What is a safe and dignified burial?

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?

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.

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.

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.

Burial Team get into PPE to collect the body from the Isolation Unit

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.)

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.

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.

Limited space available

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. 

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.

Relatives (wearing blue overshoes) standing on war grave site watching the burials below