Facing Death Without Spreading Disease

Sierra Leone’s traditional burial practices spread Ebola, and officials struggle to count the toll.

Laurie Garrett
By , a columnist at Foreign Policy and former senior fellow for global health at the Council on Foreign Relations.
Volunteers arrive to pick up bodies of people who died of the Ebola virus, against a 100 US dollar weekly risk-taking compensation, on October 8, 2014 in Freetown. Dozens of British military personnel are due to fly to Sierra Leone next week to help build medical facilities to combat the Ebola epidemic, the defence ministry said on October 7. AFP PHOTO/FLORIAN PLAUCHEUR (Photo credit should read FLORIAN PLAUCHEUR/AFP/Getty Images)

FREETOWN, Sierra Leone — The most “intense” Ebola epidemic in the world, as the World Health Organization puts it, can now be found in Sierra Leone, which is witnessing more than 500 laboratory-confirmed new cases per week, and hundreds more suspected and uncounted infections. The virus is spreading all over the country, but about half of new cases are arising in the capital city of Freetown and neighboring districts. When I was in Freetown three weeks ago the epidemic situation felt dire, but the latest statistics reveal catastrophe.

FREETOWN, Sierra Leone — The most “intense” Ebola epidemic in the world, as the World Health Organization puts it, can now be found in Sierra Leone, which is witnessing more than 500 laboratory-confirmed new cases per week, and hundreds more suspected and uncounted infections. The virus is spreading all over the country, but about half of new cases are arising in the capital city of Freetown and neighboring districts. When I was in Freetown three weeks ago the epidemic situation felt dire, but the latest statistics reveal catastrophe.

As these latest WHO graphs show, Sierra Leone’s epidemic is soaring, even as Ebola is diminishing in neighboring Liberia and Guinea.


Source: WHO


Worse, the WHO data lags a few days behind the outbreak — by as much as eight days, depending on the country and district — and only reflects cases and deaths officially reported to the Geneva-based organization by the Sierra Leone Ministry of Health. Which means of course that the situation on the ground is certainly significantly worse than even these grim findings reveal. For the first time, on Dec. 8, the WHO reported that the officially reported cumulative total number of cases in Sierra Leone (7,798) exceeds Liberia’s cumulative caseload (7,719).

There are many reasons why Sierra Leone’s epidemic is far worse than those in Guinea and Liberia: governance, corruption, the process of international assistance, lack of hospital beds, and burial procedures, to name a few. In the first installment of this series I addressed the governance and corruption issues. For the other points, consider the story of 38-year-old Musu Esther Massaquoi, a resident of Freetown.

In late October, Massaquoi’s adult sister came down with Ebola, and the entire Massaquoi household was placed under quarantine. Since late October there have been consistently more Ebola cases in Freetown than treatment beds, so Massaquoi cared for her sister in the family home. At the end of the month the sister died, and Massaquoi and her family prepared to carry out a series of traditional rituals and the burial of their loved one. But a government burial team and police arrived to not only remove the deceased from the home, but also to block all funeral services in order to prevent transmission of the virus from the cadaver to mourners.

According to court and local news accounts, a distraught Massaquoi allegedly tried to block the burial team and hit one of the officers. She was charged with three counts of violating the Public Emergency Regulations, under which the nation has been ruled since late July due to Ebola, and on Nov. 6 she was found guilty. Despite pleas from her attorney for mercy, the judge sentenced Massaquoi to either serve a year in prison or pay a fine that is the equivalent of more than 10 percent of the per capita GDP — 500,000 leones, or $115. At the time of this reporting, Massaquoi was in jail in lieu of being able to pay the fine.

Anyone who has lost a loved one can sympathize with Massaquoi’s anguished misbehavior and pity her imprisonment. But epidemics call for drastic actions, and Massaquoi not only apparently violated safe burial procedures but, as a potential carrier of the virus herself, could have spread the disease to the people she attacked. Emotions may weigh on Massaquoi’s side, but ethics and disease control exigencies lean heavily against her.

The search for balance between what seems right for the individual and what’s best for the population as a whole is the crux of the dilemma in Sierra Leone, which faces a Massaquoi-type balancing act on a national scale, as hundreds of incidents like this occur every day. Stopping the nation’s epidemic means two seemingly simple changes must take place: All burials must be safe ones, and all ailing Ebola sufferers must be removed from the care of loved ones and placed in humane, isolated treatment facilities.

