I warn you this is a rather bleak and factual blog entry… You
may have seen or heard on the news that all burials in Sierra Leone are
required to be ‘safe’ during the current state of emergency. This is certainly
meant to be the situation – but what is a ‘safe’ burial and how does it differ from
any other? What is the impact of the change in burial practice on bereaved
families? What can be done to help give a dignified burial?
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| Trevor |
I was lucky enough to meet the perfect person who could
answer these questions; Trevor works for Concern Worldwide and manages the
Kingtom Cemetery, the largest cemetery in Freetown. Kingtom is situated right on
a small headland in the centre of the city’s coastline. Originally named after
a tribal chief by the same name, Kingtom has had a cemetery for many decades but
since the start of the outbreak it has become the most important site for
‘safe’ burials. The daily and
overall organisation of the cemetery by Freetown City Council and Concern Worldwide
has been key in preventing onwards transmission from Ebola corpses, which are
extremely contagious and thought to be one of the main causes of transmission.
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| Alie |
In order to understand the process more thoroughly Trevor
recommended that Grace (one of the other KSLP volunteer doctors) and I should
join the Burial Team to follow what happens when a corpse is collected from our
Isolation Unit. So on Thursday, we
met Alie, a warm-hearted friendly Sierra Leonean who has worked for the Burial
Team since the very beginning of the epidemic. He must have worked through very
tough times in the last few months but he was amazingly approachable, calm and
patient whilst on the job.
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| The burial team arrives at Connaught Hospital |
When someone dies in our unit the first thing to do is to
inform the family. Over time I have learnt it is better to tell the male
relatives first, preferably the eldest or head of the family if they are
available. The men will then either tell the women themselves or ask you to
break the news but at least they are ready to console the women as emotional
outbursts of crying and wailing are likely to ensue. This is really hard, the
wailing can often be heard from across the other side of the hospital grounds
and it haunts you wherever you go.
If a blood sample has not already been taken
before the person died then an oral swab sample is taken to test for Ebola.
Unfortunately these swabs are not 100% reliable, for example due to inadequate
sampling or failure due to chlorine contamination. It is at this stage that a
difficult dilemma often arises… relatives often want to wait for the result of
the blood test and/or swab before the person is buried, so that if negative
they can give them a ‘normal’ funeral. However, during my time with the burial
team, I came realise that there is no such thing as a ‘normal’ burial any
longer in Sierra Leone.
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| Burial Team get into PPE to collect the body from the Isolation Unit |
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| Burial team |
The corpse(s) get collected from the Isolation Unit by the
burial team, who arrive in two vehicles; one van with stocks of PPE and
chlorine and 4 or 5 men crammed in the back and one open-air truck with some
tarpaulin sheeting to cover the body bags. The burial team gets dressed into
PPE and collects the corpse in a white body bag from the mortuary inside the
unit. They then decontaminate by the vehicle using a method that seemed very
rushed and flawed to me and yet it is a process they are familiar with having done this day in day out for months.
Grace and I followed this open-air truck around the corner to
the Connaught Hospital Mortuary where the burial team were going to find out if
there were any other bodies to be buried. The Mortuary, just next door to our
KSLP office, is for patients who die on the general wards or for the community
in general, e.g. accidental deaths. Inside the Mortuary every corpse has an
oral swab sent for Ebola and is then transferred to a body bag for ‘safe’ burial.
This means that the earlier dilemma of waiting for a result in the Isolation
Unit doesn’t change things greatly for families, although it may give them an
extra day or two to organise a coffin since body bags are allowed to be buried
inside coffins.
Grace and I were welcomed inside the Mortuary and given seats
in the director’s office since we were there to observe the burial process. We
spent the best part of a very uncomfortable hour observing the manager explain
the burial process to the bereaved parents of a child who had been killed in a
road traffic accident that morning and then to the family of a patient who died
on the wards. The manager alluded to a small, but nevertheless very significant,
caveat to the safe burial procedure when he suggested corpses could be released
to relatives for, presumably, normal non-safe burials if the swab tests are
negative and they get a certificate from a doctor. We were shown the required
certificate: a flimsy piece of paper filled in by hand that could quite easily
be forged. This flaw in the system is something that will be clamped down on
next week as a new media campaign is starting to emphasise the need for 100%
safe burials in Sierra Leone.
