By, Tim Cunningham, MS, DrPH 16’ in the Department of Population and Family Health
It’s been nine weeks since Tim Cunningham, a doctoral student it the Department of Population and Family Health, has returned from Sierra Leone where he fought the Ebola outbreak. He has agreed to have this post, originally written for the Program on Forced Migration and Health, to be reposted here as a reminder of the devastation West Africa is currently experiencing from the Ebola virus and their need for improved health systems. All forthcoming names have been changed in respect to privacy.
Fires slowly rip through fields desecrating the lowest brush. They singe the branches of the mango trees closest to the ground, creating swaths of smoldering ash following the direction of the wind. Every day, a new fire leaps from field to field. Then, it seems like in no time bright green sprouts with small leaves proliferate the scorched earth, moving everything from black and grey to green.
We turn off of the main road that heads towards Freetown, an unmarked road, like most. Patchy and full of holes with a subtle downhill gradient, just enough that in front of us opens a horizon humid and hazed with palm trees as far as we can see. Immediately to our right and left hardy undergrowth flanks the trail springing from the new ash. The road is red.
About one half of a mile down there is a tin shelter, perhaps eight feet by eight feet with an upward tilting roof that opens onto a cleared field, not black like most burned land, but red, clay, full of gravel and large stones. Beyond the field, facing this shelter is another structure, a skeleton of wood decorated with laundry drying in the sun. Around it, 28 young men stand, talking quietly.
We have arrived at the Port Loko New Cemetery. Today it is rudaceous with 522 mounds and 10 or 20 open pits, deep rectangular graves. In front of many of the mounds sits a wooden post with a black crosspiece plank. Written black white paint: A name or the title, unknown, and age or blank space, the name of the village where the expired person was found, and a site number.
Mr. Sesay has invited us to come to his work place. He built the tin structure as a viewing area in which family members can stand at a safe distance to watch their loved ones be laid to rest with distant dignity. At death, the body is most contagious with Ebola, and yet, in this place, funeral rites for time immemorial, have consisted of caring for, cleaning, and closely honoring the decedent. Mr. Sesay and his team of 28 gravediggers and burial teams try to bridge the gap between culture and contagion.
He claims he was the first man in Port Loko District to wear Personal Protective Equipment (PPE) when this epidemic was first named. His corps of young men, some ex-soldiers, most previously jobless, all strong, freely volunteered to do this work. The first person they placed in the ground was a police officer. His body lies at Site 1. His maker reads unknown. His body is buried at the base of the roots for a large mango tree.
When we, four nurses from the Maforki Ebola Treatment Unit, exit our vehicles to step on this sacred land, Mr. Sesay and the gravediggers quickly approach us saying we are welcome, but with a measured tone that another agenda is in place. Mr. Sesay encourages us to take photographs, as do the gravediggers. “That way people can know,” he says.
A gravedigger then speaks up from the crowd, “You are free to walk wherever you like. We need to speak with you when you are done.”
Mr. Sesay asks, “So, who are you here for?”
We don’t respond. We may be here for ourselves.
Since December 25th more than 100 patients have died in our facility, most from Ebola.
One of our nurses asks to see the site where a patient named Hawa lies. She was 8 years old and this particular nurse helped admit her when she cried out to her headman, “Mr. Bangura! I will die! I will die!” He comforted her, speaking her own language, Temne, calmed her and daily brought her treats during her rapid decline. He had planned to set up financial support for her to get her through school when she was discharged. Hawa, like many of our pediatric patients stole our hearts with her ferocity, her constant attempts to pull out her IV cannulas, her refusal to drink and eat when we told her, but her love to eat when we turned our backs. Even as she grew sicker, she still fought us with what strength she had, comforted only by a nurse named Cheedy, whom she trusted the most.
When Cheedy asks to see where she is, Mr. Sesay pulls out a meticulous document, a matrix of names, dates and site numbers and took us directly to her home in the earth. Then names flood our minds and we walk the coarse stone graveyard, each name provoking vivid memories covering the spectrum from joy and laughter to loss and a gnawing feeling of failure.
