Change in family dynamics/relationships.

Relationships were strained because husbands and wives were unable to be intimate with one another when one was sick during the Ebola epidemic. Additionally, due to fear of contracting their partner’s illness, wives were unable to care for their sick husbands. For many women, this was difficult because they believed their roles and responsibilities as wives had been compromised.

"Well, I suffered a lot. My husband was also seriously sick during the Ebola, and I could not touch him. I was forced not to care for him, and sometimes we don’t sleep in the same place even as husband and wife, so I have to stay away from him. It was very bad." - 35 year old, female, Stonebreaker

School closures.

During the Ebola epidemic, the government of Sierra Leone closed the schools for six months. Many mothers expressed that it was challenging for them to manage their usual daily tasks while having their children home during the day. Their children were bored, unhappy to be out of school, and they wanted to play with their friends. They were also hungry, which was stressful because food access was limited during the height of Ebola. Overall, children shared that they missed their classmates and attending school. A 13 year old grade six student shared, "I was unable to go to school; I was unable to play with my friends. I feel bad." One of her classmates, another 13 year old grade six student, similarly described the experience as, “Yes, we are indoors, and I take my book to study. I feel bad because I do not go to school.” All of the students shared that being unable to attend school was a challenging experience, especially for those whose national exam preparations were put on hold due to school closures.

The government aired school programs over the radio to help students continue their education while schools were closed; however, not all children benefited from the program. A 32 year old male teacher explained, “Well, the problem there is that not everyone can access the radio station to listen. Maybe it’ll be there but they cannot afford to get a battery.” While not all children were able to benefit from the radio program, the community still acknowledged the existence of the government’s effort.

Fear.

Living with fear, tension and anxiety was common during the epidemic, and participants reported a constant fear of someone dying due to Ebola. Fear of the disease resulted in changes to social and cultural norms and to the development of antisocial behaviors, especially before it was known how the disease was spread.

“Ebola-it was terrible, as I said. It ravaged the whole country. A lot of nurses died, doctors died, lay people died. And because of that, when it was here, we were like afraid of each other. Even in church we are sitting three per bench, nobody was touching anybody. Even at home, there was not that cohesiveness.”– 53 year old, female, Nurse

Healthcare professionals were ostracized from their own communities by their family, friends and neighbors due to fear that they would transmit Ebola to others. Ebola undermined the trust that people had for each other, healthcare workers, and for health facilities because of the consistent fear of contracting the disease.

“Especially for us as health workers people were shying away from us because they said all of us have Ebola. When going out, it was during this epidemic that nurses stop wearing the uniform. Normally we used to dress fully when going to work, but when Ebola break out if you wear the uniform and went into a cab, you would be dropped out of that cab. People were shying away from us because they said we are the ones that brought in Ebola so we are not welcome.”– 53 year old, female, Nurse

One healthcare worker even described being displaced from her home during the epidemic. She was stigmatized by neighbors because of her profession, and was forced to leave the home she shared with her parents and her son. Instead, she rented a room in an apartment where she kept her job a secret from her roommates.

“Because when I go to work, I decide to leave the place at that time because they told the landlord that I was going to work and I want to kill everybody. So I decide I don’t want my mother and dad to get confused, so I lived in another place for about two to three months, so after which I come back home, so that was the situation. It’s not easy. People are stigmatized because if you are a nurse. Even if you wear your uniform, during that time, if they know they will not pick you up. If they know you are a nurse, they will not pick you up.”– 29 year old, female, Nurse

Later in the interview, she also mentioned the following:

“I secure a room where I stayed. No one knew I’m a nurse; in the morning I just hang my bag, go after work.”– 29 year old, female, Nurse

One of the participants of the men’s focus group worked for an NGO and was responsible for discarding and replacing the belongings of Ebola victims. He began his duties after undergoing a three day training and expressed concern about the danger of his tasks with so little training:

“It was difficult because I am not a trained nurse. I am not a trained doctor. We were only trained for about three days and we were sent to the field. It was dangerous. It was tedious. It was hard for us, but we managed to get through it.”– 47 year old, male, NGO worker

People became afraid of each other and neighbors no longer welcomed each other, with one participant remarking "It was like we see ourselves as enemies, you know? We are afraid of each other. We cannot touch hands."– 33 year old, female, currently unemployed, previously a Home Health Educator

This disintegration of previously close-knit communities was a difficult social consequence to endure since this was not the typical way of life in Sierra Leone.

