo—a bustling town beside Freetown with a population around 40,000—surveillance officers locate a woman collapsed beside the road, lying in the hot afternoon sun. One of her legs appears badly mangled, and she says she cannot walk since being hit by a motorcycle yesterday, or maybe it was the day before. She is far from her village. Could we send for an ambulance?

The officers apologize and explain that ambulances are only for people with Ebola symptoms. They say they cannot put her in their car either, in case she turns out to have the disease. After we depart, Major Alex Massaquoi, a military man who monitors dozens of surveillance officers across the region, says, "It's so terrible. We have too many problems in this country. We need to build an alert system for other emergencies."

Beyond these false alarms, the surveillance officers often couldn't locate their targets. Many of the callers switch off their phones after dialing 117. Massaquoi guesses it's because they don't want to be known as informants. So the surveillance teams operate like detectives. Sometimes they succeed; frequently they don't.

The second prong of the command center's surge operation seems even more confused. The directive is to quarantine anyone who had recent close contact with a person diagnosed with Ebola. Yet it currently takes two or three days for the diagnosis to filter from the laboratory to the command center and down to the appropriate staff on the ground. An exasperated surveillance officer, Daniel Sesay, says, "Family members and neighbors are traveling for days before they know about a person's results."

One week into the surge, it's impossible to determine whether the operation will curb the spread of Ebola. There are some positive signs, including the sheer fact that people are calling. "It's good that people call frequently, even if [the individuals they report] don't meet the case definition," Massaquoi says. "At least then we can check them out."

Just outside of Freetown, Massaquoi and I come across an ambulance on the side of the road. The head of the community here tells us the vehicle arrived within an hour after he dialed 117. He called because he noticed a woman who had wandered into his village, slumped beside the paved road jutting through town. She said she felt feverish and had vomited, and he convinced her that the hospital was her best chance for survival. I watch her step into the caboose of the ambulance. A member of the ambulance team kicks the door shut behind her, douses the surrounding region with chlorine, and then the vehicle speeds away, siren blaring.



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