Why has Liberia -- once the epicenter of the outbreak -- been able to stop a rampaging killer disease, while the country next door can't even count its dead?
- By Laurie GarrettLaurie Garrett is senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.
FREETOWN, Sierra Leone — It was a terribly disturbing sight. At first glance, Connaught Hospital in central Freetown looked unremarkable; the Sierra Leone facility featured a walk-in and ambulance entrance that led to typical hospital hallways and a central patients’ garden. But the entry was flanked by tented structures — on the left, a table at which sat three men, sweating in full protection suits, goggles, gloves, and masks. On the right was what appeared to be a wood-fenced pen with a sun-shading tarp over it, suitable for livestock. Patients and visitors were required to approach the suited men on the left for triage: If they had a fever or nausea they were sent to the pen.
And inside the tent-roofed pen lay five men, waiting in the blazing heat for someone to die or be released from the hospital’s 18-bed Ebola isolation ward so they could take their place. These men lying in the street without toilet facilities, food, or water could not get into hospital beds until they were vacated. Inside the hospital grounds, a special door flap was all that signaled the location of the “Red Zone,” where suspected Ebola patients lay on actual beds. Meanwhile, routine medical care continued in the rest of Connaught, as families and patients strolled by. And as I watched a cluster of routine-care patients walk past the outside pen, through the main entry, and on into the garden, a patient poked his head out of the Red Zone door flaps, calling out to a staff nurse, who shushed him and said he should stay inside because he was contagious and could endanger other hospital visitors.
If a patient in that Red Zone tests laboratory-positive for Ebola, then that patient (and other lucky ones in that Red Zone) would be transferred from Connaught to a full-scale Ebola treatment center about two hours’ drive away, in Kerry Town. The less fortunate die in the isolation ward, or out on the street inside the pen, waiting for space to free up. Turnaround time on lab work averages three to four days in Sierra Leone — versus a mere four to five hours in neighboring Liberia — so most patients die here, without ever learning whether or not it is the Ebola virus that is driving their fever, diarrhea, vomiting, and hemorrhaging.
“We had no choice but to build this, to keep out swarms of people,” explained Stacey Mearns, her blue hospital scrubs streaked with sweat in the sweltering tropical climate. The 31-year-old Brit is a volunteer physician from the London-based King’s Health Partners. “The tent is always full, as is the isolation ward. All across the district we just don’t have enough hospital beds. And we have a long list of people waiting to come in from all over the community,” she told me. “There’s not a single treatment bed open in all of Freetown. And every day that we’re behind in building more treatment facilities is another day of transmission.”
Nationwide, Sierra Leone has only 400 Ebola treatment beds, of which 175 are located in and near the capital city of Freetown. The World Health Organization (WHO) reckons the country needs 4,800 Ebola beds.
Mearns, who has served on the front lines of the Ebola fight in Freetown since September, cast sad eyes at the delirious men lolling in the “holding center” — the pen structure out on the street — and said that only 13 percent of suspected Ebola cases ever survive their stays at Connaught long enough to make it to the distant Kerry Town treatment center. She sighed. “I feel we’re yet to get a handle on things. It’s just steadily getting worse and worse.”
Even as world health authorities laud neighboring Liberia for bringing its Ebola transmission rate down from the catastrophic levels seen in September, Sierra Leone’s situation is spiraling out of control. The officially reported numbers of the sick and dead are not to be believed, experts say; the pace of construction of treatment centers lags far behind patients’ needs; most burials and funeral practices remain unsafe; the military has taken control of the national response; and international partners are struggling to work within the government’s control mechanism. The soaring Sierra Leone epidemic was cited by the U.N. Ebola Emergency Response Mission (UNMEER) as the primary reason it did not meet its Dec. 1 target of having 70 percent of Ebola patients in treatment and 70 percent of the dead safely buried. But instead, on Nov. 21 UNMEER reported that only 13 percent of Sierra Leone’s Ebola patients are isolated from the general population to prevent spread of the disease — an astonishingly low figure compared to the more than 90 percent isolation rates reported in Liberia and Guinea. Elhadj As Sy, secretary-general of the International Federation of Red Cross and Red Crescent Societies, predicted in late October that it would be at least four months before “control” could be achieved in Sierra Leone.
