Remnants of Ebola: Contemporary Repercussions at a Former Centre of the Outbreak, by Anita Schroven (2017)

Field notes
from Kailahun and Kpemalu.

The road network in Sierra Leone has much improved in recent years, especially since the first time I travelled to the Eastern Province in 2004. Today, the tarmac ends in Pendembu, a town 17 miles from the district headquarter town of Kailahun. The district is the most eastern part of Sierra Leone and parts are nearly surrounded by Guinea on the North and West and by Liberia to the East and South. After early rains before the usual start of the rainy season, this road that connects the three countries can only be managed by okadas, as motorbikes are called here, or by strong four-wheel-drives.
The road to Kpemalu village is just as harsh, once the smooth surface roads of Kailahun town are left behind.

Former entrance to ETU, Kailahun

The site of the country’s first Ebola Treatment Unit (ETU) opened in June 2014 and was closed down 9 months later, with infections having stopped in the district and other ETUs having been built in other parts of the country where the outbreak had taken hold. Today, the site is only recognisable when you look carefully: the massive concrete floors are already giving way to the bush, to grass and small trees. At some places, big slabs of concrete floor are still visible; in others, they have been destroyed and broken into small pieces. No walls are left, no other markings of infrastructure except the mortuary, where the bodies of the dead were washed before burying them nearby. This concrete structure stands out as the only elevation in an area that is curiously flat in this otherwise rugged and hilly landscape.
A small staircase is visible behind dense grass on the roadside where ambulances offloaded the sick from all parts of the country, many dead after spending sometimes a whole day in a hot ambulance, rocked around on dirt tracks for hours to reach the first – and for some time the only – ETU in the country, before more ETUs were opened in Kenema and many other district headquarter towns across the Northern Province. Staff in Freetown hospitals have complained that they had to send Ebola patients here at the beginning of the outbreak, calling the ETU in the evening to enquire: ‘How many have survived the road?’ The answer was dreaded, as some days it would be only one, some days no one – of an ambulance carrying up to eight patients. Their drivers would not even stop to give water to the patients since they were told to drive as quickly as possible to reach the ETU at the very eastern fringe of the country.

We continue our way out of Kpemalu towards the Moa River – the border to Guinea and a potential entry point of the Ebola outbreak. A low wooden fence marks the burial ground of the ETU, an eerie place with younger bush than its surroundings, humming with the sound of insects. Only few grave signs are visible from the road. Entering, we find some graves elevated by concrete borders, headstones in the making. One such grave is of a councillor from Koindu, a border town to Guinea. The story of the councillor falling ill after himself trying to help sick persons in his constituency is reflected in many accounts of the Ebola Transition Centre (ETC) staff in Koindu, where the councillor was taken first, waiting for the results of the test, only to then be transferred to the ETU in Kpemalu. His speech to ‘his people’ is quoted by some as impressive, as forceful, taken even the breath of the Ebola team that came to pick him up. Having contracted Ebola himself asserted that the illness was real and that there was no political intent behind Ebola, just suffering, and that therefore people should use all precautions available to protect themselves. He is referenced as the person who persuaded people in this region to take matters into their hands and follow the advice the strangers were bringing to them. Before this incident, rumours provided different explanations for the mysterious deaths ravaging families: that politicians in the capital were preparing for future elections by diminishing voter numbers of this opposition stronghold, or that ‘white people’ were using the illness to remove blood and bodily organs for their own medical treatments.
The staff recall that people from Guinea and Liberia also came to the ETC in Koindu: ‘They were our family, they are our family. We marry them, they marry us, there is no difference. When they are sick, we have to help, and in the ETC we did not ask where they came from. It was hard for the surveillance teams though, to trace the families. Initially, they did not know whom to report to on the other side [of the border]. But we, we made no difference and we treated everyone.’

In the burial ground, most graves are small heaps of earth with a small white board indicating names, ages, admission numbers, dates of death, and chiefdoms of origin. Not just people from the Eastern Province are buried here, but some from the Northern and Southern Provinces, too, since for the main part of 2014 this was Sierra Leone’s only ETU. We find no graves indicating Ebola victims from the neighbouring countries, even though people remember Guinean and Liberian family or friends arriving at the ETU and never leaving it alive. Most of the readable signs that have been placed in lieu of headstones indicate the time span of deaths between August and November 2014; these signs also inform on the age of the deceased, from the age of ‘baby’ to ‘adult’. Some signs are missing information, some grave mounds are entirely unmarked. There is a weathered signpost requesting to ‘stop burial here’. Members of the local burial team say that there may in fact be mass graves here as with the increasing death toll the ETU became unable to cope with individual burials. This is difficult to confirm since many of the staff has left and local residents were not given much information about what was going on. The running of the ETU was the business of the ‘white doctors’ who came with the NGOs and who would not explain procedures and strategies to the locally recruited staff that helped construct and maintain the ETU throughout its working period. The international staff would drive past them on their way to work and when returning to their hotels at the end of their shift, without, however, meeting and communicating with the villagers.

