Altruism

I have been thinking about this word lately, especially during this largest and longest Ebola outbreak in history. The Merriam-Webster dictionary defines altruism as feelings and behavior that show a desire to help other people and a lack of selfishness.

The first time I heard the word mentioned was from the urologist who performed my kidney surgery to transplant my kidney to my sister who suffered from chronic renal failure as a result of her systemic lupus twenty years ago.  When I made the decision to do so, it did not occur to me that it was an act of altruism.  To me it was very simply out of my love for my sister.  I wanted her to be able to be free from peritoneal dialysis and hemodialysis, being tied to a procedure which did not allow her to do the things that she loved. 

It was also my way of paying back as many years ago when I was accepted to Wellesley College on a full scholarship, my sister and her husband bought a one-way ticket for me to fly from Malaysia to United States so I could attend college.  It was a great financial expense for them.  Hence I did not see my decision to donate one of my kidneys to her as an act of selflessness.  My three children were young then.  They were in the hospital when my sister and I had our surgeries, she in the next room being prepared to receive my kidney.  They had a real fear of the possibility of losing their mother. I did not think of it at the time but now thinking back my decision to do so must have made an impression on their young minds that when one of their siblings or friends is in need, no matter what it is, they should step up to the plate. 

So in donating my kidney, I might inadvertently be performing a selfish act.  When my sister and her husband helped me to fly to the States, there was no way that I could have repaid them in monetary terms for they did that out of love for me and out of the desire to help me to pursue my dreams.  My children benefited from this act by learning to treasure family tie and sibling relationship in ways that I could not have done otherwise. I delved in the pleasure of dreaming of she and her husband gallivanting about Europe once she was no longer tied to a machine.  All these rewards after an act of so-called altruism made it difficult for me to see that it was a true act of altruism and not an act of selfish pleasure.

In years past, volunteering in medical relief as a doctor in various parts of the world in natural disasters, conflict, and war, helping people to feel a little better, the refugees in the camps to regain some degree of human dignity and in the process saving some lives, actually give me a great deal of purpose in life and deep happiness.  Indeed losing oneself in the immersion of helping others is exhilarating, addicting, and intoxicating.   Studies have shown that those who help others have a healthier life and live longer.  So I may be the beneficiary of these benefits. When helping others or performing acts of altruism, the pleasure center in the brain lights up in the same area as when we are loved, when we flirt, have sex, or enjoy life’s simple pleasures.  If altruism gives us such pleasures, is it then an act that lacks selfishness? 

In my cumulative three months of volunteering as a doctor in the Ebola Treatment Units in Liberia and Sierra Leone in the Ebola outbreak in West Africa, I was emotionally overwhelmed by the intense pain and suffering of the people and felt powerless against the unrelenting waves of deaths caused by the virus.  Even in this situation of “altruism” as a volunteer in the Ebola outbreak, my rewards were immeasurable.  My volunteering gave me a strong sense of purpose in life, and a wholesome dose of incalculable fulfillment and untold satisfaction that in some subliminal infinitesimal way I played a part in something greater than myself.  I bore witness to the greater triumph of our noble, kind, compassionate, caring part of humanity which again showed its capacity to rise to the challenge of this deadly virus by the willingness of our fellow humans to even give their lives to save another.  As a participant in this outbreak I bore witness to the resilience and courage displayed by both the sufferers and the helpers, and the brave and selfless acts of numerous nationals and volunteers who displayed altruism in the true sense of the word:  “Greater love has no one than this: to lay down one's life for one's friends”. 

In less than two days I will be heading to Nepal to offer medical assistance to the quake victims. I am sure my reward will be far greater than what I could give. 
If there is internet, I will try to blog nepalkwankewlai@blogspot.com

End of Quarantine

My daughter called and said, ”Congratulations, you’re free from Ebola!”

April 15 was my last day of quarantine.  I had never once developed a fever or any symptoms except some short periods of fatigue right after a brisk run and once in a while troubled by my migraine, but no aches and pain to speak of. 

This time around after my volunteering, I was quite confident that I was not incubating Ebola. My experience in Sierra Leone was slower paced and less intense than my experience in Liberia.  I also felt safe in our infection control practices in the ETC.  Of course there were the subliminal positive thoughts of family and friends and the protective “pink bubble” into its cocoon some of my Wellesley friends have placed me for the duration of my time in West Africa.  With the end of my quarantine, I can now emerge into the world without fear of infecting a vulnerable person.