Traveling between Liberia and Sierra Leone to examine the respective countries’ Ebola battles offered stark evidence of the importance of sound local governance in epidemics. Liberia has, with great apparent success, fought back the Ebola virus and lifted its national state of emergency. In contrast, Sierra Leone’s fight with the virus is a classic cautionary tale of what happens when contagion meets governmental incompetence or — worse — corruption.
The capital of corruption
In order to get to Freetown you have to catch a speedboat or a ferry from the airport, which is located on a finger of land across the wide Sierra Leone River from the city. As seen from the water, Freetown is beautiful, its steep, verdant fingers of land, covered with shanties and houses, reminiscent of Rio de Janeiro. Hulking rust-bucket ships sit abandoned in Tagrin Bay and dot the mouth of the river as it empties into the Atlantic Ocean. The roads that branch off from Africa’s third-largest harbor and wind through Freetown’s mountains bear names that betray the country’s British colonial past: Aberdeen Road, Macaulay Street, White Man’s Bay Road, Newcastle Street. And congestion is the norm, as massive road construction projects and drainage-infrastructure improvements are underway, elements of President Ernest Bai Koroma’s “Agenda for Change and Prosperity.” Since his 2007 election, the former businessman has pushed an aggressive development strategy that features roadway expansion in support of the country’s diamond, iron, and other extraction industries. It is an economic strategy that pushed a nation torn asunder by civil war (1991-2002) to become one of Africa’s economic miracles. In 2013, Sierra Leone’s economy grew by an astonishing 20 percent.
But miracles were never meant for all, or even most, of Sierra Leone’s 6.2 million people — more than half of whom, in 2013, lived on less than $1.25 per day, according to the International Monetary Fund (IMF). Sierra Leone consistently rates among repressive economies in the world, falling near the world’s rock-bottom worst on the Index of Economic Freedom, at 148th. The $8.3 billion economy ranks as one of the world’s most corrupt and most poorly regulated by all 21 of the world’s leading assessors. For example, in 2014 Transparency International ranked Sierra Leone 119 out of 175 nations (with 175 being the worst) for corruption. More than 90 percent of Sierra Leoneans surveyed by the organization in 2013 said that they had to bribe police and/or judicial officials for all aspects of daily life, from avoiding unwarranted traffic tickets to evading false arrest; most also paid bribes to other government officials.
The most telling indication of the depth of this corruption is that Sierra Leone has the fourth-largest gap between its wealthiest and poorest citizens in the entire world, after Lesotho, South Africa, and Botswana. The wealth gap is visible at every turn in the winding roads of Freetown, as mansions behind high security walls loom over tin-roofed shanties lacking running water.
That disparity fuels a tension which feeds rumors about everything, putting corruption at the top of every citizen’s list of explanations for the country’s myriad failings — now including the Ebola epidemic.
“The root of all problems here is money-siphoning,” said a local journalist, who asked that I not identify him for fear of retribution. In Sierra Leone, such admissions are tied to a fear that thugs will beat people who voice concerns, or harm their families. The way people talked about these fears in Freetown struck me as reminiscent of the height of the mafia shakedowns in 1950s Brooklyn. One top global health official, insisting I not even identify his agency, said, “This place gives Nigeria a run for the money on corruption. Some $18 billion in foreign aid has poured in here since Koroma took office — where is it?”
The answer seems to be connected to the fancy mansions that line tony hillsides of Freetown, complete with swimming pools and shiny new BMWs.
All over the world, foreign aid and humanitarian assistance programs are subject to theft, typically executed by the government officials who are supposed to receive and process the cash. For example, a country’s farm program officer might take in $100 million in aid intended for purchasing seed and fertilizer for local farmers, and submit $100 million in receipts to the foreign aid donor. But that official may have purchased $90 million worth of farm supplies and pocketed $10 million right off the top. The frequency with which such “skimming” occurs and the size of the typical graft vary dramatically from country to country, and are measured by a variety of banking and finance institutions. Sierra Leone consistently ranks as one of the world’s most permissive environments for classic graft. No foreign aid or investment has been immune to “skimming,” including programs that are literally matters of life and death for the general population.