Rumours abound that villagers came to pillage the remnants of the ETU due to poverty – while the ETU was supposed to remain as a memorial to the disease, to the dead and the workers who risked their lives to fight the outbreak. In order to prevent Ebola or indeed any other sickness to be transferred through the remains, they were burnt and levelled by the authorities – or so the story goes. When talking to the villagers, they tell a different story, of fear of the site, fear of touching anything in case the disease still lingered. They tell of a recent NGO visit that informed them that the site was safe. Elders enquired whether they could farm the land again, and the NGO said they would enquire; as they were no medical doctors they could not answer that question. The farmers continue to await the answer, while the dry season is beginning and with it the period of brushing the land to prepare the new fields for the next rainy season that is to start in June.
Such information gaps are remarkable and yet common in many other aspects surrounding Ebola and the public health response it engendered.

Kailahun ETU Burrial ground limit

In our conversations, regret is audible. In June 2014, elders from Kailahun went to the nearby village of Danbara to ask for land in order to establish the ETU which was to serve the area. Danbara refused, stating that no land was available. Then the elders asked for land in Kpemalu where their request was granted. After the camp was closed down early 2015, people here learnt that there had been payments for the land’s use as well as its potential contamination. International organisations are supposed to have paid to compensate the village for its loss of farmland. But this rumoured money never made it Kpemalu. Not even the well that – according to local rumours – had been dug for the ETU can be used today as no one can find its trace any more:
‘It is wasted over there, while we are struggling for potable water!’ The jobs created in connection with the establishment of the ETU were rarely given to local villagers who had hoped to receive employment in exchange for granting the use of their land; only few were recruited for day labour in brushing the land or as carpenters building and extending the site as the outbreak took hold and more clinical capacities were needed. Most staff was recruited from elsewhere. Little or no information was given to local residents about what happened in the camp, who was being treated and how. They were given the same advice as all Sierra Leoneans and indeed all people in the region – to refrain from eating bush meat and from eating fruit that had been tasted by bats or other animals, to not touch each other and to report strangers in order not to contract the disease from the traveller. Those few local individuals working in the camp were no better source of information either, since they were not provided with information beyond those concerning the security measures applied in their specific work areas. Once infection numbers were declining, the few who worked for the ETU lost their jobs and at the same time were told not to move, not to go to the farm and not to trade in order to protect communities against infection. Having lost their source of income, they could not feed their families and had to spend their savings in the course of the following years 2015 and 2016, when the national economic slump hit them with high fuel prices[1] and, hence, increased prices for any and all goods travelling by road all the way from Freetown or Conakry – which today includes rice, the staple food in the region.
Today, many go hungry. This cannot be explained by the dry season’s onset alone:
‘We are farmers, we know what we are doing. During the outbreak we were told to stay put, we could not farm, we could not harvest. But we had stock left in our barns, so we could eat [2015]. But then we were not allowed to farm so we used up much of our seeds, and 2016 was a bad harvest. The season was late and when finally the rain came it was too strong. So we lost much of our crop. Now we go hungry, our children go hungry. Prices are so high now, there are stocks in the town, the traders have rice. But one bag [25kg] is 105.000 Leones, we cannot pay that.’
Evaluating the situation, Philip, a retired teacher and native of Kpemalu, points out that the situation after Ebola is worse than after the Sierra Leonean civil war that started in this area in 1991 and ended again in this area in 2002. There had been food then, and farming had been possible in the bush or across the border, in Guinea, where many migrated to and from during the war. Now, there was nothing left to fall back on. The villages in the region are suffering from crop theft, with yams and other roots being stolen directly from the field in the course of the night. He can’t even feel bad about the local thugs involved:
‘What are they to do? They need to feed their family and there are no jobs. Money is so hard to come by today – despite all the promises we were given during Ebola, that the government would create jobs, would compensate us for our sacrifice. If someone goes to work a whole day, he gets 5000 Leones, what can you do with that? A whole day of work? Even transport will eat his pay. But we need to feed our family, too. The war was bad, but after the war we could at least eat. Ebola times were worse, you cannot see who has the illness; you don’t know how to protect yourself or your family. And now, after Ebola has left, we are worse off than after the war.’
His friend Sate cuts in:
‘We are worse off than after the war, no one comes to give us help, to give us work or food. This was different after the war, there were so many opportunities to find some money, today there is nothing.’
While it is difficult to imagine that of the vast international Ebola-budgets[2] nothing was arriving in this part of the most-affected region, these statements ring true. The number of road-side NGO signs that attest to former or current so-called ‘development projects’ is indeed lower than along the main highway that cuts across the country from Freetown to the East. Concrete numbers are hard to come by, since there is no central project registry on district, province or national level. It is, however, this development industry that is the source of the much of this ‘victim language’ that can be heard today. The vocabulary is informed exactly by the post-war invasion of NGOs, bringing projects for specific groups of war-affected persons or communities, while side-lining those who do not fit the prescribed categories of victimhood.
Due to the remoteness, the disastrous road conditions and the fact that Kailahun was indeed affected most in the early stages of the Ebola outbreak, few NGO activities arrived in Kailahun during the outbreak or today – and little reached beyond the town itself:
‘We were sent food twice from the government during the outbreak, but it was not enough, even for one week. All the rest of the time we had to use up our stocks. We did that, thinking we would get assistance just like after the war, from NGOs or the government, but nothing like that happens now. We are left alone, after we were given so many promises. After the war, there were no promises, there was just hard work, getting back home and working our farms and making a living. Now there were promises, but hardly any were kept. We are not informed; we are not given all the information [about payments, NGO projects, government funding that is supposed to benefit the ETU hosting communities]. So they can lie to us… Expecting help and not getting it is worse than knowing we have to struggle for ourselves.’

