The Ebola Web

Columbians race to stop an epidemic.

by Paul Hond Published Winter 2014-15
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Wafaa El-Sadr and Susan Strasser / Portraits by Jörg MeyerIt’s malaria, she says. It’s just malaria.

A common enough malady, but you can’t distinguish it without a blood test. The woman’s husband, who was sick with Ebola but has since recovered, is with her at the house. The woman refuses to go to the nearby holding center, where sick people can be isolated, tested for Ebola, and given Tylenol and oral-rehydration salts. Holding centers have a reputation as grim, death-filled places.

The contact tracer speaks with Redd, who then addresses the woman, again from an abnormal distance. He tells her that it’s in her best interest, and in the community’s best interest, for her to go to the holding center. Finally she agrees to go.

Then the other contact tracer says that he, too, is feeling sick. I want to go to the holding center as well.

Many of the complications of the epidemic are on view this day, in this village. El-Sadr and Strasser, standing in the tropical heat, take note of all they see.


"Don't bury the dead. Don't touch the sick."

Broadcasting from high atop Leicester Peak, above the green hills and corrugated tin rooftops of Freetown as it rambles down to the sea, it’s Star Radio 103.5, live on the air. “Wash your hands. Simple hygienic techniques will get rid of Ebola. People are still washing bodies and inviting people into quarantined homes. If this continues, the Ebola still stay.” On this Sunday in November, as cases in Sierra Leone soar past six thousand, with 1,500 deaths, some Sierra Leonean journalists are in the studio, discussing the epidemic. “We can stop Ebola only if we change our attitudes,” one man says. Another laments how Sierra Leone is portrayed by outsiders. “The international media look for the negativity when it comes to Africa — war, poverty, pestilence. Not everyone is dying in Sierra Leone. People fear the virus because of what they hear in the media. You and I sitting here have nothing to fear from the virus.” Rather, he says, it’s in the remote villages and the slums that “Ebola caught us pants down.”

The same weekend, another voice is heard on Star Radio. Adeyinka “Yinka” Akinsulure-Smith ’97TC, a psychologist and associate professor at City College of New York, joins a conversation via Skype. Akinsulure-Smith was born in Sierra Leone and speaks Krio, an English-based creole that is the lingua franca of the former British colony. Her parents taught at a university in the south, and she grew up 120 miles from Freetown. After high school, she lived in England, Canada, and the US. She has been going back to Sierra Leone ever since.

HOST: Dr. Yinka, people go through things. Some people cry. They cry a lot. What would you say to such people?


DR. YINKA: I would say, “You are not alone; others are going through it, too. Yes, cry a little, but understand that you are not alone. Others have similar problems. Reach out, call people on the phone. Don’t isolate yourself.”

Akinsulure-Smith has long been a voice for Sierra Leoneans. When asylum seekers from Sierra Leone’s civil war (1991-2002) began arriving in New York, she cofounded an organization called Nah We Yone, which in Krio means “It Belongs to Us.” The group helped people, some of whom had been maimed by diamond-funded rebels, find psychosocial and legal services and apply for asylum. Soon, Nah We Yone, assisted by students at Columbia’s School of Social Work, extended its outreach to the Sierra Leonean diaspora.

The war destroyed much of Sierra Leone’s infrastructure and killed seventy thousand people in a country of less than five million. Still, as time passed, things began to improve. Schools reopened, expatriates returned. People were regaining their foot-hold. Then, last spring, Ebola came.

The new crisis, piled atop the old one, spelled catastrophe. Many people didn’t believe the virus existed. Others attributed it to bad witchcraft or foreign plots. The virus spread, and so did fear. Bodies were being dumped because people didn’t want others to know that someone in their family had Ebola.

“During the war, we knew where to go and whom to avoid,” says Akinsulure-Smith. “Ebola creates a whole other element of avoiding people. Families have been divided. Children are sick and dying, but you can’t touch them. I’m a mother. I have two kids. I cannot fathom seeing my kids in distress and not being able to hug, stroke, caress, or comfort them.”

Thousands of children have lost one or both parents, causing further social shocks. Children are traumatized by loss, separation, the suffering of family members, the terror of strangers in hazmat suits taking loved ones away, the lack of support services, and a pernicious social stigma.

Akinsulure-Smith is involved with a group of psychologists and psychiatrists in the US and Europe called the Sierra Leone Mental Health Initiative, which studies the country’s postwar mental-health needs. When Ebola struck, the group wondered how it could help from afar — how could it reach the wider population, give people a place to talk about their experiences, their emotions?

