Epidemic

by Reid Wilson

  The environmental health technicians, who had been used to traveling on bumpy rural roads to deliver messages about clean water, would be trained in something new: the safe burial and disposal of virus-infected bodies.

  Across the border in Sierra Leone, David Robinson’s network found itself in a similar position. Robinson worked for World Vision, the global charity best known in the United States for its advertisements seeking sponsors for children living in extreme poverty in desperately poor countries. The group had 58,000 children enrolled in its program in Sierra Leone, overseen by a staff of about 300 operating on a $12 million annual budget. Like Global Communities in Liberia, World Vision had a long relationship with communities in rural Sierra Leone; its staff had shown up during Sierra Leone’s civil war, helping to disarm and reintegrate members of the rebel army back into society.

  When Robinson, based in World Vision’s regional capital in Dakar, Senegal, first visited Sierra Leone in May 2014, he found a country in denial, even as Ebola cases mounted. He facilitated a World Vision airlift of some of the first personal protection equipment into the country.

  At first, Robinson saw World Vision as an important conduit to the thriving faith community in Sierra Leone. Schools and universities had been shuttered and markets went bare, but religious services continued. In many parts of the country, services at churches and mosques were the only places where large groups of people continued gathering. Before chlorine-based hand-washing stations became ubiquitous sights around the country, some of the first appeared in churches and mosques where World Vision had built a decade-long relationship.

  Most important, as in Liberia, ministers and imams were trustworthy messengers, even as mistrust in government remained.

  By September, the World Health Organization approached Robinson with a request that sounded similar to what they asked of deVries in Liberia: Could World Vision—along with Caritas, a Catholic charity based in the United Kingdom, and Islamic Relief—help rethink Sierra Leone’s traditional burial practices, to cut down on transmissions between dead bodies and survivors?

  World Vision had been hearing from religious leaders that their traditions had been overlooked, sowing still more distrust in the westerners who purported to help Sierra Leone’s rural communities. WHO’s approach to what it called “dead body management” sounded clinical, disrespectful. Instead of letting their loved ones be carted away, unwashed, and dumped in a mass grave, villagers would hide bodies or refuse access to some of the early burial teams who showed up in protective equipment.

  In smaller towns outside Freetown, faith leaders became the messengers who spread word of Ebola to a skeptical populace. In Bo, the regional capital in eastern Sierra Leone, Robinson watched as two particular preachers—a Christian pastor named Peter Kainwo and one Imam Koker—united their congregations in the fight. Kainwo and Koker visited each other’s congregations to share messages about Ebola. Their mantra became: Doctrine divides, service unites.

  Burial teams were already operating in other parts of Sierra Leone and Liberia, though few thought to implement them widely. In Monrovia, a city with a population of more than a million people, just six teams of body collectors were working by July 2014. Each team, clad head to toe in personal protective equipment, picked up at least half a dozen bodies a day. Some days, they collected twenty-five or more, delivering them to the crematorium set up outside the city. It was not uncommon for the teams in Monrovia to visit the same block of houses—or even the same home—multiple times, to collect the remains of friends, neighbors, and family members who had infected each other.

  Even in cosmopolitan Monrovia, where messages about the danger of Ebola were omnipresent, denial ran rampant. Residents of the overcrowded slums routinely told burial teams that their family members had died from a miscarriage, or a stroke, or any of a hundred other maladies, when even the most basically trained health care provider could see that Ebola was almost certainly present.4

  Out in the rural counties, burial teams encountered more resistance. Locals did not trust the government, run by the descendants of former American slaves, and centuries of tradition demanded that families take care of their own dead bodies. Muslim villages felt particularly strongly about caring for their own dead, especially if the members of a burial team were non-Muslim.

  The Global Communities teams, however, found themselves in a unique position. They had forged relations over a decade with village elders throughout the three rural counties—and, along the way, they had shown results, as the number of deaths from cholera and other preventable diseases plummeted after the IWASH system took hold. Now those same teams were returning to the villages they knew so well, promising once again to end the scourge of disease. The environmental health technicians-turned burial teams paid special attention to cultural sensitivities: Muslim bodies were handled only by a specially created all-Muslim burial team.

  Even having developed years of relationships, convincing villagers to give up sacred tradition proved difficult. In every community, the teams had to convince families and village elders that they were there for the right reasons.

  “It convinced [village] leadership that what we were doing was a real health concern, and not some conspiracy by the government,” deVries explained later.

  In Sierra Leone, World Vision employed its own version of cultural finesse. Its program integrated burial teams and faith leaders. The burial teams, some trained in Christian traditions, others in Muslim traditions, would collect the bodies and bury them in marked graves, giving families a physical location at which to grieve and honor the deceased. At the same time, faith leaders were invited to be present at burials, to offer prayers and counseling.

  It was a new mission for an old organization, one that World Vision had to learn on the fly.

  “No NGO is known to have a specialty as an undertaker. Working with burial teams is not something we would list as an organizational specialty. Nobody does,” Robinson said.