“… in our setting we used to shake hands, but during Ebola we could not. We are used to hug each other, you know, that one too. It didn’t happen. But it was difficult because it has been in our culture for ages! So for just to shut all these things out- it was not easy for people.”– 53 year old, female, Nurse

Not only were community members mistrustful of each other, but community members who typically helped each other were afraid to do so during the epidemic, feeling that they had no other choice in order to protect themselves.

“We have one kid who is at Allentown when we went to the house, they told us that the dad died and the mother. The child was there. He cried until he died … No one touched him. He cried until he died … We are afraid. If anyone see you going to that particular houses, they will disown you. Not only stigmatize, they will disown you.”– 29 year old, female, Nurse

Fear of contracting the disease was even prominent within families, causing family members to be wary of each other. One teacher noted:

“You are even afraid of your closest relative. As soon as they say, ‘I’m sick’, you’ll be afraid of your relative and even your child.”–>50 year old, male, Teacher

Financial stress.

Financial stress became a prominent burden during the Ebola epidemic. Inability to work fueled a cycle of constant worrying about money and being able to provide for their families.

“Everything was difficult. You cannot move, and if you cannot move, you cannot work. And if you don’t work, you don’t have money. And if you don’t have money, you cannot buy food.”–>50 year old, male, Teacher

Having enough food and fighting hunger was a daily struggle. Even neighbors who would typically assist each other in time of need could not do so during the epidemic for fear of not having enough for themselves and their own families.

“We don’t have enough money to buy, neither enough food to eat. And we don’t even have a place to go and buy because we can’t go out. And when you go to somebody’s home, they say ‘No you have to stay at home.’ It is true. Unless when somebody is asking food from you, well either sell or give for free. If there is any, if they are having enough.”– 35 year old, female, Stonebreaker

Some self-employed community members were able to continue working, but there was no one to buy their goods.

“Well sometimes you don’t have money, but you cannot get this food stuff. Other times there is no money, you don’t have money, and you don’t have a way to go out to get money. Even if you broke your stones, who is coming to buy them? Nobody. So you are stuck with no one to buy them. And so, you have to suffer.”– 47 year old, female, Stonebreaker

Isolation.

Participants across all focus groups shared their feelings of being isolated during the Ebola epidemic, as community members were unable to leave their homes and could not visit their friends, family members, or neighbors, whether they were healthy or sick. Church services were also suspended, and people were unable to pay their respects to loved ones. In addition to not being able to leave their homes and attend activities in their community, participants shared that they could not welcome people in their homes due to fear of contracting Ebola.

“During the Ebola, you don’t allow strangers. You don’t allow strangers. Because you don’t know, maybe if they know that this home is being quarantined, they will leave their home and go elsewhere. So when you go to maybe let them in, you become infected. So during Ebola, no visitor is allowed at your home.”– 29 year old, female, Nurse

Participants also shared that they isolated themselves when they were sick because they did not want their neighbors to report their illness to the authorities. Every illness was treated as a potential Ebola case, resulting in a widespread fear of being taken away from their homes and never seeing their loved ones again. The Nursery School teacher described her experience in the following quote:

“Well that what’s happened to me. During the closing, I was not well. I decided to stay in my room and not even come outside …because during that time, if they hear that you are sick, you will go out and you will not come again. That’s why I decided to stay in. I was suffering, I was having ulcer.”– 42 year old, female Teacher

Idle time.

In addition to not being able to freely leave their homes, participants shared that their daily activities were restricted. Because they were unable to work and children could not attend school, there was little they could do during that time. For participants who were not part of the healthcare system, there was nothing they could do to help pass the time.

