The morning of March 25th, I laid still in bed from horrible body aches that left me feeling almost paralyzed. “My small sister” my Kenyan coworker shouted as he came into my hotel room, “You are a strong girl, get up”. He was right, I was usually pretty tough but on this particular day, I was experiencing pain as I had never known. Between continuous bouts of racing to the bathroom, night sweats, shivering and sharp muscle spasms whenever I moved, I feared I was going to die. My coworker eventually returned to work to inform the others I was sick. Someone showed up from the office with an at home malaria test kit and almost instantly we had our diagnosis. I laid in bed rehydrating and trying to eat enough food that I could take my medication without my stomach feeling like a dryer filled with gym shoes. While in that small hotel room, located in the busiest part of the capital city Monrovia, I thought a lot about my own innocence and naïveté regarding this trip, how I assumed armed with a newly acquired environmental health masters degree that I could take on one of the biggest epidemics in mankind’s history.
Lying in bed in my medicated haze, I began to reflect on the end of 2014 when I returned to Tulane to complete my Thesis report. That year, New Orleans hosted two major public health conferences where the main topic of concern was the Ebola epidemic. At both the American Society of Tropical Medicine and Hygiene, where I was presenting my thesis research and the American Public Health Association meeting the pressing question was what should our role be as public health professionals in advocating for research to be done on neglected tropical diseases that affect non westerners. At the very same time, our Louisiana governor disallowed anyone who had recently been to West Africa to travel into the state. Key Scientists en route to the meetings were denied entry into the state and unable to present their research. I watched on CNN as the outbreak spread between Guinea, Liberia and Sierra Leone and felt that all of my hard work and study had been pursued for this moment.
In the evenings when I was done working on my thesis, I would apply for positions with organizations working to end the outbreak. Knowing that the best defense against the spread of the Ebola virus was hand washing and proper burials, I concentrated on groups who were completing Water Sanitation and Hygiene projects. Eventually, I received an invitation to join a US based NGO in Liberia. I packed up my absolute necessities and began my unforgettable journey to West Africa.
When I arrived in Liberia, I stood in line with all of the other passengers at the terminal to get into the airport. A guard dressed from head to toe in personal protective equipment, went one by one checking each of us with a temperature gun to ensure that no one with a fever or visible signs of illness entered the country. I grabbed my bags, walked out into the moist warm city air, past the taxi men yelling in my direction, car horns honking and towards the smiling faces holding up a sign with my NGO’s name on it.I was surprised to find two other employees from the same organization would be sharing the ride with me to our home base. One of the employees was returning and one was a new hire so we spent the entire car ride discussing critical safety issues. The long timer impressed upon us that anytime we step out into a public space we were at risk of contracting Ebola. He informed us of the dangers of consuming any food that contains bush meat, a known carrier of the virus. Most importantly he cautioned us to quickly retreat if we encountered someone showing signs and symptoms of the illness or even hysteria. The conversation took me from the theoretical to the experiential, the risk was palpable.
The next day I woke up in my new room, in the safety of my mosquito net welcomed by a soft breeze through the window. My new boss a small in stature woman who had been living in Liberia for over six years took me for a walk behind our walled compound. As we walked down the dirt roads, I was heartened by all the kids saying hello and waving as we passed by. Down the road, some small kids were playing soccer and when the ball came in my direction, I even joined in a bit to the excitement of the boys. We came to a beach area where the sand, ocean and sky blended together in variations of grey. She told me how she became entranced with Liberia, not long after what is internationally referred to as the cannibal civil led by Charles Taylor. We discussed a bit about Liberia’s hidden colonial ties with the United States. The American Colonial Society was established in 1816 in a controversial attempt to resettle free slaves outside of the United States. As an African American, whispers about freed Slaves who repatriated to Liberia floated around unformed.
Monrovia was a beautiful crumbling city with inhabitants from other neighboring countries in Africa, as well as many people from Lebanon, India and the United States. The UN peace task force brought in national armies from countries all over the world. People seemed content and satisfied under the leadership of then president Ellen Sirleaf Johnson and hopeful that Liberia would be rebuilt to be even greater than it had been before the war, and certainly before the outbreak. I did however, notice a slight presence of sadness amongst the people, and it was clear that they had experienced some communal pain as a nation. One way this communal pain was expressed was in response to “how are you doing”, which many people answered by responding, “better than worse”. The food fresh and pepper filled was not only appealing to the senses but seemed to even help regulate my normally sluggish digestion. In the midst of the outbreak, some supermarkets and restaurants remained open, all with a huge bleach bucket at the entrance and an attendant to check everyone’s temperature and make sure every individual entering into a public place wiped down all visible skin surfaces with the bleach water before stepping inside.
After spending a month preparing for the study in the city named for US president James Monroe, It was time for me to begin the long trip to the northern border, where the Ebola virus was said to have first entered into the country by a traveler coming in from Guinea.
The project I worked on was a research study entitled “Islands of Hope” that sought to identify differences in the behavioral practices of small communities who managed to have no community members affected by Ebola, while surrounded by outbreaks.