I was never cooped up in my house, having long walks into the ever changing Habitat of Belmont now that spring is coming, running almost most mornings and spotting snow drops and crocuses peeking through residual snow and dead autumn leaves.  Soon there will be the bright yellow forsythia, soft pink cherry blossoms and my backyard is already covered with carpets of deep blue Siberian squill Scilla, all signs of spring that bring a song to my heart.  There are also bright red Cardinals with their less opulently colored partners, fat red-breasted robins, Canadian geese, and ducks almost always traveling in couples.  Woodpeckers peck furiously on dead tree trunks at such a speed that one wonders why they do not suffer from concussion. Once a rafter of six turkeys flew into my neighbor’s backyard rousing the interest of Grisela who pretended she was really not interested in them and skirted around them and finally made a move for the kill.  They lived.  Another evening I saw what looked like an osprey flying in the sky with its big wing span.

Siberian squill Scilla

Grisela Stalking the Turkeys

In our neighborhood there is a lone wild tom turkey which must have lost his mate for at least a year but he roams around here, occasionally making a display of his tail and his gobbles could be heard in the evening.  He must be a very lonesome creature.  My neighbor has observed Gri stalking the tom some mornings when she is not stalking the numerous squirrels here.  In the evenings there are the Belmont bunnies coming out to feed in the gardens.

The State Health Department was quite concerned about my cat being exposed to me.  There is also a myriad of animals and living things in my yard that I made friend with…

Figuring that I was no longer a threat to anyone on my last day of quarantine, I went to Wellesley College to watch the carillonneurs play the Wellesley Carillon: 30 bronze bells from England in Galen Stone Tower.  In the evening, I attended a talk by Nicolas Kristof, the Pulitzer Price Award winner about his recently published book “ A Path Appears”

Galen Stone Tower of Wellesley College

I sneaked into the Museum of Fine Arts early one morning when I felt the crowd would be thin to see the exhibitions of the internationally known Japanese artist, Katsushika Hokusai who was most known for his woodcut print “Under the Wave Off Kanagawa (Great Wave)”.  I was actually swept away by the enormous crowd in the MFA!

Hokusai Great Wave

I was not the best behaved person during the quarantine but I mourn its passing because now I have no more excuses but to resume the responsibilities out in the “real world”. 

William Wordsworth describes my mood best in his poem: I Wandered Lonely as a Cloud

I wandered lonely as a cloud

That floats on high o'er vales and hills,

When all at once I saw a crowd,

A host, of golden daffodils;

Beside the lake, beneath the trees,

Fluttering and dancing in the breeze.

Continuous as the stars that shine

And twinkle on the milky way,

They stretched in never-ending line

Along the margin of a bay:

Ten thousand saw I at a glance,

Tossing their heads in sprightly dance.

The waves beside them danced; but they

Out-did the sparkling waves in glee:

A poet could not but be gay,

In such a jocund company:

I gazed—and gazed—but little thought

What wealth the show to me had brought:

For oft, when on my couch I lie

In vacant or in pensive mood,

They flash upon that inward eye

Which is the bliss of solitude;

And then my heart with pleasure fills,

And dances with the daffodils.

The Inconvenience of a Quarantine

Starting week two of my quarantine. 

The last time I had a fever was when I got sick with dengue almost two years ago and I have not had a fever since.  I am pretty confident that I will not come down with Ebola.  In Lunsar ETC, I don’t recall any breaches or exposure.  The time I spent in the ETC donning PPE was miniscule compared to when I was in Bong ETU, Liberia when the patient exposure was intense and the crammed quarters made maneuvering among infected patients quite treacherous.  

Asymptomatic individual does not incubate the Ebola infection and yet asymptomatic volunteers are restricted in appearing in crowds which goes against evidenced based reasoning.  Because of that, I will be missing my daughter’s first one-person Art Show in Burlington, Vermont, this evening and the Harvard Law Review Banquet at the Harvard Club next week.  I don’t care that much about the banquet but I am sure sorry to miss the opening of the Art Show.  This will be her first since graduating from Rhode Island School of Design years ago. If anyone is in the Burlington area, do drop by and view her paintings.  Break a leg, Cara or as Grisela would say,"Break four legs!"