There are two primary ways people catch the Ebola virus. The first is through physical contact with an ailing individual, most commonly in compassionate acts of care — wiping a fevered brow, cleaning vomitus and diarrhea, bathing an individual too sick to clean himself. The second is through handling a cadaver in any manner that puts someone at risk of coming in contact with bodily fluids or moist skin. The first compassionate care exposure can be reduced by removing the ailing from families and their homes, by placing them in isolation and care facilities, and, further, by assuring that everybody working in those facilities is properly trained and provided with gear that protects them from viral exposure.

Throughout the Ebola-wracked region, resources have been expended in order to provide more care and isolation facilities and Ebola treatment centers. And each country has struggled to induce families to yield their deceased loved ones to safe burial crews, banning traditional funeral procedures in favor of ignominious interment.

In Sierra Leone, “safe burials” must be executed without the traditional ceremonies that usher the deceased into the afterlife and are therefore deeply antithetical to the moral and spiritual fiber of both Muslims and Christians in this country. Abandoning these practices essentially constitutes heresy and, in the eyes of friends and family members, dooms the dead to a grim hereafter or leaves them to walk the earth as ghosts, vengefully haunting those among the living who failed to provide proper passage into the afterlife. In Sierra Leone the lines are blurred between ancient traditions that predate the arrival of Christianity and Islam, and local interpretations of the precepts of those established religions. In a country of crushing poverty, the basic practices of preparing the dead for burial are rarely performed in funeral parlors or mortuaries but are executed by surviving loved ones, who by doing so put themselves at great risk for infection.

That much is true across all three of the Ebola-stricken nations. But the burial situation in Sierra Leone is especially fraught with danger. First, more than 70 percent of Sierra Leoneans are followers of Islam, and typically practice ghusl, the ritual bathing of the body that includes pressing fluids out of the cadaver by pushing down on its abdomen. The cleansing is typically performed by elders of the same gender as the deceased, including family members who may travel a fair distance to participate, staying with the grieving survivors for days before returning home — possibly carrying the Ebola virus to a new geographic location. At the burial ceremony an ablution bowl is passed among the mourners, which is used to wash their faces, hands, and feet — another potential point of spreading the virus.

According to Olushayo Olu, a Nigerian-born epidemiologist working for the WHO in Sierra Leone, burial rituals in the country often far exceed those prescribed by Islam and various Christian faiths. “Funeral practices here are peculiar and more than 95 percent of transmission is around burials, especially in the rural areas,” Olu told me as we sipped tea in a café on a blistering hot afternoon. “The body stays in the home. They hug it, talk to it, kiss it. They clean inside the body, not just on the outside. Even here in town, educated people wash the bodies of their loved ones themselves.”

Imam Mohammad Jalloh runs Focus 1000, a group dedicated to providing the populace with safe interpretations of Quranic and Biblical burial traditions.

For example, the Quran instructs, “Do not move your hands towards destruction,” Jalloh says. So “moving” one’s hands to wash an Ebola-infected body would actually violate the teachings of the Quran. Jalloh told me that in August his organization did a nationwide survey of beliefs surrounding the epidemic, and they discovered that many of those polled believed that Ebola was a curse, or payback, for past sins, and some thought the virus was shot by the “Witches’ Gun,” a sort of satanic weapon handed down from the days when white slave drivers shot Africans with muskets. When people speak today of the “Witches’ Gun” it implies a sort of curse of intense evil that can be aimed by one individual or group against another. A shocking 9 percent admitted that they would hide the bodies of loved ones from burial teams in order to ensure their safe passage into the afterlife. But as the epidemic has swept over the nation, leaving no family or workplace untouched, these superstitions have nearly disappeared, Jalloh told me. By early November less than 1 percent of surveyed Sierra Leoneans professed belief in “Witches’ Guns,” and just 2 percent still adhered to the notion that the epidemic was revenge for past sins. This might indicate that the situation is improving.

Another member of Focus 1000, the Rev. Christiana Sutton-Koroma, has tried to dispel dangerous burial beliefs among Christians. Prominent in interfaith health-related activities in Freetown, and leader of the Christian Action Group (CHRISTAG), Sutton-Koroma is a preacher in the Congregationalist faith, but preaches across the full spectrum of Christianity. Traveling from church to church, sometimes delivering four sermons on Sunday, the petite, middle-aged Sierra Leonean takes on superstitions and draws from biblical teachings to dissuade parishioners from touching the sick and the dead.

