Ebola and Secret Societies

Always talk to the drivers.

Today, when the driver picked me up from the guesthouse to take me to the UN helicopter where I was to wait for a lift to Freetown, he immediately asked me if I was a born again Christian who believes in Jesus.

Good morning to you too.

After he gave me his testimony and he felt that I adequately appreciated his conviction, we arrived at the “helipad” (field), he turned the car off and the sweating began. And some good conversation.

I asked him about mining, the civil war, and ebola. We covered a lot of territory.

I had recently learned of secret societies in Sierra Leone and their role in coming of age ceremonies. It was previously described to me as teenagers who are kidnapped and taken to the bush for a month or so of initiation. The driver told me that this is still widely done and that members of the secret society have the most influence in politics and status in the country.

There is a separate society for men, called the Poro, and one for women, the Bondo. Young men are given a special marking on their back made with knife scarring. The driver, although he said it was forbidden to talk about or to show the markings, said he would do so because he has forsaken it as he is now a Christian pastor. He turned his back to me and unbuttoned his shirt enough to loosen it down his back so I could see the start of it. The markings are a series of a pair of downward slanted lines about one inch apart going from the back of the neck down the spine. He said the marks are given during the month long initiation where other “traditional things” are done.

Although it was clear he thought it was all evil doing now, his eyes became wide when he said the political power it gives one is the most important aspect. You cannot be anyone without such marking in this country, he told me. You have the protection of the society and the Paramount Chief (the leader) has much power.

He said the Bondo society for women is completely separate. He didn’t want to talk much about it, but did say this is when “they take the female genitals”. Female genital mutilation is very widespread in Sierra Leone. It’s done “in the bush” with crude instruments, no anesthetics, and no infection prevention. The driver proudly said that he and his wife (who underwent FGM) did not have this done to their three girls, but he said it was done everywhere “even in Freetown”.

Then he said something really interesting.

He said that he thinks both of these initiations will stop with Ebola because “much blood is spilled” during the process.

Let’s hope.

Shocking Inequity

(These women are Traditional Birth Attendants in Kenema District, Sierra Leone. They are greeting me with a traditional welcome.)

Much of my work here in Sierra Leone is centered around reproductive health care and child health care. Public health programs in the “developing world” provide services to women of reproductive age such as family planning, antenatal care, assisted births and postnatal care, as well as for children under the age of five for malnutrition, malaria, pneumonia and diarrhea (the leading causes of death). There is a wealth of evidence that health interventions in these areas for these two demographics have the greatest impact on the population’s health.

Simply put, they are life saving.

The figures comparing mortality rates for Sierra Leone to the United States are shocking.

The under five mortality rate, which tells us how many children under five die within a timeframe, is expressed per 1,000 live births. It answers the question: for every 1,000 births that occur, how many children under the age of five perish?

In the United States it is 7. In Sierra Leone it is 156.

Another significant indicator is the maternal mortality ratio, which tells us how many women die from pregnancy, childbirth, or in the postpartum period (42 days). This indicator is expressed per 100,000 live births. It answers the question: for every 100,000 births that occur, how many women are dying from pregnancy or childbirth?

In the United States it is 28. In Sierra Leone it is 1,165.

Globally, having children is one of the most dangerous experiences a woman encounters. It is the second leading cause of death in women of reproductive age (ages 14 to 44) (HIV/AIDS is the number one cause of death).

99% of ALL maternal deaths worldwide occur in “developing” countries.

This is shocking inequity.

*Mortality data is from DHS and UNICEF.

“Ebola Stops With Me”

(a slogan that’s ubiquitous around Freetown-painted on walls and printed on t-shirts worn by locals manning checkpoints, armed with thermometers and hand sanitizers)

I was joined by an American doctor working for WHO (World Health Organization) for dinner the other night. He’d clearly had a brutal day.

His job is to trace contacts of Ebola patients. He goes to the homes of patients and tries to find everyone the patient would have come into contact with whilst infected. That day, he’d gone to the slums near the beach looking for a certain contact. He was asking people where the man lived and the neighbors pointed to a shelter made of tin that was about 4′ X 4′. They named four different people, including the contact in question. The doctor said “no, no, four men can’t possibly live in there”. They all said yes, they live here. “Surely there’s a misunderstanding”, the doctor repeated, “four men can’t possibly live in there and I need to know specifically where this man lived and who lived with him”.

One of the neighbors turned to him and said “this is Africa, doctor”.

It was one of those moments that hits you like a ton of bricks.

Of course, four adult men live in a space unfit for shelter the size of a toilet room. Just like another recent case that came from an area where more than 80 people were sharing one latrine.

“This is Africa, doctor”.

He continued with the visit and uncovered some frustrating information.

When a person dies at home, the number 117 should be called immediately for a safe burial team to arrive and take the corpse. What we’re finding is that transmission is still occurring for unsafe burials despite widespread messaging on 117 and safe burial teams. What the doctor found out was that people are delaying the 117 call in order to complete the traditional preparation of bodies (washing) before their loved ones are taken away and never seen again.

Washing dead bodies is the number one cause of Ebola transmission.

This is so frustrating to learn as it feels like a major step backwards after all of the sensitization around burials. There are signs all over Freetown that say “Save Yourself Do Not Touch or Wash Dead Bodies”.

And yet here we are, 11 months since the index case in Sierra Leone, and we are still battling this. It shows just how difficult it is to change behavior especially with regards to such sensitive traditions and beliefs.

Half Way

I’m exactly half way through my time in Sierra Leone.

There were a number of reasons I chose to re-immerse myself in humanitarian aid work. If I am to be brutally honest with myself (and you), I came to Sierra Leone because I needed to feel purposeful again. I was in a place without meaningful work, feeling rejection and a loss of confidence from an abrupt fall out of a business start up, and generally feeling direction-less and unsure of where to find purpose.