"During Ebola, no work. We do not do anything. We do not even allow our children to go far from the home. While sometimes we are to go and sleep, even though we are suffering, but we have no alternative but to stay at home."– 37 year old, female, Petty Trader

Hunger.

Because individuals were unable to work, their families suffered financially during the Ebola epidemic. This made it difficult for families to purchase necessities, including food and coal, to prepare meals for their families. Because of the financial strain families experienced, extreme hunger was common during the Ebola epidemic. During the school closures, children were restricted to staying in their homes and they were bored and hungry, which was particularly difficult for their parents to manage.

"At that time, it was very hard to for us to get food, so that was very difficult for us. We really suffered a lot at that time because some people actually lived day by day except to go out and fight for food. That was really stressful for us.”– 28 year old, male, Teacher

Disparities in suffering.

During the Ebola epidemic, some groups and communities were affected more than others. Participants shared their perspectives that women were more burdened during the epidemic because of their role as caregivers of the household and having to care for sick family members. Participants perceived that women were more likely to die during Ebola and pregnant women were particularly vulnerable due to limited access to healthcare. A teacher at the school summarized this burden in the following way:

“Women suffered more because even when somebody’s sick, if the husband is sick he is being taken care of by the wife. If the children are sick they are being taken care of by the woman. So you find out that they suffered more and they died more.”–>50 year old, male, Teacher

There were also geographic disparities, when comparing the experiences of people in rural and urban areas of the country. Participants shared their beliefs that fewer people living in urban areas died from Ebola but there were more instances of hunger in those areas, while there were more deaths due to Ebola in the rural areas (locally referred to as “the provinces”) but less hunger due to access to food crops.

Compromised culture.

The Ebola epidemic impacted daily life in many ways; however, participants shared that one of the more challenging impacts of the epidemic was how it affected their ability to partake in important traditions with one another, particularly funeral and burial rites. A healthcare professional describes how her cultural traditions were compromised:

“You can’t expect my loved one to die and tell me I should not hold that person. As we are Africans, when someone died we feel sorry for that person, we sympathize with that person. But during Ebola, when someone died, they would tell you not to go to that home. Even when we have some security surrounding the entire building, you can’t go in there. There are so many things.”– 29 year old, female, Nurse

During the Ebola epidemic, individuals were unable to practice customary burial rites for their loved ones, whether they died of Ebola or other causes. Participants shared that this was very traumatic for families. One teacher noted:

“We lost our culture. People that could be buried in a respectful way, they just bury them like that. It was really sorrowful for us. It was not easy at that time”– 27 year old, male, Teacher

Participants also described how community members sometimes retaliated against the burial team when they were removing their loved ones’ bodies from the home. For instance, one stated:

“And it sometimes caused riots … Yes, among family members when this burial team, when they come to collect the corpse, some family members riot.”– 32 year old, male, Teacher

In addition to compromised funeral traditions, participants shared that they were unable to celebrate holidays and other customs. One grade six student noted, “On the holidays we go to our village and celebrate our holidays, but because of Ebola we are unable to go there.” Even typically happy traditions such as weddings could no longer be celebrated due to the inability of communities to gather together.

“When Ebola was here, marriages were postponed. Because in our local setting, whenever there is a marriage you have a reception and dance with each other and because of this transmission that one was shut up. There were no marriages.”– 53 year old, female, Nurse

Managing grief.

Ebola has a high case fatality rate, and estimates suggest that almost 4,000 deaths can be attributed to the virus in Sierra Leone during the 2014–2016 epidemic [1]. In all of the interviews and focus groups we conducted, participants shared that they had lost community members and immediate family members during the Ebola epidemic. They expressed their understanding that traditional funeral practices were forbidden due to fears that they would lead to Ebola transmission; however, compromising funeral traditions also impacted how individuals could grieve for the loss of their loved ones. Even when families held small funeral services, people were hesitant about attending.