My brother and I always dabble in painting in our spare moments; when I was twelve my colored pencil drawing was chosen and made its way in a traveling exhibition in Asia along with a whole bunch of works submitted by other children.  My brother also submitted his painting bringing awareness to world hunger.  Now and then my daughter and I have our works exhibited at the Belmont Gallery of Art.  Last but not least, Cara’s great grandmother was like my brother and me, a self-taught painter, and sold her paintings on the weekends in Greenwich Village in New York. There may be some genetic components to Cara’s art talent but her styles and ideas are uniquely her own (www.cara-doo.com). 

Great Grandmother Amolia Selling her Paintings in Greenwich Village 

I might have harbored the wish to be an artist when I was young but the reality of a starving artist was looming too large for me.  I needed to be financially independent and I definitely had no desire to depend on a spouse or others for my survival; like my poor mother who did not have a choice.  Looking back I still think being a doctor is still the best decision I made.  In my next life if there was one, I would, without a doubt, choose to be a doctor again. 

My Painting: A Swan in Trent, Italy

Homecoming

When I left for Sierra Leone in February, I did not tell my neighbors about it but did inform some friends.  The airing of the NPR interview might have reached some more of my friends.  I later learned that the news of an American being flown in for treatment for Ebola stirred up questions whether I was the one.  My family was able to quickly eliminate me by checking on my blog.  Similarly many of the American healthcare workers in Lunsar ETC had the same reactions from concerned family and friends.  Our presence in West Africa did cause continued anxiety which sometimes while we were there in the midst of the outbreak, we easily forgot.  

Upon my return, I took a long walk in Belmont and my first encounter with a neighbor was “a keep-a-distance hello” but his dog came charging to greet me as most dogs do here. On my morning run several Belmontians were carrying placards campaigning for issues to be voted on in the local elections at the busy intersection in the center of town.  One of them who was all bundled up greeted me enthusiastically, “Welcome back!”  I did not recognize her at first but soon realized she lived right across the street from me. 

Many e-mail exchanges occurred between the people at the State Department of Public Health and the Beth Israel Employee Health as to how the responsibility of monitoring of my 21-day quarantine should be divided.  In the end the state will take the lead to be followed by the local Belmont Health Department; skyping daily for a face-to-face encounter and twice daily reporting of temperatures and symptoms. It only takes a few minutes but I still feel a little bit of an intrusion and harbor a feeling of defiance.

Grisela and Me

Grisela returned home from Burlington, Vermont, the day after my homecoming; my daughter cat-sat for us.  She is a year old now and no longer a kitten.

Gri, Me and Cara, my Cat-Sitter

The British military nurse recovers in London Royal Free Hospital having received an experimental drug MIL 77 and was discharged two days ago.  The American is still in NIH listed in serious condition. 

Last night I learned the greatest news yet; the infected national healthcare worker was discharged from Kerry Town Ebola Treatment Center for healthcare workers.  He is an Ebola survivor!  (thanda kuru) He never received any special experimental drug.  I rejoice in his recovery.  The center initially had no room for him despite him being confirmed with Ebola as a healthcare worker but had rooms for other American healthcare workers with potential Ebola exposure to the infected American but with no confirmed infection.  This happened in his own country!

Screening at the Airports

Locals at Lumley Beach

I traveled to Freetown planning to leave from there to Lungi Airport again taking the speed boat.  Lumley Beach is right across from the Family Kingdom Resort where I stayed, however as a beach right in the city it is not very clean and once I saw a rotting dog carcass.  Evening breezes were quite pleasant and despite the Ebola outbreak, the locals took their leisurely evening walks.  In the morning I ran along the beach for a way and a number of fishermen were busy pulling in their nets.  This weekend there will be in a lockdown and there will not be any activities in the whole of Sierra Leone.