I turned to what I have known in the past, what I spent years preparing for, for the issues I still feel compelled by (in this case the health consequences of the ebola outbreak). I was nervous and excited about returning to the field. I came with an open mind – and the question of whether this could be the beginning of a new chapter of global health work. I really thought it could be.

The answers have been loud and clear. I am grateful for such clarity and for the affirmation that the life of land and family that I dream of is just as valuable as any other pursuit.

When I’m not straining my eyesight with spreadsheets and feeling the ills of sitting 9+ hours a day, I am dreaming of settling into a place, the daily work of chores of home and farm, and starting a family.

I am very grateful I have had the opportunity to take this job. I hope the extremely small accomplishments I leave behind will be beneficial to the efforts. But I just don’t have the all consuming passion for it-to live this life of constant travel, of hours and hours of computer work sitting at a desk, the conversations with colleagues knowing that even the friendships made will never have the time to flourish.

It reminds me of the quote by Lawrence LeShan:

Don’t worry about what the world wants from you, worry about what makes you come alive. Because what the world really needs is people who are alive.

I know what makes me come alive.

I look forward to returning home with a new appreciation for the small things, for relationships, for a place in community, for work that I love (even if it doesn’t require a degree), for family.

The countdown begins.

What Doesn’t Kill You…

One of the best lessons I learned from my time in the Peace Corps is that it’s really good for people to be miserable. Good and miserable. For quite some time.

You learn you can tolerate not being comfortable or having amenities. You learn to sit patiently for hours (and you learn to always have a book on you). You learn that time passes the same every day whether you are miserable or not. You just get tougher.

That was over ten years ago for me. I’m trying to channel that toughness at the moment.

I just arrived in Koidu which is in Kono District in Sierra Leone. This is a major diamond mining area with several international mining companies who set off explosions about once a week making the buildings shake. It’s pretty bare bones here.

It’s the hottest time of the year and I am feeling it. I am laying on a mattress that is both foam and hard as a rock (seems odd but trust me on this). I have a fan about 6 inches away from my face. I’m relishing in the air as we only have a couple of hours of power and then the generator gets switched off. It will be a long sweaty night ahead with mosquitos buzzing around. The worst news? There’s no kettle. I have several days here and I am seriously concerned with how I’ll be able to function without coffee. I WILL figure something out in the morning! Even if that means I have to pay a child on the street to run home and boil some water for me.

I will be oh so grateful for Freetown again, just 24 hours after saying how I was ready to get out of Freetown (how ungrateful I was for the air con and omelets).

It’s somehow comforting to recall all of those really miserable days and nights in Turkmenistan, and then Chad, oh and that night in Sudan…yeah, I can do this.

Culture of Aid

There’s definitely a certain type of person that chooses to do aid work. It requires a lot of travel to difficult environments, leaving your loved ones for extended periods of time and often with very little notice. The work seems to attract wanderlusts and misfits. The cadre of responders to the Ebola outbreak are a slightly different group of recruits than in my past aid work, which recruited the typical humanitarian aid worker assigned to protracted crises. The expats here in Sierra Leone comprise a mix of humanitarian aid workers (like myself), many clinicians with varying experience in these contexts, those with military backgrounds for the logistic response, and emergency responders who thrive on the chaos of the immediate aftermath. It’s a strange mix and I have to say I don’t connect with most. This is the first post I’ve had where I am spending most of my time in the capital and while I appreciate the amenities, it’s such a surreal experience going to the Radisson after work sitting amongst a patio full of white people looking like they came from their DC office and begin their evening of alcohol and smokes.

There’s always an expat economy when we flood an area for a humanitarian response, but here it is stark. Usually, there’s some shopping at local markets, only a couple of restaurants available, and one or two hotels that journalists stay in. Because of the enormity of the response, many of us are staying at hotels, there a quite a few restaurants to eat at (and without a kitchen, we only eat out), and then there are the swimming pools.

I have to say that I do appreciate having a place to go outside of the hotel and office. Freetown is reasonably safe, but I’ve found the harassment to be far greater here than I’ve experienced elsewhere. It certainly isn’t relaxing to take a walk in town.

I think the adjective that best describes my feelings about the mission (external to the job itself) is disappointing.

I’ve seen a couple of episodes of prostitution-white male expats escorting Sierra Leonean women. Exploitation of this sort is absolutely not tolerated by the major agencies, which have strict policies about such behavior. It violates humanitarian principles and reflects on all of us. Unfortunately, I haven’t known who these men are or whom they work for or I would absolutely call their heads of office.

That sort of behavior also poses risk of transmission to others. We are under a strict no touch policy, those who are directly exposed to infected or suspected patients and those that work solely in the office. Those men obviously don’t care too much.

I feel disappointment that the environment here isn’t one of a team working together for a common cause-even though that’s surely what everyone is doing. Instead, it’s a bunch of misfits with habits that I don’t share or with dubious characters.

I keep mostly to myself and just try and concentrate on my job. May can’t come soon enough.

Kenema Isolation Kenema Clinic

Above (top) is an isolation unit for people who come to the community health clinic (below) and who are suspected Ebola cases. They wait until an “ambulance” comes to take them to a treatment unit. These were taken in Kenema District.

What Excitement

I was taking a walk along the beach Saturday in the early evening when I saw a crowd of people and a line of young men pulling a fishing net in. The man in the fishing boat was paddling fiercely and there were many shouts of excitement as they could tell by the weight of the net that the fisherman had a good day. People were immediately flooding the scene for the opportunity to buy fresh fish.