I sat at a table in a small shaded area that resembled a tiki bar, trading stories of Ebola work with a doctor from Britain’s National Health Service. My driver was out at the Total gas station, filling six containers with diesel that would fuel the generator of the northern holding center for the next five days. The cost would be 450,000 leones – roughly $90.
Never did I imagine that fighting Ebola would involve finding ways to make the lights come on.
Said the doctor, “Is it usually this quiet here?”
After six weeks in a different ETU, he’d returned for one more tour, and ended up working with us to give the Nigerian physicians at the holding center a break. They’d worked for seven straight weeks.
“Feast or famine,” I said. “Enjoy the peace while you can.”
He grinned. He’d hauled as many dying patients out of ambulances as I had. He was content to sit in the shade and read a book through the most recent dip in cases in the district.
We talked of patients in the past. He’d worked in an eastern district before Ebola, and spoke of the cholera epidemic there, and how he’d been forced to leave his beloved missionary hospital after a year.
“I’d lost more than two stone.” He shrugged. “We just never had time to eat, we were so busy. If I’d stayed I would have died.”
~ ~ ~
Fuel delivered, I hopped back in our SUV and we hit the road for home. It’s a 45-minute drive from the holding center to the ETU on a good paved road. My driver tuned in to BBC Africa, and we listened to an eclectic and bizarre mix of top ten, oldies, and the 90’s greatest hits. We sang along as we roared past palm plantations, over the bridge above the Little Scarcies – the most beautiful river I’ve ever seen – and past dozens of tiny villages.
My phone rang. It was Nancy, the lead clinician from the team visiting the southern CCCs. They’d planned a busy day, visiting three CCCs in a row, distributing supplies and gathering patient data.
“Where are you?” I asked.
“We’re in Yaya,” she replied.
I glanced at my watch. 12:30 p.m. The team should have been out of Yaya by now and en route to the second CCC of the day. “You’re still there?”
“We have a problem,” she said.
~ ~ ~
When the team arrived at Yaya that morning, the holding center was quiet. Unusually quiet. Even though Ebola cases in the district had dropped dramatically in the previous three weeks, there was still a full staff assigned to the center. They should have been there. Instead, the team found only a few nurses, resting under the mango tree in the yard.
Notably absent was the Community Health Officer (CHO), a position roughly equivalent to a Physician’s Assistant in the United States. In pre-Ebola times, CHOs were assigned to various primary care clinics in their chiefdoms, doing everything from minor surgical procedures to vaccinating children. Now, during Ebola, the CHOs either ran the CCCs or assisted the contact tracers in the community.
“Where is the CHO?” asked Nancy.
“He is at the clinic,” replied Fatmata, the lead nurse at the CCC, and one of the best clinicians I’d ever met. She gave Nancy a very meaningful look, and said, pointedly, “Shall I call him?”
Nancy wasn’t born yesterday, and this wasn’t her first rodeo. She’d been in the very first cohort to arrive at our ETU, and walked in to find over one hundred patients dead, dying, or wandering aimlessly around the grounds, unable to escape. She had seen and done it all.
She understood that what Fatmata was actually saying was, Something’s up.
Nancy nodded. “Yes. Call him.”
~ ~ ~
He drove up on his motorcycle twenty minutes later, all bluster and greetings, “How very nice to see you, Nancy, how is your day?”
“I was expecting to see you here when I arrived,” she said, genially. “But I hear you were at your clinic.”
“Well, yes,” he replied, slightly flustered.
This was in and of itself a red flag. Although the clinics had not been formally closed, they were closed in everything but name. All supplies, all distribution of medication, and all the staff had been diverted into the Ebola response.
“You have a patient there, then?” she asked, her voice pleasant and unhurried.
“Indeed, indeed, there was someone who needed my help. I needed to see her this morning, because she needed a cannula.”
Cannula, the most common term here for an IV.
Nancy raised an eyebrow. “A cannula? She must be unwell.”
“No, no, just some diarrhea,” he said, and then stopped himself short.
Gotcha, thought Nancy.
“Why don’t I bring my team to the clinic?” she said, but it wasn’t a question. “Maybe we can help.”
Trapped by dictates of courtesy, culture, and by the fact that our organization supported his CCC, he had no choice. “Indeed,” he said again, meaning quite the opposite.
~ ~ ~
Back in the car, heading toward the clinic, Nancy looked at the two newest members of our CCC team as well as the data collection officer on rounds with them that day.
“Nobody goes in that clinic except myself,” she said. “When we get there, find a place outside to wait. Don’t sit anywhere, don’t touch anything, and be sure not to touch anyone.”
“What’s going on?” asked the data collection officer, off-balance by the sudden change in Nancy’s voice.