The compound of the resort was filled with a number of cars from various NGOs, there seemed to be workshops run by Save the Children and WHO.  For our departure our temperature was taken at each of the stops, at the ticket office for the speed boat, at the gate to the airport and at the entrance into the airport.  There at the health stop we filled out questionnaires on where and what we had been doing in Sierra Leone and for any symptoms.  The gentleman ahead of me set up an alarm in the infra-red thermometer; his temperature was above 38 degrees Centigrade.  The tester used three different thermometers on himself and on him again.  He repeatedly set off the alarm.  He was then pulled aside and taken to some place.  That was a scary moment.  We arrived at the airport at least six hours early.  He did not appear in the waiting area until a couple of hours before departure.

On Leaving Sierra Leone

Our first stop was Brussels.  There we filled out a Public Health Locator Form in case if we got sick the airline could locate us and identified our seat assignment.  Again our temperature was taken.   

The screening at Washington Dulles Airport was much organized compared to last year.  This time I was put in a room again with stainless steel bench and table but no sink or toilet.  The officer kept the door open and told me I did not have to sit on the metal bench and politely offered me a proper chair.  The CDC officers had a lot more questions specifically on Port Loko District where the American healthcare worker got infected.  I did not make it clear to them that Lunsar is actually in the Port Loko District, only a half hour from Marforki ETC.  Since the three healthcare workers came down with Ebola we have not heard what happened to them, except the American's condition has been upgraded from critical to serious.  Several more people returning from West Africa had a shorter time at the office bypassing the CDC officers as they were there for reasons other than Ebola.

An hour later, I was able to get my bag through customs and onwards to my next leg of the journey back to good old Boston.

Ai Ko Nay Dushit (I am going Home)

Early this morning, I woke up and opened the door to find Kalomere the sheep and three goats all lying outside my room.  The black goat which had been goading the sheep gave up a very obnoxious goat smell which permeated the cool morning air.  The stars were more plentiful now that the moon has waned.  In one corner there was a hint of the Milky Way but the light pollution prevented it from being visible.  As I pondered over my time here all of a sudden a shooting star came whizzing by across the sky.

Sunset at Bai-Suba

Today would be my last day in Lunsar.  I know I am nearing the end of my stay by virtue of the fact that I am low on my medications and my sunscreen is almost all gone. I packed up and found three big empty plastic bottles which I was reluctant to see them ending up in the pile of trash in a corner in Bai-Suba. Trash especially plastics is a huge problem here.  I have tried to reuse the bottles by replenishing my water from the water cooler in the ETC but at St. John there was no water cooler. I walked out and found some laborers who had been working at building drains, always under the unforgiving searing heat of the sun.  I was a little embarrassed about giving them such meager offerings as some empty bottles but these attracted the attention of quite a few of them.  It made me feel very bad inside that they were so happy to receive such small things like an empty bottle to use as containers for water and I could only make three of them happy.  Life is hard.

I was heading to Freetown after spending time in the Screening and Referral Unit (SRU) at St. John in the morning.  I went to pay a visit to the starving infant and to bring water to the mother, only to learn the sad news from one of the nurses that she died last evening.  The mother sat on the bench quietly, staring blankly into space; she no longer had any tears to shed.  The ward where the baby was had been emptied of patients.  Through the screened window I could see the baby swaddled in a wrapper lying all alone in the big bed.  Death seems to be so common place among the little ones here. They have to dodge a gauntlet of circumstances of poverty and diseases trying to survive the period of infancy. Yesterday afternoon she was still suckling seemingly with some relish and then her short life was suddenly ended.  Her mother would not be permitted to hold or hug her for the last time.  The rule of the Ebola outbreak dictates that any death calls for the burial team to take away the body to be buried; there is to be no traditional burial rites. I said good-bye to the WASH and triage teams at St. John. Three of the triage members are from Nigeria and they represent the African Union.

Sign for Safe Burial

At the ETC, I went around saying my farewell to the medical and kitchen staff, pharmacy and the WASH team.  There was only one patient in the Confirmed Ward and five in the Suspected Ward. Even half of the patients in the Suspected Ward had been ruled out for Ebola but had not been discharged.  Indeed this past week, there were no new confirmed cases.  Similarly in Makeni their patient census has been down and the staff who had been sent there to help, had all returned back to Lunsar. 

Ishmael died last night; the four-year-old ultimately did not win his battle against Ebola despite having a negative test for Ebola after three weeks of sickness.  With his death, his mother, Aminata, only had one child left having lost three in a span of three weeks. Ebola continues to create miseries and breaks up families and communities.  

