Ebola diaries: Crossing the border, Ebola enters Sierra Leone

Ngoy Nsenga

As the WHO emergency focal point for West Africa, whenever there is an emergency in the region, Dr Ngoy Nsenga is one of the first to be deployed. Following confirmation of Ebola cases in Guinea, Dr Nsenga went to Sierra Leone to help assess emergency response capacity. During his trip, the first signs of Ebola crossing the border were detected. Originally from DRC, Dr Nsenga quickly realized that the few cases in Kailahun could quickly become a serious health emergency.

WHO and partners  on Ebola awareness campaign, Freetown, Sierra Leone
WHO/Nyka Alexander

"I think Sierra Leone had known something was going on around March 2014, the beginning of the outbreak in Guinea, but they didn’t have any cases. So at the beginning, people didn’t really pay much attention to what was going on. In Sierra Leone, they have always had Lassa fever, so when people got sick, they didn’t think about Ebola. They were so used to Lassa fever, it couldn’t be anything else. It only became serious when the first Ebola cases were reported in Guinea near their border. It was only then that they started to pay attention.

We also have to admit that the surveillance system also was handicapped because at that time in Sierra Leone, not many healthcare workers, including surveillance officers, were very familiar with the case definition for Ebola. No one was really used to the disease, especially since some of the symptoms are very similar to Lassa fever and malaria. So they definitely must have missed some of the cases, that’s for sure.

Crossing the border – the Ebola virus moves from Guekedou in Guinea, to Kailahun in Sierra Leone

Being the WHO emergency focal point for West Africa, I was sent to Sierra Leone to assess how well the WHO country office was prepared to respond to any outbreak or emergency. While there, I went to Kailahun, the first area in Sierra Leone that reported confirmed Ebola cases. I had to see for myself how well-prepared the district was to respond to this kind of outbreak.

When I got there, it was one big surprise for me. At the national level, you could see that people were trying to organize a response, even though it was rather limited. But at the district level, I was so surprised. There was almost no one, except for the district medical officer and a few staff. There was no one from the national level and hardly any partners. There was a real disconnect between the national and district level.

One of the few partners working in the area was Tulane University. They were working on Lassa fever in neighbouring Kenema district. They converted themselves to work on Ebola, but that was about it. The districts were not really supported.

Ngoy Nsenga, WHO emergency specialist, was deployed to Sierra Leone to help assess Ebola response capacity.
Ngoy Nsenga, WHO emergency specialist, deployed to Sierra Leone to assess Ebola response capacity.
WHO/P. Desloovere

Sierra Leone urgently needed international support

Once I was back in Freetown, I made a request for more WHO staff be deployed. With two fellow colleagues, we revised the organogram for the WHO country office. I realized that if we did not act soon, the situation would get out of control. Being from the Democratic Republic of Congo, I know very well what Ebola is and how to prevent it. One of the missing elements was strong leadership at national level, someone to take the lead on the response. Furthermore, Sierra Leone has few human resources for health, so they needed international support from the outside. It was impossible for them to do it on their own.

I advocated that more WHO colleagues, be it from the technical or higher level, come see the situation in Sierra Leone for themselves. Even though my report gave many details, you still cannot really feel what the situation is like on the ground if you are not physically there. I remember very well that at the time, I asked for 6 epidemiologists. If you compare it with the hundreds of epidemiologists we have currently on the ground, it was a drop in the ocean.

This Ebola outbreak affected me personally

Another reason why we had to quickly respond was that on the other side of the border, in Guinea, there was already resistance from the community. That community resistance was also moving towards Sierra Leone. When I was in Kailahun, the doctor of the hospital said openly, “The community is threatening us. They accuse us of bringing Ebola.” The community even started to call him Dr Ebola, because they thought he was the one spreading the disease. That was a serious issue. Everyone stopped going to the hospital, even patients who had conditions other than Ebola.

If I compare this experience with other emergencies I have been involved in, this one has been by far the most challenging one for me when it comes to being personally affected. I know very well some of the healthcare workers who were at the frontline of this Ebola response. One day you would discuss with some issues with them, only to hear the following day that the doctor or nurse you spoke with had developed Ebola symptoms, and then, that they died few days later. It makes you very sad. You cannot avoid being affected emotionally.

"In any emergency, including outbreak response, the healthcare system should be ready to be able to respond. If a healthcare system is not strong and ready to respond, this is a serious threat."

Ngoy Nsenga, WHO

Ebola has taught us a lesson

As WHO, we have learned a lot from this outbreak. As I was telling a friend of mine, Ebola has been a cruel teacher. It gave us a serious test and now it’s up to us to learn the lessons. It taught not only WHO a lesson, but everyone, including policy makers.

In any emergency, including outbreak response, the healthcare system should be ready to be able to respond. If a healthcare system is not strong and ready to respond, this is a serious threat.

The second lesson is that, in an emergency response, we need to work together with the community. And by “we”, I mean all partners, including WHO, NGOs and government. We need to work together with communities. We need to build on community trust, even before an emergency happens.

We have seen it clearly during this outbreak. Going around the community to end the outbreak is impossible. We have to listen to communities, understand their issues and build trust with them, instead of telling them what to do.

We also need to rethink our surveillance system in the African context. Risk analysis should be part of our surveillance systems. Taking into account system vulnerabilities and capacity is crucial, in addition to the “all hazards” approach of disaster risk management for health.

Lastly, one thing we cannot forget is that our national colleagues in the country offices have been there since the beginning of this epidemic. These people, I really admire them. All of these colleagues did not have a chance to rest. We should not forget their efforts."