I watched as she addressed the packed congregation of Church of God Prophecy in Kissy, just outside of Freetown, on the second Sunday of November. The Pentecostal church was filled with music and a startling amount of hugging, given Ebola fears. But when the tiny Sutton-Koroma preached, her purple robe flowing back and forth as she bounced from foot to foot, the congregation was rapt.

“We are here to look at Ebola!” she cried.

“Amen!” shouted the congregation.

“And in Jesus’s name we say, ‘Ebola, go away!’” Sutton-Koroma continued, to a chorus of “Amen.”

Sutton-Koroma told the crowd that in one passage in the Bible found in Numbers 19, it is written that one should not go to the funeral of someone who “had the sickness.” There are two types of touch, Sutton explained: the actual physical contact that must now be forbidden, and the woman’s “touch,” a sort of feeling that is gentle and caressing, without actual contact.

“The cost of your casket does not take you to heaven,” Sutton preached. “The cost of your shroud is not your ticket to the hereafter. What takes you to heaven is your relationship to your fellow man. The only thing that God respects is mankind should be treated with dignity.” Use soap, wash your hands, touch no one, and shun funerals, Sutton concluded.

In her final remarks Sutton-Koroma exclaimed that in Leviticus 14 God gave Moses precise instructions for handling a plague in a household, using leprosy as an example:

And the Lord spake unto Moses and unto Aaron, saying,
When ye be come into the land of Canaan, which I give to you for a possession, and I put the plague of leprosy in a house of the land of your possession;
And he that owneth the house shall come and tell the priest, saying, It seemeth to me there is as it were a plague in the house:
Then the priest shall command that they empty the house, before the priest go into it to see the plague, that all that is in the house be not made unclean: and afterward the priest shall go in to see the house:
And he shall look on the plague, and, behold, if the plague be in the walls of the house with hollow strakes, greenish or reddish, which in sight are lower than the wall;
Then the priest shall go out of the house to the door of the house, and shut up the house seven days:
Moreover he that goeth into the house all the while that it is shut up shall be unclean until the even.
And he that lieth in the house shall wash his clothes; and he that eateth in the house shall wash his clothes.
And if the priest shall come in, and look upon it, and, behold, the plague hath not spread in the house, after the house was plastered: then the priest shall pronounce the house clean, because the plague is healed.
This is the law for all manner of plague of leprosy, and scall,
And for the leprosy of a garment, and of a house,
And for a rising, and for a scab, and for a bright spot:
To teach when it is unclean, and when it is clean: this is the law of leprosy.

Sutton-Koroma closed to a chorus of “Hallelujah!” and “Amen!” from the congregation.

But Sutton-Koroma, Jalloh, CHRISTAG, and Focus 1000 are fighting an uphill battle against deeply rooted beliefs. Stephen Douglas, a Canadian Internews reporter who has lived in Freetown for five years, says the determination to fulfill traditional burial practices has cast what is colloquially referred to as an “Ebola shadow” over the country — a sort of massive underground of activities, deaths, and illness that never see the light of official recognition. “There is a state of nonofficial treatment and activities, cases and burials that we will never know about,” Douglas told me. “The official numbers of reported cases and deaths bear no resemblance to reality. Heck, they don’t even reflect what’s officially recorded at the cemeteries.”

On Nov. 18, President Ernest Bai Koroma fired his uncle from a rural tribal chief position, charging that his relative had accepted bribes to cover up secret burials of Ebola victims, which was in direct defiance of an Ebola control edict for safe funerals. At the local level power is exerted by 1,200 chiefs who may adjudicate disputes and make decisions about nearly every aspect of commerce and social interaction in their village or jurisdiction. Koroma’s action against his own uncle, stripping the man of authority and levying a fine of $115 against him, was meant as a warning to all of the nation’s chiefs to cease allowing families to hide the sick from authorities and carry out traditional funerals.

But during my travels in Sierra Leone, I found evidence rife across the country of political interference by chiefs and politicians in Ebola control measures as well as bribery, primarily aimed at getting constituents out of quarantines or to allow potentially dangerous funerals to go forward, and to remove the stigma of “Ebola” from official cause-of-death records.