Continuing our way to the Moa River we meet Paul, who has been a border officer for years. He has been interviewed as least five times during and after Ebola had come to the area. He recalls friends phoning him from Freetown after they saw him on DSTV giving an interview on topics of border and mobility management during the outbreak. This reflects the media attention Kailahun district suddenly received in 2014, bringing it to the centre of the country’s attention after more than a decade of relative silence on the tri-border area. During the Sierra Leone civil war (1991-2002) and the wars in neighbouring Liberia (1989-97 and 1999-2003) this area had been featured in the national media as a rebel stronghold and known for intense refugee movements – and in the course of 2014, again bad news were coming from this remote part of the country.
These days, cross-border mobility is picking up again. On a busy day, there are more than 50 people crossing to and from Guinea, on a slow day maybe ten:
‘We are family, we have our parents on both sides of the river, our farms on both sides of the river. For us this river does not separate but connects…we have a memorandum of understanding for both sides. We do not harass our family on both sides, only when strangers come to cross the border do we check their papers, their luggage.’

Moa River Border Crossing.jpeg

Currently, mainly groundnuts are brought into Sierra Leone, while cassava and cola are brought over to Guinea:

‘They have more use for it than we do. They make country cloth over there, all kinds of things that we just buy here.’ I ask about the price for rice and fuel and whether the latter are traded across the river and, thereby, the border: ‘Not really that much. We here are at the end of all the countries, so prices are much higher than in the capitals. Prices in fact end up being very similar, so currently it does not make sense to trade. Before, when fuel subsidies were still there in Sierra Leone, we sometimes saw barrels crossing the river, but now, since the subsidies are gone, it is not worth the trouble.’

During the outbreak, this border crossing was closed, just as many others, but there were still possibilities for people to move across:
‘We cannot control everywhere; we cannot stop people from moving to their farms, to their families.’ After the outbreak was contained in Kailahun after 9 months, the border points were re-opened, with IOM putting up structures to check travellers’ health. IOM’s staff left in January 2017, the structures remain:
‘It is good tarpaulin, better than what we had before. So we keep it.’
There is not much official border traffic to be processed at this crossing. The neighbouring town of Yenga has better road connections – but border control is tighter there, especially when tensions are rising again between Sierra Leone and Guinea. For decades, the exact border line in this area has been disputed and when diamonds were found in Yenga, the Guinean army stationed itself there to finally claim it for themselves:
‘When the [Yenga border] guards tax people too much, bother people too much when they cross the border, people come here to cross, it is harder for transport but easier for bureaucracy to cross here […] This is where the pulse is for the relationship between Guinea and Sierra Leone. But that does not concern us, the people who live here, we are family. The government business is separate and long removed from us – except when both Sierra Leone and Guinea want to tax people, like they do in Yenga, that is just too much.’

Comments such as these highlight the delicate lines which people in this tri-border area have to tread: keenly aware of the differences in their governments and of their own centuries-old intricately linked family and trading ties that span across these borders. They experienced wars together, fled the fighting and shared resources to cope. Ebola closed down some of the border points, hindered some of the solidarity that is based on mobility and resource sharing – but did not stop the strong ties between these people.

[1] 1liter of petrol costs 6000 Leones in Freetown and 12.000 Leone on 5. March in Kailahun due to a shortage: the fuel truck got stuck in Kenema. During the rainy season, the truck cannot reach Kailahun, so it stops in Pendembu, petrol will then be manually pumped into barrels, which can cross the 17mile stretch to Kailahun – keeping fuel prices higher than in the rest of the country.

[2] The Centre for Disease Control and Prevention (CDC) calculates the cost of the Ebola Response until end 2015 at US$ 3.8bil [https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/cost-of-ebola.html], a figure mirrored by World Bank and other agencies.

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