(In fact, a couple of days later whilst another
Kings volunteer, Dominic, was visiting the cemetery he witnessed a fake burial
team turn up at Kingtom. They were wearing dubious PPE that they kept taking on
and off. The body was wrapped in a sheet (not a body bag) and when questioned
they said, “We are the Connaught burial team” which was an obvious lie. The
police where called and arrested them on the spot whilst the driver did a runner!
We have no idea who they were but the whole scene sounded very bizarre; why
turn up at the official cemetery and do a bad job of pretending to be official?
More worryingly, despite all the media campaigns and the devastating epidemic
for 8 months, people are still intent on bending the regulations.)
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| Following the burial team (Toyota) to the cemetery |
Anyway eventually, thankfully, Grace and I excused ourselves
from this manager’s cramped office which reeked of formaldehyde and waited
outside for the burial team to move one more body from the mortuary into the
back of the van. This was someone who had died on the normal wards but for all
purposes was treated exactly the same way: swab, body bag, full PPE… so “safe
burial”. Then we followed the van through the streets of Freetown to Kingtom
Cemetery, about a mile away. Little did people know that there were two corpses
under the tarpaulin and a bag of contaminated PPE on top as this vehicle crawled
its way through the crowded streets of Kroobay.
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| Creating more space; excavating the rubbish dump |
Kingtom Cemetery is a wide-open area of graves much like any
other cemetery. However, on one edge, the cemetery is a daily hive of activity,
as it now has to expand rapidly to accommodate all of Freetown’s deaths. It was
here that we met Trevor and he kindly showed us around. I felt quite unsettled,
as if I were an ‘Ebola tourist’ but Trevor reassured us that it was 100% fine
to observe and even take photographs. The cemetery’s perimeter fence is covered
in black plastic sheeting to block the view of the rubbish dump behind, giving
at least a little visual dignity to the fact that the extra space required has
had to come from somewhere. Fifty metres from where the current graves are
being dug and filled there’s a big tractor tearing through the years-old layers
of a landfill site making space for more. But Trevor tells us they are running
out of space. There’s a new site at Waterloo, half an hour drive to the East, which
will take over when Kingtom has reached capacity.
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| Limited space available |
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| A safe burial |
I suppose it’s not very often you consider the daily mortality
rate of a city. Certainly in the half an hour that I was there, I was amazed to
see a number of burial teams bring in at least five bodies and bury them in the
same amount of time. There are various practices that have developed over the
course of the epidemic to allow families to say goodbye as best they can. They
are allowed a maximum of ten relatives to attend the graveside, where they
watch the teams in full PPE bring the body bag from the van to the grave.
Muslims can be buried with a white cloth, and Christians can be buried in a
coffin but they are buried alongside each other, whilst an Imam or a Priest
guides the relatives through prayers from a safe distance.
Once the body is
placed at the bottom of the grave, the burial team decontaminates throwing
their used PPE in the grave and then, quick as anything, the gravediggers fill
the grave with soil. It was a sadly unemotional procedure to watch. The
relatives helplessly stand by and watch, hopefully with some indication of
which body bag belongs to their relative as it is carried to its grave.
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| Trevor and Grace walk past recent burials |
Concern
Worldwide will be providing gravestones for each grave, but until those are in
place they are currently being marked with a name on a wooden stick and a
number. There’s also a small area with white fencing to one side which contains
a number of graves from the beginning of the epidemic when there were just too
many corpses and too little infrastructure to organise one body per grave.
There are plans to make a plaque to indicate the names of all those buried in
that area.
I came away feeling cold and deeply saddened by this
epidemic and its consequences for all. I cannot imagine what it must feel like
to be told one morning, “your
brother/father/mother/daughter has died, possibly of Ebola (but we won’t know
for a few days), and you have to follow this burial team, who will bury the
body like every other body in a white heavy duty plastic bag in a newly dug
grave on an ex-rubbish dump.” The people are Sierra Leone are truly
resilient; they have seen more than their fair share of suffering. As if to
cruelly remind everyone of this, the raised ground where the relatives stand to
watch the safe burials is, itself, a mass burial site from the civil war.
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| Relatives (wearing blue overshoes) standing on war grave site watching the burials below |
