In a secondary school classroom in Mafaray town, about 10km from Sierra Leone's border with Guinea, 12 men and women in matching white T-shirts sit behind wooden desks, as the hot sun bears down outside and baby chickens scuttle in and out of the open doors.
A trainer asks the group to list all the Ebola symptoms they can think of.
“They cough serious, they vomit, they sneeze,” says one man.
“Your eyes become so red and you are weak,” adds a woman.
“When you have Ebola you bleed through the nose.”
“You get high fever.”
“Serious headache”
“Difficulty breathing.”
“No, that is corona, not Ebola,” the trainer interrupts the last speaker.
This session was organised by Irish charity Goal, as part of a scheme in which nearly 200 people will be trained as "community mobilisers" across 70 border areas. It is one attempt at preparing for potential impending Ebola cases. The latest outbreak was declared in neighbouring Guinea, in mid-February.
So far, just 23 cases have been reported, 16 of them confirmed by testing. Twelve people have died, five of whom were confirmed cases and the rest probable, but concerns are mounting over others that may not have been traced.
One Ebola patient fled hospital, while Guinean officials told Reuters that locals had barricaded the roads into a town in Guinea's southeast in early April, which stopped response teams from being able to quickly search for contacts.
The prospect of a large-scale outbreak is terrifying for locals. Between 2014 and 2016, Ebola ravaged Guinea, Sierra Leone and Liberia, killing more than 11,000 people. The disease incubates for as long as 21 days, and causes death by organ failure or extreme dehydration. In some contexts, as few as one third of victims survive.
This time, Ebola would be striking on top of the coronavirus pandemic. While Sierra Leone – a west African country of more than seven million people – registered just over 4,000 Covid-19 cases over the past year, and only 79 deaths, the economic impact has been pronounced.
The government ended a one year state of emergency only on March 25th, lifting a nightly curfew. Citizens are being encouraged to call the same hotline number that was used during the last major Ebola outbreak – 117 – to report both Ebola and coronavirus symptoms.
Improved treatments
There are reasons to be optimistic. Improved treatments for Ebola now exist, vastly increasing the prospects of survival for those who contract the disease, as does a vaccine to stop people getting it in the first place. More than 6,700 people have been vaccinated in Guinea, and the first consignment of the drugs – meant for healthcare workers – arrived in Sierra Leone last week.
“In 2014, we were so ignorant,” said Amimata Fofanah, a community health supervisor and trainer for Goal.
“At the start the healthcare workers were saying ‘Ebola has no cure and if you catch Ebola you will die’.”
This was the wrong strategy, she said, because in Sierra Leone people are “so connected” it is impossible to abandon loved ones, meaning victims stayed away from hospitals.
“[This time] we have mobilised all over the place,” she said. “Now people have seen survivors, they know if I get sick and report early I will be saved.”
At the Mafaray training session, community mobilisers list challenges they’re facing. In one town, there is a single water pump, so everyone gathers there together, creating a potential infection hotspot. Another man worries that there will be too many teenage pregnancies if schools are closed.
“One way of getting the virus is through your hand because it is our culture to always greet,” says a participant, as the trainer holds up a crude drawing of a person and encourages them to mark body parts that could transmit Ebola. The disease is not airborne; it passes through the exchange of fluids.
“How do we prevent it?” asks the facilitator.
“Always wash your hands,” comes a response. “When you go to the toilet, when you eat, wash your hands”
After two days of exercises and direction, the mobilisers will get a stipend of 350,000 leones (€29) a month to go out to villages and towns, helping locals come up with action plans on what to do if Ebola starts to be detected.
A lack of community engagement was one of the reasons the last Ebola outbreak spread so widely.
"We are all afraid. We know the cost of Ebola," says the paramount chief of Dixon chiefdom, Alimamy Fabeh Kondogbala II, who oversees 2,000 people in 40 communities. He says the new cases stirred up difficult memories for locals, but he is feeling optimistic.
“I think Ebola will not come because we are prepared.”
Training session
Down the road from the training session in Mafaray, he points out volunteers manning a checkpoint: a piece of rope strung across the road between sticks. They hope to identify anyone coming into Sierra Leone illegally who may have Ebola. There is a hand-washing bucket, but no thermometer; the volunteers say they’ll rely on their eyes to spot symptoms.
"People come through here if escaping customs," says Ibrahim Soriesuma, the chairman of a local task force in charge of Ebola preparedness. The borders are porous, with many unofficial crossings, necessitating extra checks.
“We pray Ebola will not come,” he adds.
In the capital city, Freetown, international aid organisations have been holding meetings with the government to figure out what should be done, in case the worst happens.
"Ebola preparedness and response plans are elaborate, but somebody has to pay," said Ibrahim Younis, Sierra Leone head of mission for the aid agency Médecins Sans Frontières. "That's where what they call partners come in: people like MSF, or the NGOs, the United Nations family and then the donor community."
During the last outbreak, there were more than 60 Ebola holding and treatment centres in Sierra Leone – now there is one centre that could treat a case, according to MSF.
Younis said the healthcare system was currently understaffed and lacking critical medical supplies, with huge funding gaps, but this could be overcome.
“I know if there is one case the wheels will turn,” he said.
"Ebola is [a] scary disease and the communities are worried, as well as the healthcare workers," said MSF's medical co-ordinator Kalyan Velivela.
“Decentralised Ebola isolation and treatment centres in the district are crucial for patient management as well as for community acceptance, compared to [a] centralised approach of treating patients in two or three locations.”
Irish Aid has contributed to the response. In March, Minister of State for Overseas Development Colm Brophy announced €350,941 in funding for Goal, Plan International Ireland and World Vision Ireland to support efforts to combat the Ebola threat in west Africa, as well as a concurrent outbreak in eastern Democratic Republic of the Congo.
“Covid-19 has forcefully demonstrated the vulnerability of the world to infectious disease outbreaks,” Mr Brophy said in an emailed statement.
“It has also taught us the crucial importance of fast, no-regrets responses. I am pleased to be able to announce this funding to our NGOs partners, putting our policy commitment, to leaving no one behind, into action.”
Previous outbreak
Disturbingly, for survivors, the new cases are linked to the previous outbreak. The disease was likely transmitted through the semen of a male survivor, meaning it can stay in a living body for years longer than previously known.
Yusuf Kabba, the head of the Ebola Survivors Association, said this revelation caused massive insecurity among the 4,000 Sierra Leoneans his organisation represents.
“It created so much room for fear and discomfort in our community,” he said. “People are still afraid. Our greatest fear is stigmatisation.”
More research into how long Ebola can live in semen and efforts to test survivors and tell them if they are clear would help alleviate concerns he said.
“I’m not married yet but I have a girlfriend and she started asking questions, whether I’m infectious. Similar to other people. Some face other difficulties, people are afraid.”
He said survivors felt abandoned when the latest outbreak was announced, and he called on the government to continue to engage with them and seek their input.
"We are feeling left out of the government's attention. We are battling whether to say survivors are safe or not safe," said Roseline Ansumana, a nurse and social worker, who also holds training events for Goal.
Until now, she said, people believed survivors were the safest people to be around because they were immune from getting Ebola again.
In Kabala, in Sierra Leone’s north, she watched last month as healthcare workers role-played burials and practiced donning protective gear.
Ansumana says she feels a duty to help, but it is painful for her to be back in this situation.
During the last Ebola outbreak, she was pregnant, but lost the baby after someone dropped dead at a training session she was running. It took time to clarify that the death wasn’t Ebola-related.
“You can imagine the stress,” she said. “People are so worried. I am worried. I know when we’re responding I’ll be on the frontline.”