“There is no sympathy. Someone died, they want to attend the funeral? No. Because you are afraid. You don’t know what killed that person. You are afraid to attend the funeral. So you just decide, you just cry for the person, you just feel bad, but you will not go there. Except the close family members …”– 53 year old, female, Nurse

Compounding their grief, participants described that they did not know where their loved ones were buried, as individuals suspected of having Ebola were taken away in ambulances and sometimes never heard from again. Participants described the trauma and grief that they continue to feel over the loss of their spouses. One participant shared:

“They ask you out, take the body away from you, spray the house for any remaining virus, and then you will not be visiting them. And that happened to me. Up until now, I have never seen my wife again.”–>50 year old, male, Teacher

Another community member also shared her grief due to a similar situation:

“My husband was sick, and then even when he died, he finally died, I was going to go to see him, they forced me, they take him away from me, so I couldn’t do anything. And up until now, I’m still suffering because that space is still empty so I have to manage.”– 47 year old, female, Stonebreaker

Not all of the participants we interviewed had lost immediate family members during the Ebola epidemic; however, they did lose colleagues, friends, and members of their community. They described the grief for their community in the following passage:

“We cried a lot because seeing a colleague dying, seeing a member of your family dying, seeing a friend dying, seeing a relative dying, and you can’t do anything. You can’t touch them, you can’t bury them, you know it was terrible.”– 53 year old, female, Nurse

Belief that Ebola was man-made.

Lack of communication from government officials and health workers created confusion about Ebola. Although most people learned about Ebola through the radio, many people, including healthcare workers, initially ignored the information.

“We just heard it’s a disease outbreak in some of the African countries-Ebola-that killed thousands of people, but … we never experienced it, so we just ignored it. We didn’t take it seriously.”– 29 year old, female, Nurse

Additionally, many people were suspicious that the disease was connected to an upcoming election. This led to widespread distrust toward the government with people speculating, “When Ebola started, people were- they just thought that the government wanted to make money. Some of us did not believe.”– 29 year old, female, Nurse

Misunderstanding Ebola transmission.

Many participants shared that there was confusion about Ebola transmission during the epidemic, and indicated that people primarily misunderstood how they could contract the disease. Additionally, participants were still confused about Ebola transmission at the time of our interviews. One participant in the men’s focus group commented:

“I think that Ebola is like an airborne disease. I think Ebola is like airborne disease, right? Like TB, you know. Because of the air we breathe or whatever, then we can get Ebola.”– 42 year old, Construction Worker

In addition to not understanding Ebola transmission, some Sierra Leoneans believed that Ebola was a “curse” and not a disease. A healthcare professional relayed what she heard people say about the origins of Ebola in one village:

“What they say is that that they stole something from the neighbor village and they placed a curse on them. So that is their idea, they are going with that. It’s not Ebola. They even advise them not to eat bush meat, because at that time we don’t know, but we say bush meat can cause Ebola.”– 29 year old, female, Nurse

Fear of government services and healthcare.

During the Ebola epidemic, people were afraid that if they reported their symptoms to health authorities, they would be sent to the health center and never see their families again. For instance, one participant stated:

“And even if you are sick, you can’t go to the hospital. Because you are afraid. You think, when I go there, I will die.”–>50 year old, male, Teacher

This led to a fear of government and healthcare services throughout the country. Even when healthcare services were used, participants expressed fear of the outcome of these services.

“Because the feeling was that no sooner you enter the ambulance, and you are taken to the hospital, well about call it 80% chance you would die.”–>50 year old, male, Teacher

There was also reluctance to alert the authorities about potential Ebola cases, as homes with an Ebola patient were quarantined for a period of 21 days after the patient was taken away [22].

“They invite the team- the burial team, they will come and take the specimen. After they take the specimen, they will know if the person die of Ebola or not. If the person die of Ebola, that particular household is going to be quarantined.”– 29 year old, female, Nurse

Additionally, due to the similarities between the symptoms of Ebola and malaria, people feared they would receive an incorrect diagnosis of Ebola. This led to an underreporting of illness and underutilization of healthcare facilities during the Ebola epidemic. One member of the school personnel stated:

“… and so people decided ‘well, let me die in my room.’ Because most people when they go [to the hospital], they will never come again.”–>50 year old, male, Teacher.