In December 2011, the U.S. Agency for International Development (USAID) audited spending for food and agricultural development in Sierra Leone, discovering $794,664 in “cost overruns” in a $13.2 million program implemented jointly by the government of Sierra Leone and the Christian charity World Vision. The audit concluded that “[p]rogram performance data could not be verified, and impact could not be measured,” and that “[t]he partner incurred unreasonable expenses and exceeded line-item budgets.”
The following year, the GAVI Alliance (formerly known as the Global Alliance of Vaccinators and Immunizers) put a $6 million campaign on hold due to misuse of funds. In a November 2012 letter to the Sierra Leone minister of health, GAVI stated that the Geneva-based organization had “serious concerns of misuse of GAVI funds” totaling $1,099,640.
In March 2013, 29 Sierra Leonean government officials — including the country’s chief medical officer, Kisito Sheku Daoh — were charged by Sierra Leone’s Anti-Corruption Commission with defrauding GAVI. Investigators maintained that GAVI was billed for meetings and training sessions that never took place, and that government officials owned mansions and luxury vehicles that were “not consistent with official salaries,” according to the New York Times. None of the high-level government officials were convicted in Sierra Leone courts of any wrongdoing, although the Anti-Corruption Commission demonstrated that there was evidence of malfeasance. At least a half million dollars in GAVI funding was never accounted for. In April 2013, GAVI stated: “Funding for HSS in Sierra Leone was suspended in November 2012 after initial findings from the GAVI review, which covered the disbursement period 2008 to 2010 and funds which were spent between 2008 and 2011, raised concerns over possible misuse of funds.”
In May, just a little over a year after the GAVI debacle, the Global Fund to Fight AIDS, Tuberculosis, and Malaria’s office of the investigator general (OIG) “found evidence of fake invoices and fictitious vendors in the procurement of office equipment for the Sierra Leone Ministry of Health and Sanitation, a Principal Recipient of Global Fund grants. In an assessment of the ministry made in 2011 by the Local Fund Agent, losses of USD 167,947 were highlighted in the purchase of non-health products. In its investigation, the OIG identified a further USD 70,510 of compromised expenditure.” In plain English, the inspector general concluded that $238,457 was unaccounted for, and had likely been used to buy such things as personal cars and houses unrelated to the intended mission of vaccinating Liberian children.
Samuel Sam-Sumana, currently the vice president of Sierra Leone, was allegedly involved in a November 2011 bribery scandal dubbed “Timbergate,” in which the politician was accused of accepting kickbacks in return for giving the nod to illegal logging operations. The Anti-Corruption Commission indicted two individuals who paid the kickbacks, but did not charge Sam-Sumana due to lack of direct evidence that the now-vice president accepted bribes.
Sources in Freetown told me a failure to pay bribes was the reason shipments of Ebola medical supplies never get out of customs — and in one case even sat inside a ship’s hull for more than two months.
Given the political atmosphere in Sierra Leone, replete as it is with real and rumored corruption claims and alleged criminal cover-ups to protect government officials and their cronies, it is perhaps inevitable that the buzz and chatter on the streets of Freetown would freely mix comments about failures to slow the Ebola epidemic with talk of graft. All of the local media, both broadcast and print, tap dance around the corruption issue, and every substantive conversation I had with either foreign Ebola fighters or local Sierra Leoneans eventually led to exasperated chatter about lost funds, unpaid staff, delays due to bribe demands, or incompetent government officials who retained positions granted them in exchange for deals made by other officials. It is not possible to confirm or refute every rumor, or confront all of the accused; some claims must be false. But the sheer scale of the allegations, the casual way in which they slip into every conversation and are greeted as “normal,” is staggering, even over the course of a short visit amid an epidemic.
For example, over the American Thanksgiving week, unpaid Ebola burial teams nationwide went on strike, saying they had not received a single paycheck since September. One team was sacked by the National Ebola Response Center (NERC) for staging a protest by publicly dumping the bodies of 15 Ebola victims, including two babies, into a street in the town of Kenema, near the Liberian border. Other health care workers, including doctors and nurses, have staged strikes and walkouts in recent days over salary nonpayment, and NERC spokesperson Sidi Yahya Tunis admitted to the BBC that, “Somebody somewhere has to investigate where these monies have been going, who have been paid these monies…. Action will definitely be taken against those who delayed their pay.”