The clinic came into view. The driver slowed to a stop. “He’s got an Ebola patient in there,” she said, grimly, and got out of the car.
~ ~ ~
She heard the patient before she saw her. Arms close by her side, Nancy looked in the front door, and saw that the waiting area was large enough for her not to brush against anything. She stepped in, and from there could hear the hiccups.
Hic. Hic. Hic. Hic.
Through an open doorway, she saw the woman’s legs, lying on a cot in a small room, framed in the weak sunlight through a window. A bag of IV fluids dripped quickly down a line. Someone sat at the foot of the bed, a family member keeping watch.
And then the legs suddenly went stiff, and began to tremble. A moment later, the patient shook with convulsions, rattling the cot against the wall, sending ripples up the IV tubing. The family member began to scream.
Nancy turned and ran back outside. The CHO was running towards the door. She circled away from him. “She’s having a seizure,” she said, and continued to run for the car, “And I’m calling the Command Center for an ambulance.”
~ ~ ~
“So the ambulance is on the way,” she said to me, as I gripped my phone in disbelief. “We’ll get the names and numbers of everyone at the clinic, including the family members and the nurses.”
I’d thought I couldn’t be any more shocked. “Nurses?” I said, horrified.
“The CHO may have started the IV,” she said, “But I found two nurses eating lunch out back. And they were the ones who administered the medications.”
We hung up. Beyond furious, I texted my favorite member of the management team, the one person I could always complain to, the one person I trusted the most.
–I need kerosene and a match– I said.
Less than a minute later, he replied. –Why?–
–Because I’m going to burn the clinic at Yaya to the fucking ground.–
My phone rang. “What the fuck is going on?” he said.
And for the rest of the ride, he listened quietly as I screamed into the phone.
~ ~ ~
The team stayed at Yaya until the ambulance arrived. The patient, limp and somnolent after a dose of diazepam during her seizure, was carried out by the ambulance nurse in full PPE and a member of the patients family. The family member curled himself over her body on the stretcher, weeping, until the nurse physically pulled him away and slammed the door shut.
The family was rich, Nancy said. They had their own car. Every member of the family was dressed in beautiful clothing. And the patient was fat. In a district where half the children are suffering from some degree of malnutrition, this was a family where everyone was plump and well-fed.
They drove the patient to the clinic early that morning, and called the CHO to meet them there. Maybe they didn’t want anyone to know that the patient had Ebola. Maybe they didn’t want her to die at a holding center, and have her buried at the Ebola cemetery. Maybe they hoped she could be treated quietly and quickly at a clinic that should have been closed, and had enough money and connections to entice the CHO to break the law.
As they waited for the ambulance, Nancy continued to pump the CHO for information, calmly and patiently, never accusing him of doing anything wrong.
“Why didn’t you bring this patient to the holding center? Weren’t you worried she might have Ebola?”
He avoided her gaze. “Well, you see, when she arrived here to the clinic, she was very weak. I had to help her from the car…”
Nancy let the statement pass in silence. His answer was no answer at all.
~ ~ ~
Back at the ETU, I watched our triage team pull her from the ambulance and carry her to the Suspect Probable Ward. I intercepted them as they exited the doffing station, drenched in sweat and exhausted.
“How is she?” I asked.
“Oh, she definitely has Ebola,” replied one.
“She won’t survive the night,” said the other.
~ ~ ~
I walked to a small shaded bench outside the ETU. I called Fatmata, back at the Yaya holding center.
“The CHO was caring for a patient at the clinic, and that patient probably has Ebola,” I said.
“I see,” she said. She knew, of course.
“We’ve called the W.H.O., and they’ll be investigating.”
“I see,” she said again.
“Fatmata…” I said, and paused.
I thought about the two nurses at the clinic, now exposed to the virus. I thought of them, helpless within the deeply ingrained hierarchy of the Sierra Leonean healthcare system. When the CHO gave the order to give the medications, they had two options: obey the order, or lose their jobs.
They must have known the patient had Ebola, and yet for the sake of someone else’s bribe, they were forced to risk it anyway.
I thought about the hundreds – literally – of nurses that had died in Sierra Leone since the start of the Ebola outbreak.
I thought about Fatmata, living two chiefdoms away from her beautiful eight-year-old son, in an effort to keep him safe.
“Do not let the CHO near the holding center,” I said in a rush. “If he comes there, call the police, and then call me, but do not let him in the gate. For your own sake, Fatmata, and for the sake of your son -”
My voice broke, and I took a second. “Stay away from him. Please.”
Her voice softened. “I will, Martha.” And then a pause. “It will be ok.”
~ ~ ~
I hung up the phone, covered my face with my hands, and wept.