Inside the Red Zone: Sierra Leone's terrifying mpox outbreak

Telegraph

5 days ago

Inside a quarantine zone on the edge of a military hospital, a 32-year-old man with lesions all over his body is losing his battle with disease.
Ibrahim Turay, a construction worker from the capital, Freetown, has a severe case of mpox, the virus formerly known as monkeypox that exploded in Sierra Leone earlier this year.
For more than a month he has been unable to overcome the infection because his immune system is compromised. A secondary infection has resisted every antibiotic available, leaving him in a horribly precarious position.
'My situation, it is getting worse – some areas are getting better, but there are more boils popping up all the time,' he said, referring to the lumps and blisters that continue to erupt all over him.
He's among more than 5,000 people who have now tested positive for mpox in Sierra Leone since the first case was confirmed in December last year. At least 47 people have died, according to the latest update from the Ministry of Health on Monday.
While in the West mpox is largely seen as a problem only for certain at-risk groups, particularly gay men, mass outbreaks in Sierra Leone and the Democratic Republic of Congo have shown that, under the right conditions, it can cause devastation.
Gay or straight, young or old, rich or poor – all are proving vulnerable to variants of the disease that appear to spread more easily, and experts now fear that outbreaks like these could eventually become a bigger global problem. Many thousands of children have been affected.
At the peak of the outbreak Sierra Leone was reporting more than a hundred new cases a day – easily enough to overwhelm its fragile health system – and by June three quarters of all the new mpox cases in Africa could be found within its borders.
The number of new infections has plummeted in recent weeks, in a sign that a vaccination campaign and a bold decision to stop encouraging people to isolate at home and instead go to treatment centres are working.
Yet even as the outbreak slows, medical facilities scattered across the country continue to receive a steady stream of mpox patients and it remains to be seen whether the government's new strategy will be enough to stamp out the disease for good.
The Telegraph gained rare access to Sierra Leone's Red Zones – the isolation wards where mpox patients are treated – to find out how the country managed to fight off the worst mpox outbreak in its history.
'Our most critical case'
Were it not for the plaque commemorating its opening in 2020, it would be hard to believe that the infectious diseases unit at Freetown's 34 Military Hospital is only five years old.
The faded Chinese lanterns hanging in the corridors are a giveaway as to who built it. When it rains heavily, as it often does, the roar of water crashing onto the roof is deafening, and the sheet metal walls are pockmarked with rust spots that look like mpox lesions.
These weeping sores are the defining feature of the virus. They begin as a rash, then turn to flat spots and grow into bumps before bursting, scabbing over and falling off, often revealing raw flesh beneath. The itching and pain they cause can be extreme.
'I have had many sleepless nights,' said Mr Turay, who sat on the edge of his bed, completely naked and hunched over, unable to sit, stand, or lie down comfortably. Arrayed around him were seven other men in varying states of undress and discomfort.
There is no specific antiviral treatment for mpox, so patients have their wounds cleaned, receive painkillers ranging from paracetamol to tramadol, and take antibiotics to fight further infections. Sometimes they must undergo 'debriding', a process where necrotic and damaged tissue is removed surgically.
Most people get over the virus in a couple of weeks, but Mr Turay has had to watch on as other patients recover and return to their lives. He has been on painkillers for so long now that they are becoming ineffective.
'He is our most critical case. When he sees others leaving, he is discouraged,' said Dr En Ebbie, a military doctor. The psychological toll of mpox can be as hard to bear as the itching it causes, so therapy often forms a significant part of the treatment process.
The hospital has been on the front line of the outbreak, dealing with many of the most serious cases. A tally on an office white board says that 379 people have come through its doors, with seven of them dying.
All but one of those who died had a co-morbidity that made them more susceptible. HIV, malaria, diabetes, tuberculosis and cancer are the most common causes of complications.
'Mpox severity or mildness depends on your immune system. That's the truth,' said Dr Adama Kamara, an infectious diseases specialist and the clinical lead for the mpox treatment centre at 34 Military Hospital.
'If you have a good immune system, it can be mild. But when you are immunocompromised, then it becomes very virulent,' she told The Telegraph. 'It looks for an opportunity to thrive and that often comes with immunocompromised and immunosuppressed patients.'