Participants also shared widespread reluctance to report their symptoms because they believed there was no purpose in seeking healthcare services since Ebola cannot be cured. Therefore, many ill individuals remained in their homes because they preferred to die at home than at the hospital. However, this put their families and caretakers at risk and contributed to Ebola transmission between family members.

"Well, again at first, we are taught that when you catch Ebola, you won’t be cured … So, with that people will say, ’Well, if I have Ebola I don’t see the reason why I should go to the doctor.’ So, they just decide to run away by themselves and hide in place. And at the end of it, they die there. And the family that is helping them and contacting them also die."– 32 year old, male, Teacher

Participants also expressed widespread fear and concerns about the methods officials used to prevent Ebola transmission. In particular, people were concerned about the chemical spray that officials used in their homes, reporting that they believed the prevention methods could have contributed to other health problems.

"When one person sick, he will report that feeling malaria, and all of us stay at this house. When they come, they will spray, and take everybody out, and spray, maybe one week, and after one week when you get inside that house all of us would die because of the chemical is too strong!"– 36 year old, female, Baker

In addition to concern about the chemicals such as chlorine that were used to treat the homes of suspected Ebola cases, community members also did not feel that the officials relayed proper instructions on how to stay safe during and after the spraying.

"When they first started spraying homes with chlorine, they did not tell people to wait three days before re-entering their homes. Like they are spraying a room, like when somebody has died, they will go test the person, the family, the whole family in there. Then after the spray they will say ’Ok this one is Ebola free’ but when they spray that area of the room, there is no ventilation and they will not tell the people to go out … So when you don’t go outside the people died. Maybe the whole family will die."– 33 year old, female, currently unemployed, previously a Home Health Educator

Trust of NGOs more than government.

Although there was widespread distrust of the government, Sierra Leoneans trusted the work of NGOs and their services during the Ebola epidemic. NGOs provided a variety of services to families during that time, including food and water provisions and healthcare. Although the rations were less than their normal dietary intake, they eased the challenges many families endured during that time.

“No sooner the ambulance picked up the body, the NGOs- one of them will come- and see the number of people in that particular family. Maybe other ones will come and supply the food, the other one will give you water to drink, the other one will give you charcoal to cook. I mean, just like that. If you are fortunate on that day, if you are not fortunate then you have to, you have to bear it. But however if you are within the city, within three days you must get a little help. Although it is not enough. Because if you used to eat, call it four cups of rice and they say now you have to eat two, well you have to manage with two, because you have no alternative.”– 47 year old, female, Stonebreaker

Ongoing fear and stigma.

Immediately after the end of the epidemic, community members continued to be fearful about Ebola transmission. Although Sierra Leone had been declared Ebola free, it was difficult for people to interact with one another like they had before the Ebola epidemic.

“I was afraid to go back to work. Because everybody is afraid of everybody. If you ask me to do a job for you, I am even afraid to come to your house. I’m even afraid to touch your children in your house. You give me water I am even afraid to drink water from your cup. Because I don’t know. Because it was very fearful.”– 42 year old, male, Construction Worker

Following the official end of the epidemic, fear and uncertainty still permeated the community. Ebola survivors were stigmatized by their fellow community members because they continued to be afraid of Ebola transmission.

“They are stigmatized … The President go to the village and announced that anyone that survived of Ebola that is being stigmatized- anyone that is stigmatizing that person should be taken to the police station. Because we are all one, that is what he told all the nation- that we are all one. We should not be stigmatizing. It can be to you, it can be to me. If someone survived, people think the best thing is we should avoid the person. Because of that, the president said that if you stigmatize someone, you are taken to the police, so it became lesser. So now we can interact with them, we can talk to them, yes.”– 29 year old, female, Nurse

Children were also stigmatizing survivors following their return to school as described by the fourth grade teacher.

