Outside Connaught Hospital, the woman with the glassy eyes and raging fever had been waiting all day, hoping that a doctor might be able to answer her questions: Did she have Ebola? Could someone treat her?

But five months and 24 days since the first case of the disease was confirmed in Sierra Leone, there was no bed available for Aminata Dowhertoi. She sat with other would-be patients in a plastic tent, where people often died waiting for treatment.

“There’s still no space,” said her husband, Salifa Konu Conteh. “After so much time, still no space.”

It’s a scene that recalled the earliest days of the outbreak — before hundreds of millions of dollars were committed to the fight against Ebola, before volunteers arrived from around the world, before the number of cases in neighboring Liberia began to decline.

But while resources were committed and progress occurred in some parts of West Africa, the disease crept toward Sierra Leone’s largest city. New hospitals didn’t open on time. Makeshift holding centers filled up.

Time-lapse of the Ebola epidemic

“We take as many people as we can. The rest we have to send back to their communities, where they continue infecting their neighbors. What else can we do?” said Yusuf Koroma, the coordinator of Freetown’s Macaulay Street holding unit.

On Tuesday, 40 people in Freetown and the surrounding area called the government’s emergency response number asking for transport to treatment centers. Eleven were left at home because there was no space.

Holding units, like Macaulay, were intended as a stopgap measure — a place for patients to be tested and isolated until room became available in a treatment center. But the holding units quickly filled up. And many of the admitted patients never make it to treatment centers. In his blue logbook, Koroma has noted that more than a quarter of the people admitted to Macaulay died before receiving proper treatment.

In July, as Ebola ravaged Sierra Leone’s eastern districts, like Kenema, doctors in the capital started to worry that it could spread to Freetown and wreak havoc on
a dense, urban population of 1.2 million people.

“We saw Monrovia explode, and we thought, ‘Okay, there’s no reason that’s not going to happen here,’ ” said Oliver Johnson, a program director at Britain-based King’s Health Partners, which helps oversee Connaught Hospital.

But while bed space expanded in Liberia’s capital, it did not here. Pledges were made to build new treatment centers, but many were delayed — sometimes because of logistical challenges. Some aid groups canceled their plans altogether, unable to deliver on their commitments. The closest treatment center with consistently available beds is eight hours from Freetown.

“We thought we would have all these beds coming on line, but it didn’t happen when we needed them,” said Winnie Romeril,
a spokeswoman for the World Health Organization. “Everyone knew the problem here was going to get bigger.”

A boy rides his bike through the Monkey Bush neighborhood of Waterloo, Sierra Leone. (Nikki Kahn/The Washington Post)
Early intervention

In Liberia, where the Ebola caseload appears to be declining, health workers say the improvement is due largely to the increase in treatment centers, particularly in Monrovia. When infectious people are taken from their communities to health facilities, it serves a dual purpose: They no longer infect their friends and relatives, and they receive care earlier, which is more effective.

There were 1,197 new confirmed Ebola cases in Sierra Leone in the 21 days before Nov. 12, according to WHO. There were 335 confirmed cases in Liberia during that same period.

British officials who have been charged with leading the international Ebola response in Sierra Leone say their timeline reflects the evolution of the outbreak.

“We’re where Liberia was three weeks ago, not because we were complacent but just because it didn’t kick off as early as Liberia,” said Donal Brown, head of the U.K. Ebola Task Force. “We’re not a month behind because we were sitting on our hands. We’re a month behind because of the way the disease has played out.”

But others say that approach implies a reactive response rather than one that prepares for inevitable outbreaks in urban centers such as Freetown.

“There was no effort at all here. If there had been more smaller treatment units, there would have been a huge impact,” said Monique Nagelkerke, the head of mission in Sierra Leone for Doctors Without Borders, one of the aid groups most involved in responding to the Ebola crisis.

An accelerated disease

Over the next few weeks, a number of facilities will open their doors or increase their bed space. The British government has completed construction of a 92-bed treatment center in Kerry Town, about 30 miles south of Freetown. But only a fraction of those beds are available while the center trains staff and gets its safety protocols in place.

The British government has promised to build enough treatment units to house a total of 700 Ebola patients. So far, 140 of the new beds have been made available.

“The point at which, as in Monrovia, we have enough beds, I think we’re going to see a decrease in caseload,” said Johnson, of Connaught Hospital.

“When those facilities open, we’re going to see a sea change,” said Paolo Conteh, the head of Sierra Leone’s National Ebola Response Center.

But at the moment, the disease is growing much faster in and around Freetown than the medical infrastructure.

Experts agree that adding bed space must be accompanied by other efforts — such as campaigns to encourage safer burials in which infectious corpses are not touched and “contact tracing” to monitor and isolate possible victims.

In Freetown, such efforts are underway. The government and international groups are also providing lessons and materials that will help families care for the sick.

“It’s now a necessity to teach people how to take care of the sick at home, because there’s nowhere else to put them,” said Romeril, the WHO spokeswoman.

After her 11-hour wait, Aminata Dowhertoi was eventually loaded into an ambulance that would take her to a holding unit. Her husband slipped her a bottle of water through the window. She leaned back, exhausted.

While she had waited, more of the sick had gathered outside the tent, some lying on pieces of cardboard, others holding their heads in their hands.

A doctor learned that another rare bed had become available at the holding center. He opened the door of the ambulance where Dowhertoi was resting and looked at the crowd.

“Okay,” he said, “which of you has been waiting the longest?”