Howling screams were emanating from the women's ward as the patients had their lesions cleaned and dressed with fresh bandages – an agonising but vital part of the care routine.
It's not just those with compromised immune systems who are being hit hard. Young and otherwise healthy people are suffering, and they make up the bulk of the cases.
Rafael Koromah, a 29-year-old local councillor with the country's ruling Sierra Leone People's Party, reckons he got mpox after going home with a girl he met in a nightclub while on the road campaigning.
'It started on my privates, so I kind of thought it was a normal thing,' he said. Clade IIb mpox often attacks the genitals, sometimes with horrific consequences. (The Telegraph was told of one patient whose penis was affected so badly that part of it had to be amputated.)
'A week or two later, I started seeing others appear on my fingers. Then they started appearing on my hand,' he said, lifting up his arms to reveal the gaping sores on his palms and knuckles.
In the end it was a month before he sought proper medical care, and he soon found himself in a treatment centre in the Freetown suburb of Calaba Town.
Delays like this, with patients initially misidentifying their rashes as more mundane sexually-transmitted infections, are common. As well as giving time for mpox to spread further, the delays can lead to more severe illness.
'The fever, the headache – it's really bad,' said Mr Koromah. 'I was fucking almost gone, I was under the blanket, shaking, I couldn't even talk.'
The young politician admitted that, like many Sierra Leoneans his age, he did not always take mpox seriously, but he now warns his friends about its dangers.
'I say to my friends: 'You shouldn't joke about this,'' he said, hinting at the stigma around it, which can persist even after a patient has recovered. 'It's really not a good virus for humour.'
Dr Elin Hoffmann Dahl, a specialist in infectious diseases with Doctors Without Borders (MSF) who was dispatched to help run the treatment centre, said overcoming this stigma had been one of the most significant challenges in the outbreak response.
'There is a lot of fear and stigma in the population, which is a barrier to seeking care, and when it's also driven by sexual transmission this is, of course, adding to stigma and makes people seek care late,' she said.
For some, the shame of an mpox diagnosis can be a heavy burden.
Dominic Oumar Alieu Sesay is a 28-year-old marathon runner known as 'Champion Boy' for his exploits in long-distance foot races across West Africa. His personal best, set in Senegal, is 2 hours 28 minutes.
Despite being at the top of his game physically, he cut a dejected figure in his room at 34 Military Hospital and seemed to believe his mpox was a punishment from above.
'Even yesterday I was meant to present my trophy on television,' he said. 'I am disappointed at myself, but I know I can go back on with life, by the grace of God.'
The Health Ministry and its international partners are devoting considerable resources to breaking down the stigma around mpox.
The Telegraph joined a community outreach team from MSF as they went into the village of Pamuronko, outside Freetown, to put up posters and field questions from the locals about the virus.
Misinformation, rumours and conspiracy theories abound, and getting accurate and useful information into remote communities is difficult.
'This is a very remote area – they don't even have a primary health unit around with medical staff to help them, to orientate them,' said Maria Diaz, from MSF's Health Promotion and Community Engagement team.
In areas like this it is traditional healers, rather than doctors, who hold sway, and they are often the first place people go for help with mpox.
The government says it is working to incorporate these healers into its outbreak response, but it is not clear how successful it has been.
In Pamuronko, The Telegraph met a traditional healer who showed off the leaves she uses to treat a range of ailments from broken bones to impotence.
While she claimed she had never seen a patient with mpox and would send anyone who came to her with symptoms to hospital, she said treating it traditionally was just a matter of finding the right herbs.
'When they go to these traditional healers, there is a method,' said Dr Kamara, the clinical lead at 34 Military Hospital. 'They say they have to 'cook' it out of you, so they take mud, take herbs, put it all over your body, then cover you with blankets and steam you.'
For mpox patients covered in lesions and sores, who are vulnerable to infections, receiving this treatment can be deadly.
'Our first mortality, he came from a traditional healer,' she said. 'He came and he died in 72 hours.'
Such was the ferocity with which mpox spread through Sierra Leone that some experts initially believed the virus had evolved to spread more easily, even without sexual contact.
'The spread of mpox in Sierra Leone is unlike anything we have ever seen,' Professor Kristian Andersen, an evolutionary biologist at Scripps Research, said on BlueSky as cases soared in May.