“You know, kids are now using words against those that were affected. The stigma makes them to put far away from us, but we do encourage them to come to us because it was-just like it is meant to encourage them not to separate themselves from us. We are one. But that’s it- the stigma is a great thing that affected us up to now.”– 27 year old, male, Teacher

Teachers also expressed that they were initially fearful of putting themselves at risk when they returned to school after Sierra Leone was declared Ebola-free. However, this fear eventually subsided as classes continued and a sense of normalcy returned.

“For us in the lower classes during that time, they said nobody touch hands, but when we came to school, there was no boundary between us and the pupils. We rub our skins together, so it was really a risk for us as teachers.”– 44 year old, female, Teacher

Impact of losing loved ones.

Following the fear of Ebola transmission, participants shared that they were more aware about hygiene and proper sanitation. However, a major challenge after the epidemic was managing how losing loved ones had impacted their daily life. For many people, the loss of family members was a poignant reminder of the epidemic and a difficult hurdle to overcome. Orphaned children struggled with the loss of their parents and had limited access to education. Additionally, some girls who were unable to continue their studies during the epidemic became pregnant.

“The effect of Ebola on Sierra Leone was great. Especially on the children who lost their parents. Because when you look at them- the majority of them are suffering. Because of the economic status of our country, you know, these children are not cared for. Most of them have dropped out of school, most of the girls have become pregnant, they are not going to school anymore. The boys are on the street …. so the lasting effect is there.”– 33 year old, female, currently unemployed, previously a Home Health Educator

Financial challenges.

An unforeseen consequence of the Ebola epidemic was its impact on the economy of Sierra Leone. Even after Sierra Leone was declared Ebola-free, participants shared they were struggling financially. During the epidemic, food was scarce due to the reduction of imports into the country and the inability of commercial farmers and food manufacturers to continue working under government-imposed restrictions. The cost of food increased drastically as it became unavailable and community members had to change their eating habits due to limited accessibility and high food costs after the Ebola epidemic. One member of the school personnel explained the ongoing struggle to purchase food in the following passage:

“Things are becoming very hard, because, I can remember, for me, I used to buy a bag of rice for just 120, that was the baseline. And now it costs me 160 thousands … I buy sometimes certain rice that is very nice, very fine, and so a lot I buy half of that one for breakfast, right? But now I cannot do it, so instead I buy bread. And even at that is still costly. Because the bread we used to buy for 500 now is 1000, the one we used to buy for 1000 is 2000.”–>50 year old, male, Teacher

Caring for displaced family.

Additional challenges after the Ebola epidemic included caring for family members who had lost their loved ones and opening their homes to children who were orphaned, which was a strain on their already limited finances.

"The cost of living. You know- too high. Because when you compare with before Ebola, you just stay with the children, but then after Ebola maybe your relative will lose a father and a mother, so all the family comes here. And so it’s not easy for us because the family is increased." - 33 year old, female, currently unemployed, previously a Home Health Educator

Continuing distrust of the government.

After the epidemic ended, distrust of the government continued. Participants expressed knowledge that money was being donated from other countries and aid organizations to assist with Ebola recovery; however, it did not seem to them that the money was used for its intended purpose.

“People didn’t trust the government because there are rumors that payments are coming from everywhere. Money is sent for us that the facilities will be treated, but we did not see it … They didn’t use it on us, they only use it for their own interest, forgetting about the lower people.”– 27 year old, male, Teacher

Other community members felt that the government should financially assist victims of the epidemic, but that help was not forthcoming.

“It’s just a fact …..our government should pay victims, should help orphans, but on the whole, we are not seeing that … That mistrust is there ….We heard from other countries, like we were after Ebola has happened, like in Guinea what they did for their losses, but for us really I don’t know what is happening.”– 53 year old, female, Nurse

These feelings of fear, distrust, and frustration with government support were consistent across the adult focus groups and interviews.