Sunset at Lumley Beach in Freetown

National ‘Zero Ebola’ Campaign

Today marks a year since the World Health Organization confirmed that the haemorrhagic fever killing people in remote parts of Guinea was being caused by the Ebola virus.  Since then Ebola has infected 24,701people and killed 10,194, in West Africa. 

Sign for Zero Cases of Ebola in Freetown

On Saturday March 21^st, 2015, the day after Sierra Leone recorded its first day of “Zero Number” of cases since May 25^th, 2014, President Ernest Bai Koroma is launching a 4-week national ‘Zero Ebola’ campaign. This campaign is a national lockdown calling on all Sierra Leoneans to stay home for three days from 27th to 29th March 2015 and for three consecutive Saturdays; 4th April, 11th April and 18th April. There will be no markets or gathering of crowds but there will be a window for people to attend church on Palm Sunday.  During the lockdown surveillance teams will look for symptomatic individuals and there would probably be a surge of patients referring to the ETC for admission. 

Ebola Signs in Freetown

Guinea still has a significant number of new Ebola cases and the distrust of healthcare personnel persists.  Sierra Leone still struggles with continued transmission.  Liberia has a recent set-back with a new case of Ebola in a 44-year-old woman who had no contact other than with her husband who is an Ebola survivor.

April 15^th is the original date for getting to zero cases for all three countries but that seems to be impossible to achieve considering the current situation.  The West African Ebola-affected nations may have to move the date further along and it may be more realistic to wait till the end of summer.

Breast-feeding her Baby

But life goes on.  The starving infant is looking more alert and suckling eagerly.  She is very pale and her hemoglobin is 6.8 mg/dl.  She will receive transfusion today.  One of the babies whose mother refused to let the ambulance take him to the ETC is being treated in the hospital for malaria, looking rather well.  

Beach Therapy

We got a vehicle early enough in the morning to enable us to go to the beach at River No. 2 just right outside Freetown.  This would be my last day off and I left with two of my colleagues both from Africa.  It took us almost two and a half hours to get there.  The tides were going down.  A river flowed into the ocean as the tides slowly receded, it physically separated our beach from another beach and two wooden boats ferried people across at frequent intervals.  At this time the currents of the river were too swift for anybody to attempt to swim across without being washed into the ocean.

Where the River Meets the Ocean

Unlike Bureh, this beach was frequented by many expats including many with families who came with their nannies.  The waves were gentler and the temperature of the water was just perfect.  Many vendors tried to ply their wares on the beaches: dresses, skirts, bags made with African fabric, carvings, trinkets, and lappas.  My colleagues felt that the beach outing was the perfect therapy to release the stress from working in the ETC.  They thanked me for motivating them to come out to the beach, they would have stayed in their hot room as they always do in Bai-Suba searching for things to do to while away their long day or trying to find someone to skype with if there was WIFI.

Beach Therapy

The driver took the coastal road on the peninsula on our way home.  For an hour we traveled on bumpy red dirt road over three very narrow bridges with missing guard rails; a misstep would send us plunging into trickling brooks with big boulders.  In fact we saw the remains of a huge lorry lying on its side resting on the boulders.  There are new and smooth roads on the other side of the peninsula built by the Chinese like in many countries in Africa.  Those with no such help continue to be troubled with poorly maintained, pot-holed roads. 

Along this coastal stretch, deforestation is rampant, burning of forests for charcoal and cutting down gigantic old trees to make rooms for buildings.  Up high in the mountains there are still forests but they are also being threatened; they would be bald in no time and would resemble the landscapes in Haiti if no effort in conservation is in the immediate offing. The old indigenous trees would be a thing of the past not to mention the creatures that inhabit these areas.  As we drove along, several areas of the mountains were slowing burning away with smoke rising to meet the haze of the afternoon.

Water Melon Patch

In the evenings I often visit the vegetable garden in Bai-Suba which is very therapeutic for me.  Their main problem is the lack of irrigation system so watering is done with the use of watering cans.  Many of the new seedlings shrivel up and die in the hot sun.  As far as I can tell there are Irish potatoes, beans, carrots, turnips, cabbages, eggplants, tomatoes, lettuce, onions, cucumbers, and water melons.  For some strange reasons the sheep and the goats never seem to wander in here to feast on the vegetables.