Scientists have also been struck by the way in which Clade IIb mpox appears to be spreading in the same way as Clade Ib, its more virulent East African cousin that took off in the Democratic Republic of Congo (DRC), prompting the World Health Organization (WHO) to declare mpox a Public Health Emergency of International Concern in August last year.
'In terms of how they transmit, I don't think we are going to see any significant difference between both of these clades,' said Ifeanyi Omah, a researcher in pathogens and global health from the University of Edinburgh.
While young adults undoubtedly played a significant role in the explosion of cases, the virus has surged through the general population, including to children, indicating that it is not only spreading sexually.
'People thought that it was a sexually transmitted disease,' said Dr Sartie Kenneh, Sierra Leone's Chief Medical Officer. 'We were very fast to say: 'No, it is not.'
'We can't class it as a sexually transmitted disease. It is just a contact disease,' he said.
Overcrowding helped mpox to spread rapidly, particularly in Freetown where people live cheek by jowl in cramped accommodation, he added.
Nobody knows how 11-year-old Paul Nyandemah picked up mpox. His father Benjamin, a school teacher from Freetown, noticed the spots all over his body one morning, when it was time to wash his clothes.
'In that moment, I saw those spots on his body and I said: 'What might this be?''
Over the next couple of days more spots began to appear and Mr Nyandemah decided to seek medical attention, and he's glad he did.
'The infection is much worse now,' he said, peering through the door of the containment room to Paul, who had been caked in calamine lotion to relieve some of the itching.
'Yesterday night they called me and told me that he was crying.'
Benjamin is not allowed any closer because of the quarantine rules, and because he has to work and his wife has just given birth to a baby, Paul spends most of his days alone at the facility. He has been in there for three weeks, but he is on the road to recovery.
Encouraging people to come to treatment centres like 34 Military Hospital is now a central pillar of the government's strategy to contain the virus. It represents a marked shift from the early days of the outbreak, when those with suspected mpox were told to isolate at home.
The advice advocated by everybody, including the Africa CDC and other countries, was 'home management,' said Professor Foday Sahr, the Executive Director of Sierra Leone's National Public Health Agency, which was born from the Ebola epidemic.
'But since we observed that home isolation was not working, we decided that every positive case should be managed in a facility,' he told The Telegraph.
'We quickly activated 1,000 beds countrywide, and then moved to ensure that all positive cases should be extracted from the community and brought into facilities.'
Prof Sahr was keen to stress that the decision to switch to treatment centres was 'not a magic bullet' in tackling the outbreak, but it proved decisive when combined with a vaccination campaign and the work of specially trained teams who went into communities and university campuses to warn of the risks and start breaking down the stigma.
The jabs, once they arrived, were initially reserved for front-line health workers, but when the NPHA realised that none of them were getting sick, they were able to target close contacts of suspected cases and then open up vaccinations to everyone, he said.
'Sierra Leone has always stood out with vaccination campaigns,' he said. 'What we saw was that the appetite for the vaccine was really, really huge.'
Owing to its experience in dealing with outbreaks of haemorrhagic fevers like Ebola and Lassa Fever, Sierra Leone has a wealth of epidemiological talent and experience to draw on. So why was the country overwhelmed?
Dr Kenneh, the Chief Medical Officer, conceded that the initial strategy of isolation at home was a mistake.
'To tell you [the truth], we actually underestimated it, because it was a contact disease … Shifting them out of the home – that's what has been working for us, and engaging the community.'
Not everyone is convinced by the government's new strategy, however.
It is difficult to comprehend the strength of the fear and suspicion around hospitals in Sierra Leone and other parts of West Africa.
The terror of Ebola is a recent memory, and many people watched as friends and neighbours left in ambulances never to return.
Lunsar, a small mining town a few hours outside of Freetown, was hit hard in that outbreak. Soldiers wielding thermometers manned checkpoints and enforced strict controls on movement. Several outlying villages were placed under quarantine, and entire families were wiped out.
With this in her mind, Isatu Kabia, 46, was terrified when her youngest son came down with suspected mpox. She described how she had been assured that she would be allowed to look after him at home, only for an ambulance to arrive and take him away to a government hospital 30 miles away.