Because Sierra Leone has low literacy rates and scant Internet access, most people get their information by radio. And so the group decided to produce a radio show: four hour-long segments on the independent Star Radio. Akinsulure-Smith could call in, and people throughout the country could listen.

DR. YINKA: We’ve been talking about adults, but children also can have these mental-health challenges, these stressors. We have to remember that their reactions, the way they feel, the way they behave, can be different from adults. So we have to adjust for them, too. Crying, nightmares, regressive behaviors — it’s not that they are choosing to behave badly. You can’t just beat them.

Recently, the Christian development organization CBM trained twenty-one psychiatric nurses to help the public cope with the myriad mental-health problems caused by the epidemic. Now, Akinsulure-Smith is looking into another use for telecommunication: the long-distance supervision of these nurses.

“Unfortunately,” she says, “one of the nurses just died of Ebola.”

“I cannot fathom seeing my kids in distress and not being able to hug, stroke, caress, or comfort them.”

GUINEA - The outbreak began in December 2013 in a village in Gueckedou, in southern Guinea, near the border of Liberia and Sierra Leone. Months later, investigators traced the source of the epidemic to a two-year-old boy named Emile. It appeared that Emile had contact with a fruit bat, the animal widely thought to be the virus’s natural host. After four days of fever, vomiting, and bloody diarrhea, Emile died. Then his sister got sick and died, then his mother, then his grandmother. The bodily secretions of Ebola victims are most infectious at the time of death, and anyone handling a body for burial is at risk of catching the virus. This is what seems to have happened in Gueckedou.

By April, eighty people had died in Guinea, and the virus had gotten into the capital, Conakry, a city of 1.7 million — a grave event, as previous Ebola outbreaks had been confined to sparsely populated areas. Picture, then, the branching patterns of transmission, the points and lines multiplying and crisscrossing, going from village to town to city to village, in a widening meshwork of out-of-control contagion. Flung into this web is the contact tracer, who must follow the lines, untangle them, and cut them off. The obstacles are dizzying: huge geographic expanses, bad roads, poor infrastructure, meager resources, and, among the populace, a fierce distrust of foreigners.

Anne Liu came to Guinea with a plan. Liu is the lead manager of the community-health worker program of the Millennium Villages Project at Columbia’s Earth Institute, where she sets up health systems for maternal and child health. Now she and her team (five from Columbia, two in Guinea) are building a system to help stop an epidemic of global range, using a technology that is commonplace in much of the world: smartphones. “Our goal is to prevent further transmission by being able to track the entire chain of response once you identify an Ebola case,” Liu says. “We’d be able to see if there were any gaps.”

The chain of response is this: contact identification, contact tracing, diagnosis (lab results), treatment (outcomes at the tent-based Ebola treatment units, or ETUs), burials (safe or unsafe?), and community awareness. The phones would allow all the partners — contact tracers, doctors, lab technicians, NGOs, and the government — to share data instantly in a region where it can take days just to transport a blood sample to the nearest lab. If the enemy is time, the weapon is speed.

“To catch up with and beat Ebola, we need to substantially scale up our response,” the Guinean president Alpha M. Conde announced on September 18. Conde had been having discussions with Jeffrey Sachs, the Earth Institute’s director. “The immediate deployment of community-health workers,” Conde stated, “trained and equipped through an initiative of professor Jeffrey Sachs from Columbia University, will accelerate and strengthen our national response to Ebola, as well as structure a response at the level of our local communities.”

A month later, Liu is in Conakry, meeting with UN agencies and NGOs in the lobbies of the two hotels where everyone is working and, disappointingly at such a critical hour, squabbling. Liu’s objective is cohesion: to turn a slow paper-based system into a nimble digital one, in which everyone in the response chain can send, receive, and access information in real time. The plan calls for two thousand smartphones for two thousand contact tracers, and another five hundred smartphones for workers in labs, treatment centers, and government and nongovernment agencies.

Ericsson has donated a thousand phones. The phones use the mobile medical-software program CommCare, created by the company Dimagi, which is working with the Earth Institute on customizations for the contact-tracing protocols of this epidemic. Users will need Edge, 3G, or Wi-Fi to submit data. If they’re out of network, the program saves the data, then sends it when they reach a network. Meanwhile, the UN Emergency Telecommunications Cluster (a group of organizations that works to coordinate communications during humanitarian crises) and companies like Facebook are looking to expand Internet connectivity in Guinea’s forested region.

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