KENEMA, Sierra Leone -- Highly contagious corpses rotted in the rain amid a shortage of body bags. Nurses turned to plastic packaging as protective gear ran out. Even some of the chlorine provided to Sierra Leone's Kenema Government Hospital last year was suspect -- in one case more than a year out of date and effectively worthless.
The 2014 Ebola epidemic pitted a lethal virus against barely-there health systems, and it was always going to be deadly. But an Associated Press investigation has found that a string of avoidable errors badly undermined the work of international aid workers.
The World Health Organization, charged with leading the fight against global outbreaks, already has been criticized over its management of its clumsy efforts to stop Ebola. Earlier this year, an AP investigation found the UN health agency delayed declaring an international emergency -- similar to an SOS signal -- on political and economic grounds.
Newly obtained emails, documents and interviews show that WHO and other responders failed to organize a strong response even after the signal was issued.
Experts say the fumbling ultimately cost lives across West Africa.
"We would like to think that WHO comes in as the cavalry, but they were bungling the response as they came in to try to rescue people," said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. He described the WHO problems uncovered by AP as "horrifying."
To date, Ebola has killed more than 11,000 people and officials estimate the epidemic won't be stopped before the end of the year.
Kenema, a diamond town in Sierra Leone whose potholed roads turn to red sludge in the rainy season, was a microcosm of the Ebola-fighting efforts across West Africa as the disease spiraled out of control.
The situation at the city's hospital was horrific. Blood-drenched patients lay in agony in understaffed wards and WHO staffers made repeated requests for support that went unanswered. Other aid workers declined to work there, citing the dangerous conditions.
As Ebola cases climbed in July 2014, WHO Director-General Dr. Margaret Chan identified Kenema as one of two priority areas. "Transportation, PPE (personal protective equipment) and other equipment must (be) provided," she wrote on July 24 in an email to her senior staff.
But staffers regularly received expired or questionable chlorine, incidents that spooked already rattled staff, according to interviews and emails seen by AP. Nurse Donnell Tholley said workers sometimes resorted to donning ill-fitting gloves for their hands and using stray plastic packaging on their feet instead of the tall protective rubber boots they needed. More than 40 health workers died and others abandoned the hospital out of fear.
Joseph Fair, a U.S. disease expert advising the Sierra Leonean government in the capital, Freetown, described WHO as "paralyzed," recalling interminable conference calls debating things like the colour of body bags -- even as supplies ran out.
When the Red Cross offered to build an Ebola treatment centre to alleviate the pressure on the hospital, it was held up because no one in Sierra Leone's government or WHO could tell them where to build it. Days passed without a decision as frustration built on all sides.
"We are at risk of very poor perception by the public when we send in IFRC (Red Cross) then block their ability to care for patients," WHO's Ian Norton wrote in a note to his colleagues.
Mark Honigsbaum, a medical historian at Queen Mary University of London who is writing an oral history of the outbreak, said Kenema was one of two key places in Sierra Leone where the spread of Ebola might have been averted. Honigsbaum said the AP's findings showed the "extreme confusion and lack of co-ordination in the critical months when they could have arrested the epidemic."
By the time the Red Cross clinic was finally built, the peak of the outbreak in Kenema had passed. Twenty health workers had been infected in the interim. Many patients who succumbed to the virus were buried in a cemetery behind the clinic, their graves marked with numbers instead of names.
Dr. Bruce Aylward, WHO's top Ebola official, said it was common for Ebola treatment centres to be caught up in political wrangling. "Undoubtedly in some cases there was bureaucracy," he said.
But he argued it was wrong to lay the blame at WHO's door. "These were government decisions at the end of the day," he said.
Complaints about WHO leadership focused in part on Jacob Mufunda, the agency's top representative in Sierra Leone.
Requests to fix critical problems like the hospital's shaky generator regularly went unfulfilled by Mufunda's office, leaving staffers to cover thousands of dollars' worth of expenses out of their own pockets, according to two people there at the time. They spoke on condition of anonymity because they weren't authorized to talk to the media.
An email from Chan which AP obtained corroborates allegations of tight-fistedness, not just in Kenema but across West Africa. Chan told Mufunda and other senior officials that only a tiny fraction of needed cash was being released and that the problem had festered for four months.
"I expect all our colleagues ... to facilitate experts and staff to do their field work and not to post barriers because business as usual does not work during crisis," she wrote.
Mufunda, who was reassigned to run WHO's office in Mozambique shortly thereafter, didn't return messages seeking comment.
The problems that hamstrung the Ebola response have prompted soul-searching at WHO and across the world's public health community.
Two months ago, a WHO-commissioned panel criticized the organization's lack of leadership, but didn't mention the logistical problems uncovered by AP. All of the top leaders at WHO during the Ebola outbreak remain, except for its Africa director, who retired after serving out his term.
That has left outsiders dismayed.
"These official inquiries they just talk in general terms about leadership," said Honigsbaum.
Fair said the entire world had to share the blame.
"The world simply did not respond to the disaster in West Africa last summer," he said. "It truly was like fighting a forest fire with a spray bottle."
Maria Cheng and Raphael Satter reported from London and Paris.