'It did not make me feel good,' she said. 'I was worried, because I recalled what happened during Ebola. At that time, so many people died.
'I was so worried, I was afraid, and I was frightened. He was on his own and I could not visit him because I could not afford the fare,' she told the Telegraph from the porch of her house. It was several days before Ms Kabia was able to get to the hospital to see her son, Osman Kargbo, 12, and realised he was safe and well.
The next morning, The Telegraph watched as Ms Kabia and her son were reunited at the mpox treatment centre in Port Loko.
Separated by bright green cord demarcating the red quarantine zone, he lifted his T-shirt to show her the small marks left by his lesions. Later that day he was discharged and was able to return home.
The fear of hospitals themselves only partly explains why people are reluctant to visit them.
In a small isolation room at the back of a pediatric ward in an MSF-run hospital outside Kenema, in Sierra Leone's East, the mother of a baby sick with mpox was visibly distressed.
The two-year-old had arrived at the hospital unconscious and covered in rashes, but her mother, Mami Samai, was now terrified at the thought of being sent away from the MSF-run hospital to a government-run facility.
'She thinks we are here to refer her,' said one of the PPE-clad nurses standing in the doorway. 'I already talked to her and told her we are not here for that. She doesn't want to go.'
All mpox care is meant to be free in Sierra Leone, but corruption is widespread and extortion and bribery – even in health centres – are common, and Ms Samai was afraid she would be asked for money.
'I have no relatives who can help,' she said, tears still streaming down her face.
Sierra Leone's Health Ministry has launched a major push to bring case numbers right down within the next couple of weeks, but several health and NGO workers The Telegraph spoke to said they were concerned the government's strong emphasis on treatment facilities may be driving people underground.
The Telegraph was told of numerous mpox patients who had attempted to self-medicate, often by washing their bodies with alcohol, or else sought out the services of traditional healers.
Dr Joshua Sandy, a Public Health Nurse from Lunsar's Hand of St John of God Hospital, warned that mpox could make a resurgence.
'It is possible for this to come back, and more severely than what it is now,' he said. 'In fact, we had the same thing during Ebola: just a few months after the government had announced that the Ebola had ended, we had another upsurge which was very, very difficult.'
It was perhaps telling that, at the MSF treatment centre, a new ward was under construction.
Nevertheless, it is clear the government has had success in bringing case numbers down.
What is less obvious is the extent to which Clade IIb exploded because of factors that are unique to Sierra Leone, and whether an outbreak like this could happen elsewhere.
Clade IIb is already in Britain, for example, causing anywhere from one and 41 cases a month for the last two years, according to the latest report from the UK Health Security Agency.
The virus is being kept in check by high vaccination rates, but could it explode as it did in Sierra Leone?
'[In Africa] we're most likely now going to see an explosion of cases,' said Mr Omah, the researcher. 'But the chances of seeing that in Europe and the Western world is quite low compared to seeing it on the continent.'
Ghana and Liberia have both reported dozens of cases already, and last week Gambia reported its first case of Clade IIb.
Mr Omah said mpox was zoonotic, meaning it's a disease that has jumped from animals, in this case forest-dwelling rodents.
Sierra Leone's mpox outbreak is believed to have begun in this way – from a single person eating an infected animal and then spreading the virus to a sex worker.
Risk areas like West Africa will continue to see outbreaks like this unless there is 'a targeted effort to make sure that we vaccinate as many people as possible, to break chains of transmission early on,' he said.
Back in the military hospital, a commotion was unfolding over Mr Turay, the man with the compromised immune system.
He had been due to leave that evening for Connaught Hospital, in the centre of Freetown, to undergo debriding and reconstructive surgery.
The referral papers had been signed, and a bed was ready for him there.
But members of his family had arrived and, despite the pleas of the nurses and doctors who had cared for him for weeks, persuaded him to leave the hospital.
'I feel bad because we've tried our best. We've been working so hard to bring him up for weeks,' said Captain Alimany David Fornah, one of the military nurses on the ward. 'But psychology has come into play.'
Perhaps they were desperate, perhaps they had lost faith in his carers, perhaps he himself understood that his chances of ever recovering were slim.
Whatever the reasoning, he was led out of the hospital, bundled into a car and taken off to a village eight hours away near the border with Guinea, where a traditional healer awaited him.