My organization has worked in these communities long before Ebola to help reduce the rate of open defecation and encourage hand washing. We had a number of communities self organize and in partnership with the organization educate their community on the health risks associated with the common practice of open defecation, and raise money as a community to purchase the supplies to build a community latrine. Communities that had successfully completed this task and managed to end the practice of open defecation entirely, received the honor of being titled Open Defecation Free or ODF. It was these ODF communities in particular that in spite of being equally as vulnerable to the virus as their neighbors, managed to keep their community Ebola free. It was in distinguishing the unique behaviors within these communities that we hoped to identify protective factors that could prevent the spread for future similar outbreaks.
The drive to the capital city of Lofa County, Voinjama was about 17-19 hours from Monrovia. We all loaded up our luggage on organization branded land cruisers and jumped in for the bumpy ride. Late in the night we arrived at our accommodations, a building that looked like an abandoned mansion that hadn’t been slept in for at least a century. When we checked in we were handed our bucket for showers and told that the electricity would only be available until 10pm, and to plan accordingly.
We got up early and drove for a few hours before we reached the home that had been hired to provide breakfast for us. There were not quite enough plates to go around, so we shared each plate. I was grateful to get some scrambled eggs and sliced bread. I noticed my Kenyan team mate was only having the bread, but I looked around and saw all of the local staff members eating their eggs without hesitation, so I ate mine happily and got back in the truck with a fuller belly. About 2 hours in to our bumpy ride my stomach started rumbling and I could not wait until our next rest stop. Our driver pulled over in a local village and people were nice enough to lead me to the shared latrine. I raced in barely closing the door behind me and It was all I could do to land over that hole, in explosive relief. Immediately it was coming out of both ends was experiencing explosive diarrhea and while trying to let the bug pass while keeping the latreen relatively tidy, I began vomiting uncontrollably also. Eventually I had emptied my stomach of all of its contents from both ends and I slumped down against the wall a sad sorry mess completely fatigued and out of breath. I was worried about not leaving the latreen as clean as I had found it and by luck, I had just enough water in my bucket to wash down the cement surfaces clean. I got back to the vehicle and popped an anti-diarrheal pill and was fine for the rest of the long car ride.
Once we arrived in Lofa County, we needed to hire a number of local enumerators from nearby communities to go door to door to carry out the survey. The hiring process and enumerator training brought forth a huge number of smart, energetic, Liberians eager to help restore their country. We worked with our local staff to put together our residential Head of Household survey, during which they informed us of common misconceptions around how the disease entered into the country, how the disease is spread, and what to do when a community member gets infected. One of our enumerators organized a community entry session where the local chiefs and town members gathered to hear about our research project and to permit us to conduct research within their community.
The survey process went incredibly well with almost 100% participation from the local communities. In our off time my co-worker and I would take walks around the neighborhood and observe the women selling fruits and vegetables along the road. We watched as children walked to and from school in their green and white uniforms, and we giggled at all the movie and video game center’s with their funny names that played off US pop culture like Facebook room. It was amazing how life for most people happened outside of their homes, which was only used for sleeping. You could smell the delicious scent of cassava leaf cooked over charcoal, watch people listening to music and dancing in the street and people ate their meals outside. It was always an awkward time for my coworker and me because if anyone we knew saw us walking past while they were eating they would often insist that we sit and join them. In spite of how delicious the food looked, we knew not to join them because food sharing was one of the primary ways Ebola was transmitted. In the north food is served in a large bowl and eaten with bare hands.
After about 17 days in Lofa County we returned to Monrovia to analyze the data and finalize the report. We returned back to the capital city after eating all of our meals together and spending all of waking moments together stronger than we when we set out on the trip. I exchanged email addresses with many of our enumerators who were eager to one day travel outside of Liberia to continue their educations and we vowed to keep in touch. Celebrating them at the end of the data collection portion of the study with certificates of recognition for their talent and hard work felt insubstantial as a proper means to truly honor these courageous individuals who worked tirelessly driving all day and working often times well into the night to make sure each home had an opportunity to participate in the project.
There was not one Liberian untouched by the outbreak. Every single person I met had people whom they knew personally die from the virus. They all experienced the presence of bodies that layed lifeless in the streets awaiting a man dressed in head to toe in white plastic to pick it up and carry it away. No longer allowing family and friends to wash and dress the body as was the tradition or to bury the body on ancestral lands to reside in the afterlife in soil that was familiar. Instead they cried when the body snatchers arrived to bring the bodies to the approved safe burial site located outside of Monrovia where many families could not even travel to to attend the funeral. The Liberian people in their inherent graciousness accepted the national burial grounds as a compromise to seeing their loved ones bodies burned. They worked to fight back against a disease never before seen in their region as their culture and way of life was scrutinized and judged as the cause of their suffering. They remained cohesive as the world shut down their borders to them and punished people who dared go over to help with a cumbersome 40 day quarantine when they arrived back or if they were citizens of West Africa trying to flee the epidemic disallow them entry entirely. Many Liberians likened the death, destruction and militarization happening all around them to the infamous civil war which like the outbreak left hundreds of bodies lying dead in the streets.
While walking home from a friends place in the upscale Sinkor neighborhood in Monrovia, I was bitten by a mosquito and left unable to do much more than lye on my back and reflect on the generous nature of vulnerability. There is no difference between offering service and being served both require us to trust in to what’s unseen while having limited or no control over the outcome. In the end, we are both saving each other.