The hazy orange sun peeked through the palm fronds at sunset.  I only have a few days left in Lunsar and will leave for my home sweet home very soon. 

To Be Triaged to the ETC and a Set-Back for Liberia

Our first patient was a six-month old baby brought in by his tired-looking mother, wrapped up in a worn lappa.  The baby did not breathe and once in a while, a gurgled breath rattled from the chest through his throat.  He looked lifeless.  Mom said baby had had trouble breathing for two days but according to her still nursing well as recently as this morning.  It was hard to believe a barely conscious child could be nursing.

For a while we were hesitant whether to let the mother and baby sit in a corner till he drew his last breath and informed the burial team, however a doctor from the hospital seemed to think the patient should be brought into the inpatient department.  There at least three quarters of an hour of resuscitative effort was performed with ambu bag and CPR.  Apparently his pulse returned and since there was no ventilator, no one could be squeezing the ambu bag for a prolonged period of time.  Eventually when there was no spontaneous respiration, the resuscitation stopped.  The baby was back to drawing a rattling breath every few minutes and there was still a flutter of a heartbeat.  The grieving mother was told there was no hope and she was quietly sad and tearful sitting in a corner with no other family for moral support.  Once the breathing and heartbeat stopped the hospital would inform the burial team.

The starving baby from yesterday was alert and drinking from a cup held by her mother.  There were still two thirds of the infant formula left. 

Back to triage, two women with their babies fulfilled the symptom criteria for the ETC but they had no Ebola contact.  They could just as well be any baby with gastroenteritis or malaria in ordinary time.  But these are not ordinary times.  Both women were robustly built and vocal.  After some time of waiting in the corner together, both of them came to the conclusion that they would not let their babies go to the ETC.  I probably would protest as well if I were the mother.  There is always a danger of exposing your child to patients with Ebola when he is staying for the few days in the ETC waiting for testing results.  Any mother would fear for her child and worse to be separated for days without the ability of any physical contact.

In the end the surveillance team came and agreed to let them stay home.  They would monitor them closely for symptoms.  The babies were discharged home with antipyretics and anti-malarials.

We learned from a woman that Ishmeil’s mother refused to admit him to Port Loko Hospital yesterday after his discharge from the ETC.  Last night this lady said Ishmeil was “trying to die”.  The last we heard he was brought back to the ETC. It might have been premature to celebrate his recovery yesterday as he did not seem to be out of the woods.  Ebola which has ravaged his immune system may still be waiting to claim its victim.

Liberia is no longer Ebola-free.  It suffers a set-back; a new case was reported after 20 days of being free from Ebola, a woman was diagnosed with the infection presumably through sexual transmission.

The Cry of a Starving Infant

Ishmeil and his mother finally left the ETC.  This is a victory and joyous occasion that everyone has been waiting for as we have had few Ebola-free discharges and especially discharges for someone as young as four years old.  I was at St. John so could not share in the celebration but I am glad to have been a participant in his care. I had a feeling that Mariatu would die and she did.  Asiatu is doing well and her child has been tested negative for Ebola. 

Triaging had been brisk all morning.  A 25 year-old mother brought along her one-month old baby all wrapped up wearing a colorful winter hat.  When she slowly unfolded the wrapper from the baby, we were speechless looking at a baby who was starving; face aged and wrinkled, skeletal arms and legs and skin stretched thinly over her prominent and delicate rib cage.  This was her second child and she said she was not producing sufficient milk. The young mother did not look particularly malnourished. The crying baby was eager to suckle when she put her to her breast.

In the afternoon I went to the Pediatric Ward in search of the infant.  Since my last visit, the ward had quickly filled up, a very good sign for the hospital.  A woman lying next to her boy called me by my name but I drew a blank when I looked at her.  She told me her name which I had not heard of before and explained that she works at the ETC but she has not worked with me.  I am very humbled by the fact that the people in the ETC seem to take an interest in the visitors and I hope I have also reciprocated by my genuine desire in getting to know them. 

I found the tiny baby with two nurses hovering over her busily placing an IV in her arm and they were so skillful, they succeeded.  As a nurse took the baby to be weighed, she cried loudly and we could see that there was a big defect in the soft palate; the baby had a cleft soft palate which might have cause her to have trouble breast feeding and resulting in malnutrition and starvation. She was only 1.8 kg.