The money boat
Despite concerns that money is unaccounted for, Ebola funds are pouring into Sierra Leone — as they must. The country is in desperate need of outside aid to stop the virus, and the entire world needs to see the epidemic brought to a complete halt.
In September, the United Nations estimated that stopping Ebola in West Africa would require $987.8 million in donor support, $220.5 million of that for Sierra Leone. A week later, on Oct. 1, the British NGO Save the Children released an alarming document attesting to a skyrocketing epidemic in Sierra Leone that claimed, “An estimated 765 new cases were reported last week — a rate of five every hour — while there are only 327 beds in the country…. Ebola is spreading across Sierra Leone at a terrifying rate, with the number of new cases being recorded doubling every few weeks. At the current rate, 10 people every hour will be infected with Ebola in the country before the end of October.”
Because of the country’s former colonial ties to the United Kingdom, British Prime Minister David Cameron has made Sierra Leone’s epidemic his nation’s special concern, and asked the European Union to pony up 1 billion euros ($1.2 billion) for the Ebola-hit country. Cameron committed his own government to providing $322 million towards that $1.2 billion goal.
At the end of October, the British Navy and Royal Marines sailed the RFA Argus into Freetown, bearing medical supplies and 750 unarmed soldiers and sailors meant to assist the country in its Ebola battle. Justine Greening, the U.K.’s international development secretary, pledged, “Britain is determined to stand with the people of Sierra Leone as they battle Ebola.” Former Sierra Leone Minister of Defense Alfred Palo Conteh greeted the British ship on Oct. 30 in his then-new role as head of the NERC. Conteh, a former army major, looked the British gift horse in the mouth and told reporters, ‘‘We are in a crisis situation which is going to get worse. What is happening now should have been done three months ago.’’
The U.N.’s Financial Tracking Service (FTS) endeavors to keep a scorecard on donor pledges and actual expenditures on the Ebola effort, but clear discrepancies and unknowns are already emerging for Sierra Leone, and it is almost impossible to sort out cash versus in-kind donations and pooled funds “to the region” from targeted Sierra Leone-specific programs. One of the most valuable “donations” to the region has been Cuba’s commitment of 165 medical workers, spread over the West African countries, but the FTS places no monetary estimate on that effort. Specifically for Sierra Leone, a total of $255.4 million in cash or services has been committed by outside donors, and another $134 million is pledged. Of the “committed” cash and services, it appears that roughly half has actually been delivered to Sierra Leone for disbursal. This falls well short of Cameron’s call for $1.2 billion.
Nevertheless, a great deal of money and outside expertise has poured into Sierra Leone since September, yet the country’s epidemic remains out of control. By mid-October the virus had reached every district of the nation, and by the end of that month, some six weeks after the world started promising cash and expertise to Sierra Leone, the contrasting rates of success between Liberia and Sierra Leone were raising tough questions, both from the outside and from domestic media and political opposition leaders.
Too slow to act
When the Ebola epidemic first leaked across the Guinea border into Sierra Leone in early May, government leaders were slow to recognize the threat the virus represented to the whole nation. President Koroma left the problem to his health officials, even as it continued to spread along the border region throughout the month of May. Then the virus spread across Sierra Leone’s eastern districts, eventually reaching Kenema, where U.S. military and university researchers had long maintained a Lassa Fever treatment and laboratory center. Lassa is a rat-carried virus that produces a deadly hemorrhagic fever disease in people that resembles some of the symptoms of Ebola, and Kenema’s hospital had in place security and infection-control procedures approaching the scale required to protect health workers from catching Ebola from their patients.
The Ebola outbreak in Kenema drew swift worldwide attention due to the international presence there, and raised red flags in President Koroma’s office in Freetown. As the death toll climbed in eastern Sierra Leone, one district, Kailahun, declared a state of emergency on June 9. As June wore on and the epidemic spread in geography and volume across eastern Sierra Leone, officials from Doctors Without Borders (or MSF, as the group is known by its French initials) declared that the outbreak was “totally out of control,” drawing fire from President Koroma’s press official Theo Nicol, who said that if the epidemic wasn’t controllable it was likely MSF’s fault.