We visit Hassan next, a boy who was just past his first birthday when he died. He had days of looking like he could die at any minute and then his last day was his best. He was beginning to recover, we thought. He looked better, stronger, his skin took on a healthy tone and then the next day he stopped breathing in his father’s arms. We have seen this trajectory with children before. They look horrible and we fight to resuscitate them, they take a turn for the better, they eat, sit up and play. They have their best day, and then it is their last.
Hassan’s gravesite is mammoth compared to the size of his body. All graves are uniform in length, depth and width. This one-year old fought like a grown man, like an adult, he fought like the strongest we’ve seen. His fight fills this grown man’s grave.
More visits, more sites, a sea of names. We walk for I don’t know how long.
The cadre of gravediggers approaches us again. Perhaps we have spent enough time in near silence. A mass of burly young men present their spokesperson, Ali. He appears younger than the others and is energetic. Ali speaks like a politician, vehement and focused. His speech sounds well-rehearsed.
There is a discourse that I have heard at the ETU and in all of the communities I have visited in the Port Loko and Kambia districts. It has shifted from, “How do we contain this disease and end Ebola?” to “What will we do now?”
Ali speaks about how he and his colleagues came to this work, one of the most important fronts in the fight against Ebola. They are jobless, but want to serve their country. They have all experienced the war that ravaged their homeland, a visible war confused by enemies, politics and power, and now they see themselves at the front line of an unseen war with a known enemy that is unquestionably evil. And they are afraid.
Ali describes how NGOs came after the visible war and provided work and assistance rebuilding. He talks about how, over time, the NGOs left and then there were no more jobs. He and his compatriots are concerned that once the Ebola war is over, NGOs will again leave and then leave an all too familiar swath of joblessness.
“Will you all leave us again?” he asks. “Who will remain and help when you are gone?”
Ali’s team is proud of the work they have done. They no longer have to volunteer as they have been hired by a large NGO and have been given tools to provide safe and dignified burials. Through their work, this disease is closer to being contained. He rallies his group at the end of his speech with words of hopefulness and ideas, of rebuilding his country, springing forth from the damaged earth. He asks again what we could do to help. We respond as best we can, that we don’t know what the future will bring.
Tearfully, we thank him for his work caring for the patients we loved. We also commit to him that we will share his story: the story of the gravediggers. Their bravery, their commitment to their country, and their dedication to rebuild after this second war. Ali is happy and thanks us. He and his team pose for a photograph, explicitly asking us to share it with their story.
We are ready to leave. Mr. Sesay asks again that we share photos and stories of the graveyard.
The four of us walk back to our car parked on the opposite diagonal of this field. We walk from site 1 to site 522, each taking a different line of the grid in order to walk alone and have one last goodbye.
As if my path was predetermined, I glance at a marker while exiting the space and see the name of the first child who died in our hands, Issa. He had a good death–good in that his body was clean. He wore the most colorful lappas as bed sheets, and he was not alone. He had been sick for days. When we found him while doing our morning rounds, he lay in his own bodily fluids, with agonal respirations.
We cleaned him, lifted him to a bed, and rolled him in a position where his breathing seemed a bit less painful. He shortly succumbed to the virus. He was 9 years old.
At the foot of his grave, amidst this field of rubble, is a tall green sprout. It stands just a foot high off the ground with stalwart blades that will soon become leaves. It had pushed its way through the dry stone with little water and in spite of the pounding sun.
Clinics and hospitals are slowly reopening here, schools as well. The need is great: for health care workers, for teachers, for community servants able to make this place fertile again*. The fires are subsiding.
*As a post script, I feel that it is important to recognize that leading universities in the United States, including Columbia University, were reticent to allow any students to participate in the Ebola Response in West Africa. Schools of Global Health and Public Health should be at the forefront and on the frontlines of such global catastrophes. A more supported response from American institutions could have more rapidly controlled this epidemic and understand the impact it would have on the area. More lives could have been saved.