Ebola emerged in Sierra Leone in Kailahun district, and for a period was confined there. MSF set up its case management center there. However initially all lab testing was being done at the lassa fever lab in Kenema, the only lab then able to do these tests. At some point, it was decided to start treating Ebola patients in Kenema, and a section of the Kenema Government Hospital became the Kenema Ebola Treatment Center.

Ebola quickly engulfed the Kenema Ebola Treatment Center. Dr Khan and several of his assistants were infected and succumbed to the disease. Ebola spread from the treatment center, which was supposed to be a separate, isolated facility, to the general hospital. An unknown number of nurses and patients became infected there. There has, perhaps understandably, not yet been a proper inquiry. At one point, soon after the death of Dr Khan, the hospital had reportedly been abandoned by staff and patients, and it required a personal visit by President Koroma to bolster morale. It was during this period that Kenema became the second epicenter of Ebola in Sierra Leone. How much of this infection was actually spread by the hospital and staff should be a matter for serious scrutiny when this crisis has passed. However the infected staff were members of the Kenema community and would have had multiple contacts with the community during a normal working day.

Sections of the Kenema community certainly believed that the treatment center had a role in the spread of the disease in the city and strong representations were made to government to relocate the treatment center to a suitable location well outside the city. Government agreed to do this, although it is not clear whether this new facility has become operational.

The initial understanding in Freetown was that a treatment center would be constructed well outside the city, in Lakka or Kerry Town. Now, however, we are hearing news reports of "Ebola holding centers" at 34 military hospital at Wilberforce and the police hospital at Kingtom, along with a treatment center at Connaught. Is this wise? The difference between a "holding center" and a "treatment center" is not that great, especially for a disease like Ebola that manifests its outcome in just a few days. The holding center sends blood samples for tests and until those results come back it has the responsibility to care for the patient. If the test comes back positive it has still to keep the patient until arrangements can be made to transfer him/her to a treatment center. And if there is no bed available at the treatment center then the holding center has no option but to hold on to the patient and administer whatever treatment it can.

Are the above-mentioned general hospitals in built-up locations of the city really suitable for these functions? Didn't we learn from Kenema that Ebola is best handled in a specialized facility well away from population centers, such as what MSF has in Kailahun? The military and police hospitals, in particular, are not normally regarded as being among the top medical institutions in Freetown. Do they have the caliber of staff and the institutional infrastructure to handle a disease as deadly as Ebola? The large, closely-packed barracks populations which they serve would appear to provide an even greater risk of transmission of infection. In a fluid, fast-moving situation it is easy to get carried along with the exigencies of the moment and to forget recent lessons. Yes, we need holding and treatment centers, but they should be located and organized with great care in order not to multiply avenues for Ebola to spread.

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