According to local journalists, bribes are routinely paid to health officials and police to look the other way, ignoring quarantines, cases of Ebola infections, and deaths. President Koroma may have been signaling his intention to flush the Ebola shadow out of hiding by penalizing his errant uncle, but the practice is so widespread as to constitute the norm, experts told me.

“Whether it is deliberate or not, I cannot tell but those stupid statistics being released by the health officials are being done with breathtaking, barefaced cheek. The Health Ministry is insulting our intelligence as if we cannot count,” Sylvia Blyden, a medical doctor and former special advisor to Koroma who was recently sacked from her post in an apparent power struggle, told a local publication. “Those government officials have turned this country to a joke in some scientific circles; I know diplomats who laugh behind our backs because of this. When they persist in under-reporting infection and death rates, it lulls into complacency and the end effect is to negate all effort of dedicated officials. Citizens just do not fully realize catastrophe’s extent; it is being hidden from them.”

Consider the case of the country’s super hot spot for Ebola, the Western Area Rural district, which spans a peninsular region south of Freetown, alongside a lush rainforest, down to the small seaport area of Kerry Town. A single tarmac road is the backbone of the district, from which hundreds of muddy, unpaved spans stretch out like vertebrae along the spine. Small towns featuring tin-roofed stores and roadside snack shops dot the spine, with colonially inspired names like Waterloo, Hastings, and Kerry Town. And hidden along the dirt roads and walking paths behind the roadside commerce are tens of thousands of houses, most without running water or electricity. Under the President’s state of emergency enacted on July 31, any household here, or anywhere in the country, that has a confirmed case of Ebola must be placed under quarantine and its inhabitants’ movements restricted for 21 days. But security forces are commonly paid to remove themselves from quarantine observation in the region, and members of Parliament have interceded on behalf of constituents to remove Ebola stigma from key families. Demands to lift quarantines may arise because families are unable to obtain food, but more typically are associated with stigmatization and the desire to bury loved ones with full traditional respect — and without “Ebola” on their death certificates.

By late October the district’s Ebola crisis ranked second only to Freetown in numbers of officially reported illnesses and deaths, and in the reckoned scope of its Ebola shadow. In a Nov. 6 press release, Koroma targeted the district and widespread violations of safe burial and quarantine regulations, saying, “This is time for action and you must stop the hypocrisy in the fight against Ebola. There is no time for meetings and you must enforce the law and take out the sick.”

And by the end of November the cumulative laboratory-confirmed caseload for Western Area Rural was more than twice the number of Ebola hospital beds nationwide. The town of Waterloo, in particular, drew fire because it has long been a sort of transition point for the country’s bumpkins, who move from rural villages to the rural western town before daring to venture into the big city of Freetown. The epidemic, which until September was almost entirely focused in the northern and eastern regions of Sierra Leone that border Guinea and Liberia, shifted westward, sweeping through Waterloo to Freetown. Today, cases of Ebola can be found all over the country, but some 90 percent either arise in Freetown and Western Area Rural or are spread by urban residents who return to their home villages, taking the virus with them.

One indicator of the scale of Sierra Leone’s Ebola shadow can be found in the contrasting data the nation officially reports to the WHO versus that supplied by Liberian officials. Cumulatively, as of Nov. 26, all but 16 percent of Sierra Leone’s cases are listed as “confirmed,” while 62 percent of Liberian cases are either “suspected” or “probable.” At first blush one might mistakenly conclude that Sierra Leone had superior laboratory capacity and was therefore confirming its caseload more rapidly than is the case in its neighbor. But although there is a vast gap in lab turnaround time between the two nations, it falls decidedly in favor of Liberia, where it only takes hours and not days to turn around lab results. The correct interpretation of the paucity of “suspected” and “probable” cases in Sierra Leone is that the country is not finding and isolating the infected, and most Ebola victims perish without ever being accounted for in the logs.



By late November Sierra Leone had five laboratories capable of diagnosing Ebola, one of which is operated by the U.S. Centers for Disease Control and Prevention (CDC). The CDC’s Freetown-based Tony Mounts told me there was no doubt whatsoever that the disease was highly underreported, but that the labs were working as fast as possible.

By late November Sierra Leone had five laboratories capable of diagnosing Ebola, one of which is operated by the U.S. Centers for Disease Control and Prevention (CDC). The CDC’s Freetown-based Tony Mounts told me there was no doubt whatsoever that the disease was highly underreported, but that the labs were working as fast as possible.

