The heart of an emergency

Photo of Aimee Voth Siebert with her language and cultural facilitatorsSierra Leoneans teach staff member community input is essential to changing behaviors
By Jan Stapleman | Office of Communications
Forty-two. That’s the number of days Sierra Leone went without a reported Ebola case (two 21-day incubation periods) to secure “Ebola-free” designation Nov. 7. It’s also the number of days Aimee Voth Siebert spent working there as a health promotion specialist. Although her work ended seven days before the nation’s all-important Day 42 celebration, she exchanged virtual high-fives from Colorado with an expanded group of Facebook friends in Sierra Leone.
Voth Siebert deployed under an agreement between the Colorado Department of Public Health and Environment and the CDC, negotiating a two-month leave from her work as a disaster behavioral health specialist with the department’s Office of Emergency Preparedness and Response. After two weeks’ training at CDC headquarters in Atlanta, she arrived in Freetown, Sierra Leone’s capital, Sept. 20. There she learned she was being sent “up country” to the Port Loko district, which was approaching 100 days without a newly reported case.
As a health promotion specialist, Voth Siebert conducted “rapid behavior assessments.” She traveled out to remote villages for one-on-one interviews of residents to determine the “why” behind trends in community behaviors. She credits her driver, Pa Baimba, for delivering her to all 11 chiefdoms in the district, negotiating seemingly impassable, mud-rutted roads and willing the team’s four-wheel-drive, stick-shift SUV out of flooded ditches. She credits her two language and cultural facilitators for teaching her rudimentary Krio words and coaching her on cultural norms that opened doors to communication.
When village children stared or cried in alarm at seeing a white person for the first time, Voth Siebert  eased their fears by asking, “Mi nem na Aimee. Wetin na yu nem?” [I’m Aimee. What’s your name?] A local volunteer boosted her credibility by giving her a traditional name, Ami Kamara. The first name, pronounced Ah-mee, is short for the common name Aminata, and last name is the equivalent of Smith in English.
“I rarely feel unobserved,” Voth Siebert wrote in the blog she kept about her journey, “and this forces me to live inside my white identity in a way that I am rarely forced to do at home.  It diverts a lot of attention, being aware of other people being aware of you. … I cannot change my skin tone … so I have to find other ways to build bridges from my identity and culture to others here.”
Photo of Aimee Voth Siebert standing on rutted, flooded road
 
That bridge-building was essential, because Voth Siebert was asking difficult questions. She was trying to find out why some communities were rejecting the new infrastructure and systems put in place to improve health care. For the first time, the nation had a fleet of donated ambulances. Straw beds in many health centers had been replaced with cleanable beds made of metal and plastic. If someone got sick or died, residents by law were supposed to call 117 to summon local field officers who went out on “live alerts” and “death alerts” to rule out Ebola and collect bodies for “safe-and-dignified burials.”  
But why were few 117 calls coming in from certain chiefdoms? Why would villagers pay taxi fares they couldn’t afford rather than call an ambulance? Why were burial teams stoned and chased from some villages? It was Voth Siebert’s job to find answers, drawing from her behavioral health background and the community inclusion skills she learned in her work at the state health department.
She started interviews with positive questions:  What do you do to keep yourself well? If you get sick, who will notice? The answers were heartening, revealing residents’ knowledge about healthy behaviors such as hand washing and their cultural norms for taking care of each other.
When she moved on to more difficult questions, she posed them in ways that allowed people to save face and not admit breaking the law: Do you know why some people don’t want to call 117? Do you know why some people don’t like ambulances?
The answers revealed what Voth Siebert calls the biggest takeaway of her time in Sierra Leone: The community determines whether systems succeed, and systems will fail if they’re created without community input. It’s a lesson that applies to communities in the U.S. as well, she noted.
Villagers’ answers revealed a deep social stigma related to “turning in” fellow villagers who were sick. They associated ambulances with Ebola. Ambulances took away loved ones, who were never seen again. Allowing outsiders to care for the sick violated villagers’ deep belief in caring for each other.
“This experience has been an exercise in curiosity, in learning how to ask the good questions, and remembering that at the heart of every emergency are the people whose behaviors make the difference,” Voth Siebert wrote in her blog. “This is ALWAYS about people.  Always about loss.  And witnessing that is, I think, an important reminder to us all, and should be a point of focus even as we all work to keep the country safe and healthy.”
Voth Siebert described watching as a burial team, dressed in full biohazard suits, removed the body of an elderly woman from her home. The woman didn’t have Ebola. Villagers joined the woman’s family in sending up wailing cries to grieve the loss of a beloved person in their community.
“On the response side, it is easy to see the safe-and-dignified burial as a protocol that is always followed,” Voth Siebert wrote. “And it is important, no argument. But communities still struggle with it, because it is such a strong departure from the ceremonies of burial that people used to practice. One woman told me that to not wash the body is to miss their parent’s last blessing. Imagine believing that, but also knowing that the safe-and-dignified burial had to happen to keep people safe.”
Voth Siebert witnessed a nation in transition, recovering from an outbreak that took almost 4,000 lives, one-third of all the region’s Ebola deaths and more than the number of deaths in Liberia and Guinea combined. With response efforts winding down, CDC has established a permanent presence. Other organizations with longer histories there, such as UNICEF and WHO, are pressing on with their original missions.
As Voth Siebert watched the nation settling into a new normal, she hoped the villagers’ traditions of caring for each other would be redirected to helping each other with prevention. She worried about the future for locals who worked long hours burying bodies and risked their lives to protect their communities. Will their nation give them the emotional care and support they need to shed the stigma and trauma of overexposure to death?
During her long trip home, Voth Siebert was self-conscious about the smallest cough and determined to appear well, despite 19 hours without sleep. Officials in Sierra Leonean and Belgian airports checked her temperature repeatedly. U.S. Border Control agents in Atlanta gave her a face mask to wear during her health check there, much to the dismay and discomfort of other passengers who had been on her flight. She continued to check her temperature twice a day for 21 days before she attained no-risk status.
The best thing about coming home, Voth Siebert said, is physical contact. Social distancing was such a necessary reality in Sierra Leone that it was startling to be touched, as she was one day by a group of children. Now, accepting hugs offered by friends and colleagues, and her husband Michael, she is struck by the depth of what was lost in Sierra Leone.
In a recent blog post, Voth Siebert wrote about her desire to return to Sierra Leone one day. “I am so excited to see where the country goes next, knowing some of the remarkable leaders who will find new roles to usher them into the future. I pray for healing rest and sustained support for everyone, especially the responders who had profoundly difficult roles. May they be confident that their work brought health and safety to so many, and so many are thankful.”