  Having been dispatched to pick up a body, burial team leaders would make their first stop at the home of the deceased. They would speak with the family and with community leaders to explain step by step what they had arrived to do. As was custom, the burial teams—handpicked to come from nearby villages—would explain their tribal ties to the village, to prove they shared common foundations. They asked to hear about the life of the deceased; often, families would deny their relative had even fallen ill. Denial was easier than acceptance of an invisible microbe in their midst.

  Soon after the IWASH teams had become Ebola-fighting burial teams, deVries accompanied his men to a village where a suspected victim lay. After what seemed like hours of talk between the team and the dead man’s family, as they established a careful rapport, a village elder stepped forward to say there had been other strange deaths, after a visitor from Monrovia arrived. The elder’s wife had died, then another friend, and now this man. The villagers realized Ebola was among them.

  The family led the burial team, six Liberians from nearby villages, to the body, down a hill, through a swampy marsh, across a rickety bridge that was little more than wooden branches strung together with twine. They came to an island in the marsh, where crops were growing around the body.

  Together, the burial team suited up in full-body protective equipment, under the blazing equatorial sun. One member of the team sprayed chlorine on every available surface, to kill any virus lurking about. They hoisted the dead body, oozing with blood, onto their shoulders and retraced their steps, through knee-deep marsh water and up the steep hill to a waiting grave, dug by the man’s family. As the burial team explained every step to villagers, they lowered the body into the grave and filled it with dirt. Villagers attended the burial, though they were kept well back.

  It was not long before Global Communities’ work started to show some promise. Case counts in Monrovia continued to rise, but the rates of new infections in Bong, Lofa, and Nimba Counties began to tail off. Through August and September,
just as the American response began to ramp up, USAID took notice. Soon, deVries got a phone call from a senior USAID officer: How soon, the officer asked, could you set up burial teams in other counties?

  Within weeks, Global Communities teams were everywhere in northern counties, overseen by a tall, commanding Liberian named George Woryonwon. Dubbed Uncle George by the environmental health technicians he had managed for years, he was known as a fixer. When one of the burial teams had a problem with a motorcycle, or when their salaries didn’t arrive in time, or when they needed some vital equipment, they called Uncle George. He came through.

  Now he burned up the phone lines, establishing burial teams through as many county health offices as he could reach. Once those burial teams were set up, Global Communities would ship in the personal protective equipment, the body bags, vehicles, and supplies. Each team got three vehicles: an ambulance to carry the body, a truck to carry the burial team, and a second truck to carry those who would spray an affected area thoroughly with chlorine. In Monrovia, deVries was buying as many cars and trucks as he could get his hands on.

  “We had every jalopy that was available in very rural places,” he said.

  The remoteness of rural West Africa is difficult to comprehend. Communities can be an hour’s walk from the nearest passable road. The Liberian burial teams carried supplies on their heads, through thick jungle along barely visible trails. Some burial teams took canoes through murky rivers, which meant they needed life preservers. After retrieving a body, oarsmen would paddle canoes back downstream, still clad in full protective gear.

  In Sierra Leone, where World Vision worked in some larger cities, they took extreme precautions to protect their employees. Staff were not allowed to attend burials, and they were not allowed to eat outside the office. World Vision satellite offices built their own kitchens to feed staffers.

  By September, the first Global Communities–backed burial teams arrived in southeastern and northwestern Liberian counties, areas where the group had not operated before. It was the middle of the rainy season, and roads turned so bad that what should have been a long day’s drive turned into a several-night-long odyssey.

  While the international response had focused on Monrovia and the rural northern counties, the virus had moved south and east, decimating new counties that had gone overlooked. Parts of those counties remained out of government reach even after cessation of Liberia’s civil war; now they felt neglected. The communications efforts that had so rapidly raised awareness in the capital and even up north had not reached the southeast. The problems with a parallel governing structure that had vexed some Ebola response efforts in Bong, Lofa, and Nimba Counties were doubly difficult in the southeast, where tribal governance dominated and Monrovia’s control was symbolic, at best.

  The first Global Communities burial teams met resistance, some of it violent. In River Cess County, south of Nimba along the Atlantic coast, a mob commandeered one burial team’s vehicles. The team had to walk home. To the east, in Sinoe County, a mob stoned the house where a new burial team was being trained.

  In Monrovia, a group of traditional elders, led by the paramount chief, Zanzan Kawa, came to see deVries at Global Communities headquarters. They offered to help in any way they could, and deVries thanked them for coming. Still, he could not immediately think of a way they might be of service—and he did not immediately grasp the significance of the role they played. After he escorted the elders to the door, one of his Liberian staff members pulled him aside: That was the National Traditional Leadership Council, the staffer explained. It was the equivalent to the traditional government what a president’s cabinet is to a formal government. They needed those leaders on their side if Global Communities was going to have any chance of introducing itself to communities in the southeast.