The problem, Mounts said, was logistics: Much of the country is so inaccessible that without helicopters, “the challenge is simply getting a tube to a lab fast enough. It’s hard to get reliable specimens.” Worse, the National Ebola Response Center, which commands the epidemic control effort, insists lab results must be processed by the slow bureaucracy of the Ministry of Health before the Ebola holding centers and treatment facilities can be informed — a provision that can slow reporting time down to four to six days.


In a situation as dire as Sierra Leone’s is now, with its vast Ebola shadow, laxity in following regulations, and the necessity of bribes to forge records and other certificates, health care workers, ambulance drivers, and burial teams have no idea which people and bodies they handle may be contagious. The danger is very real, and hundreds of Ebola fighters (a force that includes everyone from the nurses and doctors offering treatment to the burial teams and ambulance drivers) have become sick, most of them dying of Ebola infections acquired on the job. Those who remain on the job are traumatized and fearful. The nation desperately needs more Ebola treatment centers (ETCs), as they are called here, but staffing them in the absence of enormous numbers of foreign physicians and nurses will be next to impossible.

Nurse Melrose Koroma (who is of no relation to the president) still pulls long hours on the Ebola isolation ward at Connaught Hospital in Freetown, but only with regular daily prayer. The nurses and doctors of Connaught went on strike on Dec. 8 over Ebola safety conditions, but I spoke with Koroma before that walkout.

“I lost most of my friends,” she told me, waving to a bulletin board on a hospital wall on which were posted the photos and brief biographies of several health workers who died there of the disease. “We worked together, we drank together. They were my friends, four nurses and a doctor.”

Listening to her nurse, British doctor Stacey Mearns says she is determined to stay at Connaught treating Ebola “until it’s over. The local staff is amazing. They have watched colleagues die and I find it really amazing that they still come in for work.” The organization she works with, the U.K.’s King’s Health Partners, has built three additional small Ebola holding centers scattered around Freetown, adding about 100 beds in primitive settings, costing roughly $20,000 per center to construct.

If a possible Ebola sufferer in the Connaught isolation facility tests lab-positive for the disease, he or she will be sent to one of the only two ETCs located within two hours’ drive of central Freetown. I journeyed to both facilities.

Cuban MDs suiting up
Cuban MDs suiting up

Image: Laurie Garrett


On my way to Kerry Town, I met a busload of exhausted Cuban physicians buying snacks at a roadside market midway through their two-hour journey to their hotel. Every day, the doctors complained, they piled into the bus for a two-hour drive in the morning, worked long hours in the hot sun, and then bused back another two hours. After a month of training the Cuban doctors had only just seen their first patients the day I visited, and their faces betrayed weariness. But other than admitting to exhaustion from their long commute, the men (all Cuban Ebola fighters are male, for reasons not explained by Havana) dodged specific questions from this inquiring American.

Further down the road in the town of Hastings, I reached a police training school (PTS) and wandered into the 120-bed PTS-run Ebola treatment center. Another group of Cuban physicians greeted me in a chaotic setting where lines of civilian-attired nurses awaited payroll, clusters of Cubans struggled to comprehend enough English to figure out what they were supposed to do, and families loitered, hoping to see their hospitalized loved ones. Sierra Leone armed forces physician Komba Songu–M’briwa runs the center, which had six more patients than beds when I visited on Nov. 9.

“We are full,” Songu–M’briwa told me, “but if they come we just have to accept them.” Since the PTS unit opened on Sept. 19 it has been full — or over capacity. Despite Songu-M’briwa’s claims that the PTS takes in all comers, at least three dozen Ebola victims have died outside the facility’s walls, waiting for free beds. It only accepts diagnosed patients referred from holding centers, like the one at Connaught Hospital. The facility boasts a survival rate of “50 to 60 percent,” he said.

Hasting Ebola Treat Unit
Hasting Ebola Treat Unit

Image: Laurie Garrett


Compared to the rigid Doctors Without Borders clinics in Liberia, the Hastings PTS seems utterly chaotic, and it can be hard to tell where the Red Zone ends and safe areas, not requiring dressing in Personal Protective Equipment (PPEs), begin. I strolled freely, with no security, and nearly bumped into an Ebola patient who was leaning on a fence speaking to her visiting mother. Songu–M’briwa alerted me, pointing to a sign dangling from up high that warned visitors to stand back one meter from the Red Zone.