Next they placed a naso-gastric tube for feeding.  In the meantime they handed mom a cup for her to express breast milk.  I asked if they had infant formula if the mom was not able to produce enough milk.  One of them told me that the hospital had no milk and did not know when they would receive a shipment.  They also had no idea if the feeding centers in Makeni or Port Loko were open but even that would entail discharging the baby from St. John and the mother had to find her way to the center.  I could only envision the death of the child with all this logistical nightmare that a poor mother had to navigate by herself.  I called the ETC if they had infant formula milk and very fortunately they had a small supply, perhaps enough for a day.  In the late afternoon, I delivered that to the patient’s bedside.  A nurse was patiently giving a syringeful of breast milk through the naso-gastric tube.

Tomorrow I shall check on the infant again.  If the infant formula has run out I will go to Lunsar Pharmacy and buy a supply for her.

“The Reports of My Death Have Been Greatly Exaggerated”

Last evening rain clouds gathered with a slight wind.  For a moment it seemed quite hopeful that we might have a shower but soon the clouds dissipated as quickly as they gathered.  Pretty much like this Ebola outbreak in Sierra Leone when in February there seemed to be a downward trend in new cases then a resurgence plummeting hopes and shattering dreams of seeing the light at the end of a tunnel.

This morning as we were triaging patients at St. John, a pitter patter was heard on the roof and for a while I thought it was just the WASH person filling his bucket from a tap but it was in fact a shower.  It did not last very long or bring relief to the heat only more intense humidity.

The two Nigerian nurses worked as a team triaging patients in Krio.  I have reached a point when I could understand some of their Krio.  Esther in particular was shrewd in questioning the patients about their possible exposure in Ebola and she did it in great humor.  She created scenario in which exposure could happen in the context of their occupation, many of the women were “traders” or owners of a small business, that is they sold a sundry of things ranging from sweets, tiny bags of peanut butter, salt, sugar, or as one of the drivers said “funny things”.  Other people worked in the mines, fixing Caterpillars, there were tailor, student, a boda boda (or motorbike taxi) driver who stopped working because of Ebola and an unemployed nurse who once interviewed for a job at the ETC, in the end she decided that she did not want to work in a high risk zone.  There was a very happy couple in their forties with a newborn and they traveled all the way from Freetown to be seen at Mebesseneh Hospital because of its reputation of providing high-quality care.

We saw many pregnant women and children but none of them were suspected cases of Ebola.  Most patients were happy, healthy, and robust with the exception of a young man with hollow cheeks and sunken temples, aged beyond his years. The triaging record book showed very few referrals at least in the past week so we kept the outpatient department at St. John busy instead.

“The Reports of My Death Have Been Greatly Exaggerated”.  This strange title does not fit well with this post but that has to be a story for another day.  It is best understood by those in the know who despite their veiled objections continue to be drawn to the blog.  

Our Tenuous Fate

I was on night last night.  During the day a group of us traveled to Bureh Beach.  I would have loved to go to River No. 2, another beach run by the community where any income earned gets ploughed into the local people but that was not going to be the case.  Nevertheless we all had a relaxing time but for some of us we had to return on time for night duty.  On our way to the beach, we passed Kerry Town ETC and we wondered briefly whether we should pay our sick fellow Ebola fighter a visit.  However we did not stop.  At the entrance to the beach, the community cordons off the road and requested that we came down to wash our hands.  Unlike other places, I was told that this community has not been visited by Ebola.

On the beach there were some volunteers from GOAL who were enjoying their last day in Sierra Leon.  A couple of them were definitely upset about the American doctor who fell ill with Ebola because, according to them, he was not careful with his practices and when he fell ill, several people were exposed including three of their own colleagues who were evacuated back to Denmark.  GOAL and PIH volunteers live in the same compound in Port Loko.  Not knowing that I too am an American, they told me that all the Americans have gone home and the Marforki ETC in Port Loko is now only run by the nationals.  Even so I think they should be more sympathetic and forgiving since it is one of us volunteers who fell ill and is now listed in critical condition.