  DeVries called Kawa back to ask for help. They would need to break down the barriers between traditional government and the federal government, they agreed, to coordinate supplies and help to these new communities just now being introduced to Ebola. The National Traditional Leadership Council helped set up partnerships with local county health offices. The tribal leaders would introduce the health-care workers to village elders, giving them an important endorsement as the health-care workers brought with them the foreign concept of burial teams.

  So Global Communities started over. Led by another veteran of the IWASH program, Tamba Boima, the group and its partners from the council and county health offices held community meetings across River Cess and Sinoe Counties to introduce Ebola, to give a name to the deadly virus stalking their villages, and to lay the groundwork for burial teams. Between August and December, Boima and his colleagues met with more than 15,000 community leaders in the two counties.

  Soon, the first ambulances arrived, as Boima had promised. Community leaders got the message: the capital cared about them, and help was on the way. Traditional leaders asked their fellow tribesmen to end bush schools, those secret societies that performed rituals like circumcision—potent havens for transmission.

  Back in Monrovia, another Global Communities staffer was having trouble with the outbreak. Before Ebola, Freeman Kamara, the group’s Liberian accountant, was used to a desk job, where he kept the books and made sure the environmental health technicians got paid. But once the outbreak began, and especially after USAID asked Global Communities to expand its burial team practice so rapidly, he was pressed into a different kind of service.

  There are few working ATMs in Liberia. Outside Monrovia, there are hardly any. While the Western world has moved on to credit cards and electronic payments, West Africa still runs on cash. Someone had to pay the hundreds of new employees on the Global Communities payroll, and that job often fell to Kamara. He was frequently dispatched from the safety of his desk to the rural, remote roads in a jeep laden with $50,000 or $100,000 in cash, money stuffed into backpacks or hidden in secret compartments in the floor.

  Because of the remoteness of the burial teams who worked for Global Communities, Kamara often found himself on long walks through the jungle, or on canoe trips up long rivers. He couldn’t swim; after deVries posted a photo of Kamara on the group’s Facebook page describing their often-treacherous treks, Global Communities was inundated by offers to send Freeman a life jacket.

  As the rainy season ended, public health officials in Washington and Geneva watched as the instances of postmortem transmission in rural counties where burial teams were operating plateaued, and then tailed off. It was hard to escape the conclusion that a solution—not a silver bullet, but a long-term solution—was at hand. A total of twenty-seven Global Communities–run ambulances ended up stationed in key sectors around Liberia.

  “The number one driver of transmission reduction were the burial teams,” said Rajiv Shah, who headed USAID during the outbreak. “The Global Communities people single-handedly did more to solve Ebola in Liberia than any other partner on the planet, including all the doctors put together.”

  “They understood how to go into those communities without terrifying people and being generally respectful at a community burial, which, you know, had very ingrained social practices that you’re trying to change in a rapid form,” Shah said. There were times when ambulances funded by USAID and run by Global Communities burial teams showed up near villages before Ebola did.

  But in Washington, one of Shah’s closest advisers, Jeremy Konyndyk, was puzzling over some troubling data. Health officials led by the British military were operating burial teams in Sierra Leone, with only a fraction of the success they found in Liberia. In Liberia, burial teams arrived at a home to find an Ebola victim untouched; in Sierra Leone, they often found bodies lying serenely on a bed, washed, cleaned, and dressed—which negated the point of burial teams meant to limit contact between the deceased and those who could become the virus’s next generation of victims.

  Health officials came up with two main theories for the discrepancy. On one hand, those who set up burial teams in Liberia were
well-known to and trusted by a local community. Aside from World Vision, those who set up burial teams in Sierra Leone and later in Guinea were usually the military or foreign organizations, both groups that generated their share of skepticism in villages where burial teams were most urgently needed. The second theory was that most rural villages in Sierra Leone were Muslim communities, where religious tradition demanded a stricter set of burial practices.

  While Freeman Kamara bounced and bumped his way along rural roads to pay Global Communities workers, emergency health professionals in other parts of West Africa were not being paid. On November 25, a burial team based at the hospital in Kenema, Sierra Leone, dumped three bodies—two adults and a child, all victims of Ebola—in front of the hospital’s gates, to protest the lack of pay. The twenty-three members of the burial team were owed €100 a week, or about $115, in hazard pay. They had seen no money for two months. (After the entire team was fired, some members continued working for tips.)5

  The problem of unpaid workers extended far beyond Kenema, more evidence of a woefully inadequate health-care system in a nation rife with corruption. Before the central government could issue payments, it had to build a list of its actual employees. When the World Bank stepped in to ensure that hazard payments would get to emergency workers, they found corruption on a massive scale. Some Ministry of Health officials had created dozens of false names to which paychecks were being issued. Others had put relatives on the employment rolls for no-show jobs and pocketed their pay.

  As late as November, the government was handing out cash to its employees. By December, they had set up a direct deposit system, managed by a small team representing the United Nations Development Programme based in Freetown, either to bank accounts or to cell phone accounts, in a country where many people still did not use Western banking systems. Officials from the UN had to sign off on payrolls before anyone got a check, to stem corruption. Soon, 23,000 nurses were paid a total of €21 million through the system.