Further down the road in Waterloo, I encountered a hospital that, like Connaught, had erected a pen covered by a tarp — another holding center for possible Ebola patients. As I continued my southward journey through Western Area Rural district, a steady roar of ambulances could be heard, whizzing past in both directions to collect or deliver Ebola patients. Outside the lushly green town of MacDonald, a U.K. military roadblock forced a halt and fever checks. Waved through, I continued on to Kerry Town and a large, new, white compound of wooden-and-tarpaulin structures surrounded by layers of chain-link fencing and barbed wire. It looked like a prison.


Image: Laurie Garrett


In contrast to the lax atmosphere at Hastings PTS, the Kerry Town Save the Children facility and neighboring U.K. military-run ETC operate under rigid rules enforced by military personnel and hired security specialists. The military-run facility has operated at full capacity since opening on Nov. 5, but most of the 80 beds in the Save the Children hospital were empty — and remain so today, despite the country’s dire need. London School of Hygiene & Tropical Medicine public health expert Francesco Checchi helped create the facility, and gave me a tour. Staffed by 60 Cuban physicians, 30 health professionals from the Sierra Leone Ministry of Health, and five European Union doctors, the facility was meant to be the premier Ebola treatment center for the nation. But it hasn’t turned out that way.

The day before the facility officially opened, four Ebola patients staggered in, begging for care. Checchi raced about, trying to teach people how to don PPEs and apportion supplies in what he called “the most stressful day in my 38-year life.” Since then Save the Children has struggled to figure out how to run the facility and safely provide care. NERC officials have both pressured the U.K. group to take on more patients and defended the facility against withering criticisms from international and local Ebola fighters impatient to see the Kerry Town ETC take on hundreds of needy patients.

Checchi was embarrassed by the cost of the facility and its inability to take on a full patient load. Especially disconcerting, he said, was its cost of operation — roughly 200,000 British pounds ($315,000) per day. “It’s a huge operation,” Checchi explained. “It’s so far away that we had to build a public transportation system just to get staff here. It’s incredibly labor-intensive. And we have staff staying at a nearby resort,” at a cost of about $350 per person per night. “We have to have ‘lessons learned’ after this,” Checchi sighed.

Behind the Save the Children complex is a smaller ETC exclusively for infected health care workers, operated by the U.K.’s ministry of defense. I was denied entry to the facility by its army commanders, but from the outside the 18-bed facility resembled a small version of the Doctors Without Borders-run Ebola units I’ve seen in Liberia. Privately, U.K. military staff told a former Royal Marine traveling with me that the command structure and terms of engagement for the U.K. military presence were very confusing, and that much of the humanitarian and British government interaction with Sierra Leone’s NERC was not clarified.

Another 60-bed treatment center located near the Liberian border in Kenema is run by the International Federation of the Red Cross (IFRC). But the larger roles served by the 2,500 Red Cross volunteers and 300 paid staffers are contact tracing of those close to known Ebola sufferers and transport and burial of the virus’s victims. American Steve McAndrew runs the IFRC in Sierra Leone, which he likens to an old Chevy truck. It’s got heart, he says, and if you constantly make repairs the darned thing runs. “But that old Chevy is sitting in the garage with 100,000 miles on it and suddenly in this [Ebola crisis] it needs to be a brand new BMW.”

McAndrew says the IFRC needs about $45 million to meet its needs, including buying new trucks and equipment and protective gear for its volunteers. Amazingly, despite the fear and stigma surrounding Ebola, the epidemic has brought in more volunteers and McAndrew’s teams have been able to find and safely bury 100 percent of reported Ebola-infected bodies. “But that’s 100 percent of the ones called in,” McAndrew told me. “There’s no true data on how many folks are getting buried. Nobody knows. Nobody.”

Along the road from Kerry Town, heading back to Freetown, I spotted a sign indicating that the Red Cross was on my left. Traversing a rugged mud slope, I finally reached a small brick building in front of which were parked four run-down old ambulances. Drying in the sun were two washed protective suits. And sitting in the shade was a cluster of volunteers, waiting for their next call to Ebola action. Members of the group declined to answer questions, insisting I needed to speak with McAndrew in Freetown. But the beat-up vehicles and tired faces were typical of those I saw with Red Cross volunteers in Sierra Leone. Given what they face — the risk of infection, angry families unwilling to part with loved ones, grief — such volunteers are remarkable and courageous.