Frustrated by inaction at the top government levels, the business and mining community in early July called for drastic steps to stop Ebola. But the Koroma government’s response remained sluggish until the first cases of Ebola reached Freetown in mid-July. By then, the eastern outbreaks had grown dire and violence against health care workers erupted in Kenema. Political opposition and religious leaders decried the Koroma government’s inaction, calling for a national all-out effort to stop the plague. On July 18, the government created the first of what would be a succession of national plans and offices to tackle Ebola, this one dubbed the Emergency Operations Center, or EOC. A sense of genuine urgency finally imbued the national response when the nation’s top Ebola doctor, 39-year-old Sheik Umar Khan, died of the disease, having acquired the infection while treating patients in a remote eastern clinic. At the end of July, President Koroma declared a national state of emergency.
Since then, Koroma has shuffled the leadership of the Ebola response at least three times, changed the national strategy, and sowed considerable confusion regarding how Sierra Leone plans to stop its horrible epidemic.
Most recently, on Nov. 4, Koroma quietly changed the entire Ebola response for the third time, pushing civilian Ministry of Health officials aside and putting the Sierra Leone armed forces in the lead. Claiming frustration over the chaotic responses executed in August through October, he created the NERC and put former Minister of Defense Alfred Palo Conteh in charge. And on Nov. 5, the president activated Section 29 of the Sierra Leone Constitution, giving himself state-of-emergency powers that included the authority to place any individual in jail without a court order or formal indictment.
The first of Koroma’s shake-ups came in late August, when the president sacked Minister of Health Miatta Kargbo, saying that her handling of the Ebola crisis was incompetent. Kargbo, who had previously served as a political advisor to the president but had no experience in health or training in medicine, was already despised by Sierra Leone’s medical community for her handling of a 2013 doctors’ strike in which she bitterly condemned physicians, even portraying those requesting unpaid salaries as greedy. Kargbo had become a lightning rod for attacks on the Koroma government’s response to Ebola when, on June 17, she delivered a speech to Parliament in which she blamed Ebola victims for their own infections. Speaking of a nurse who died of Ebola, Kargbo told legislators the woman had brought the illness upon herself because she had a boyfriend and, “They stayed in the same house and throughout the process when he was infected, they were sleeping together in the same room as boyfriend and girlfriend; most definitely, most definitely.”
Koroma eventually fired her for incompetence, saying that it was “in order to create a conducive environment for more efficient and effective handling of the Ebola outbreak in the country.” (Kargbo’s firing came just days after the U.S. government declared the Ebola crisis in Freetown sufficiently dire to mandate evacuation of family members of embassy and consulate personnel.).
On Aug. 29, Koroma appointed medical college professor Abu Bakarr Fofanah as the new minister of health and sanitation, and political operative Madina Rahman was designated his deputy. While Fofanah’s appointment was hailed by the medical community, Rahman swiftly became another lightning rod for criticism after she publicly denounced unpaid gravediggers in two districts for going on strike. At roughly the same time, Stephen Gaojia was named head of the Emergency Operations Center that took over the national Ebola response. Under his leadership, in mid-September the entire nation was placed on a three-day lockdown, a move that proved wildly controversial. During the house-to-house searches, hidden bodies and 130 Ebola sufferers were discovered, but in rural areas the national quarantine spawned food shortages and hunger. Though Gaojia declared the national lockdown a success on Sept. 22, by Oct. 11 the EOC’s efforts were declared “a failure.”
At the end of October, the EOC was dismantled, the NERC was created, and five days later the military was put in charge, with Palo Conteh at the helm. Under Conteh’s leadership the NERC convenes twice a day and the pressure to provide the former army major with impressive presentations finds officials from the government and outside organizations, such as the U.K. military and Save the Children, scrambling to prepare snappy PowerPoints and rehearsing their short talks, according to three participants with whom I spoke.
Conteh is a controversial character, in part because of his rumored relationship with ex-Minister of Health Kargbo. According to veiled press accounts, in May, while still minister of defense, Conteh ordered his entourage into a high-speed chase of Kargbo’s vehicle, which was taking the minister of health home from an Ebola funeral. Kargbo’s car was rammed, several people were injured, and two members of Conteh’s security detail died in the horrible accident. Some media hinted that Conteh was in love with Kargbo, who allegedly dumped him for another suitor.