Back in Freetown, traffic is often congested as Red Cross entourages and ambulances scream through streets, forcing other vehicles to pull aside. Adult Ebola victims, their infections lab-confirmed, are often hauled off to distant Hastings, Kerry Town, and even far-away Kenema, leaving families behind.

“We find kids, alone, dying at home,” Connaught’s Mearns told me. “They have lost their whole families, and they are sick.”

Before Ebola struck, Sierra Leone had one of the worst health care infrastructures in the world, with an average life expectancy of just 57 years, and 0.4 hospital beds and 0.2 physicians per 1,000 people. By comparison, Cuba — from which the region has received 165 Ebola-fighting health care workers — has an average life expectancy of 78 years, and 5.1 hospital beds and 6.7 physicians per 1,000 people.

The WHO’s Olu says things have steadily worsened as Ebola’s roots have taken hold in the country’s urban centers, especially Freetown. It’s one thing to walk into a rural village, negotiate with the chief, and find all the cases and their families, “But here in Freetown housing is very dense. And in a house you have three, maybe four families. When one is infected how do you protect the rest of them? How do you do contact tracing when people here don’t have addresses?”

According to the Koroma government the country needs 3,000 Ebola treatment beds, but has only 400. The United Nations puts the need even higher, at 4,800 beds. The ambulances that make their way through every major artery in the country responding to 117 calls bear those fortunate enough to lay claim to one of those beds, or the unfortunate destined for burial. But the ambulances won’t respond to 117 calls if no empty beds can be found, and the burial teams are often overwhelmed by requests, leaving bodies — dangerously — in the villages and homes for days.

“We’re five months down the line, health care workers go out on strike, and nobody’s getting paid,” Olu continued, speaking with emotional weight in his voice. “The government has $20 million for Ebola but nobody’s getting paid. I spent days with a burial team. These guys are highly stigmatized. In one hour I saw almost 40 bodies. Can you imagine that? Forty. And these guys after all that work don’t get paid. We bear collective responsibility for this mess. WHO — we have proposed too many strategies to these people. The process here is overly political. We need massive treatment centers. We need a command-and-control structure. We need to conquer denial and conquer underreporting — it’s at least two and a half times the reported numbers. We need to build a health system here.”

Looking out at the ocean, sipping his beer, Olu said that he knew the world can’t wait for all these fixes, or for local corruption to magically disappear. He knew the stakes in this Ebola catastrophe were far too high, not just for Sierra Leone and its neighbors, but for all of Africa.

“The message to Africa is we must sort out our health issues. If we don’t, we’ll never get anywhere. Primary health care, if it existed here, would take care of 90 percent of infectious diseases. Good-quality personnel, simple technology. This is it! But as long as we don’t do these simple things even a little stress makes it all collapse.”

A day after having drinks with Olu, I boarded a speedboat named after President Koroma, and crossed the Sierra Leone River one final time to the airport. There, I paced in front of the sole working air conditioner, waiting for the flight back to Liberia. The airport shops and eateries were closed, the waiting room lounges empty, and the only sound a TV broadcasting a local soap opera. There were only three of us travelers in that airport, and no commercial flights.

As I boarded a small United Nations jet, I looked back from the stairs at the vast, empty tarmac. And it occurred to me that Ebola’s claim on the people and economy of Sierra Leone will persist long after the virus is defeated. Its once-booming economy has been crippled, its already deficient health care system taxed beyond its most extreme capacity, and the scrutiny of the world focused on government corruption. If sometime in 2015 the people of Sierra Leone can safely turn their backs on the Ebola threat, perhaps the pall it casts over the government and society will open the door to reform, construction of a serious health care system, and genuine governance.

Coming up in part three of this series: “Pushing Ebola to the Brink of Gone in Liberia”

 Florian Plaucheur/AFP

Laurie Garrett is a columnist at Foreign Policy, a former senior fellow for global health at the Council on Foreign Relations, and a Pulitzer Prize-winning science writer. Twitter: @Laurie_Garrett

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Kurdish military officers take part in a graduation ceremony in Erbil, the capital of Iraq’s Kurdistan Region, on Jan. 15.
Kurdish military officers take part in a graduation ceremony in Erbil, the capital of Iraq’s Kurdistan Region, on Jan. 15.

Iraqi Kurdistan’s House of Cards Is Collapsing

The region once seemed a bright spot in the disorder unleashed by U.S. regime change. Today, things look bleak.