In July, Freetown’s popular radio host David Tam-Baryoh asked questions on his popular independent weekly program “Monologue” about Conteh’s behavior, drawing the defense minister’s rage. Tam-Baryoh’s show was later suspended by the Sierra Leonean Independent Media Commission for 60 days because:
“David Tam-Baryoh threatened the security of the state, by the inciteful [sic] comments he made against the Minister of Defence.… He was calling on the Army to take immediate action, because, two of their colleagues had died in a road accident.… He blamed the Minister and by extension the government for the accident.…”
In early November, shortly after Conteh took charge of the NERC, the daring radio host took to the air again to recite a list of unmet Ebola control measures. Asking where the funds had disappeared to and why the government had not met its own targets for construction of treatment facilities and other activities, Tam-Baryoh and his opposition party guests called for accountability. Midway through his broadcast, six armed police stormed the studio and Tam-Baryoh was arrested live, on the air, and accused of making ”disparaging and inflammatory statements” about the government ”that in no way would aid the collective efforts we are making as a nation in the fight against the Ebola virus.” The broadcaster was further accused of rousing Kono ethnic hatred against the central government.
According to a fellow journalist I spoke with in Freetown, Tam-Baryoh’s arrest was ordered by Conteh, in part as revenge for the reporter’s prior comments about the deadly car accident. Conteh appealed to President Koroma, who signed a decree ordering the reporter jailed without indictment or trial. Tam-Baryoh was reportedly subjected to severe beatings and jailed in a 324-bed prison that contained more than 1,200 inmates. Two weeks later, the journalist was released on bail after his case was raised by politicians in the British Parliament, which passed a resolution calling for his freedom. Legal experts in the country warn that no reporters are immune to such actions, including the foreign press.
Members of political opposition parties now charge that Koroma is using the Ebola epidemic state of emergency to “create a police state in Sierra Leone.” A month after Tam-Baryoh’s arrest, the Kono district did indeed explode, but not politically: Ebola emerged with with such ferocity that between Nov. 30 and Dec. 10, the World Health Organization announced, 87 bodies were buried and 119 cases were officially reported in an outbreak so extreme that one government official said, “we are only seeing the ears of the hippo.”
By early December, the center of gravity of the entire Ebola epidemic of West Africa had shifted to Sierra Leone, with the country not only having the vast majority of new cases and deaths reported daily, but by Dec. 8 eclipsing Liberia for the dubious distinction of witnessing the largest officially reported cumulative case burden. As the Koroma government struggles to stop the virus’s spread, especially in Freetown and its neighboring districts, pressure is building from domestic and international health communities for a more strategic and accountable effort. Publicly, the WHO, the U.S. Centers for Disease Control, and U.K. agencies have resisted issuing direct criticisms of Sierra Leone’s response or the quality of the nation’s governance.
On Dec. 1, the WHO issued statements and convened a press conference to put a positive face on the epic battle against Ebola, highlighting the achievements made in Liberia and downplaying defeats in Sierra Leone. MSF was not pleased. In its Dec. 1 counter-report, MSF insisted that, “The fight against Ebola in Sierra Leone is being outpaced by the increasing number of infections. Despite efforts by the national authorities and support from international actors, the situation is far from under control. Every district in Sierra Leone is affected by the epidemic, and the number of infections has increased alarmingly.”
Supplies are inadequate, MSF wrote, international assistance minimal, and the Sierra Leone government is in dire need of assistance. “In the absence of adequate facilities to isolate, diagnose and manage Ebola cases, Sierra Leonean healthcare workers are struggling with the needs and are forced to face the epidemic with whatever support they can get.”
Though Sierra Leone is, indeed, in desperate need of far more international assistance, especially for treatment and isolation of Ebola-infected individuals, the epidemic will only come under control when the nation itself — the NERC, the government, and the people — confronts the virus squarely, without any hint of corruption, and with willingness to change behaviors that spread the disease.
Coming up in part two of this series, “Facing Death Without Spreading Disease”: Sierra Leone’s traditional burial practices spread Ebola, and officials struggle to count the toll.