Just before we started our shift, the lab results came.  Unfortunately there is a slight setback for Faday who really wants to go home.  His first negative Ebola test is now followed by a positive test, albeit we were told the titer is a low one.  The best news of all is that Ishmeil has his first negative Ebola test and everyone cheered for this little one.  He has been here for 17 days, probably an eternity for a youngster, having lost 2 siblings and a great grandfather in the ETC.

There will be two discharges in the morning, these patients do not have Ebola, they have malaria.

Three-year-old Ibrahim, Asiatu’s son was brought into the Probable Ward from the village.  He is stable, eating and drinking well.  Asiatu remains without symptoms but overnight Mariatu started to have high fever, bloody diarrhea and also coughing up blood.  She is keen on taking her ORS and does not want all that IV fluids but we explained to her that we need to catch up on the losses through her diarrhea.

As our morning shift drew to an end, a national worker brought in two live chickens into the ETC heading for the kitchen.  The fate of these poor creatures was sealed.  They would be someone’s lunch today.

Here is a link to an article in the New York Times regarding the differential treatment of Ebola infected foreign and national healthcare workers which I raised in my last post.

http://www.nytimes.com/2015/03/17/world/africa/hospital-says-american-clinician-being-treated-for-ebola-is-worsening.html

A Moral Dilemma: Do Some Lives Matter Less?

During my morning run I try to avoid the open meeting hut of the drivers but this morning there was no one there, then it dawned on me that today was a Sunday.  So I went to St. Peter’s.  This time I sat in the back bench against the wall.  From there I could observe that many of the women had their babies with them and they stuck to the back in case their babies made too much noise.  Outside like in past Sunday, a gathering of disabled and elderly folks waited for church dismissal.  How they could withstand the searing heat of the hot and unforgiving sun was beyond me.  A little boy dressed in a suit which was probably bought deliberately oversized so it would last longer walked with his proud mother elegantly dressed in a deep purple traditional dress with an equally fantastic headdress.

Back to the ETC in the afternoon, the 14-week pregnant woman who died had Ebola.  Yesterday a mother Mariatu and her sister-in-law Asiatu who lived in Rosemarie’s house were admitted.  Rosemarie died of Ebola a few days ago; Mariatu and Asiatu were tested positive.  These two looked well now but it might be the calm before the storm of Ebola havoc.  Asiatu was tall and attractive with prominent high cheek bones while Mariatu was topless with dangling breasts the whole time she talked to us, never once felt self-conscious about her revealing condition.  Instead she asked for a wrap to cover her head. It must be the natural thing here for even the two healthcare workers rounding with me seemed pretty much unperturbed.  We were there for a fairly long period having to wait for her 1000 liters to drip in while I dripped sweats inside my PPE.

Faday had one negative test and a second one would declare him Ebola-free.  The Lunsar ETC is really starving for a celebration, it has been about two weeks since we last had a victorious discharge.

The infected national healthcare worker was finally to be transferred to Kerry Town ETC for infected healthcare workers.  Why it took two days to get admission there was a mystery.  The patient refused to go at first having had a good experience in our ETC.  As the disease progressed, diarrhea had started with fairly significant abdominal pain which required morphine, we gave aggressive hydration.  I could just picture this strong patient becoming weaker in the next several days.  Just before the transfer, six of us in our PPE surrounded this patient to give us our support, rallying the cry that the patient needs to be strong in the next several days.  I will always remember this tableau of solidarity for one of our own who has fallen ill.  As everyone then got busy getting things ready, I spent a few private moments holding the patient’s hand as I would like to have done to me, giving some words of encouragement.  Just before departing we gave the patient a shot of morphine for the abdominal pain and the IV fluid was still hanging.

As the infected American healthcare worker was medevac’d to NIH in US, some volunteers asked the question why a national who had worked alongside this American with the same NGO, risking his/her life in the front line is not given the same aggressive care.  Is a national life less than an American's? I had asked myself the same questions as I watched the patient got off the ambulance and took the long lonely walk down the corridor to the Confirmed Ward. Did the patient feel abandoned by his/her colleagues? How does one reconcile with this moral dilemma?  As the American media reported that 10 more potentially exposed Americans from PIH were evacuated to be isolated in US and to be close to facilities that could take care of them immediately if the need arises, the national who is infected and symptomatic stayed in our humble ETC where we have no ability to do more aggressive treatment than vigorous IV hydration.  Oftentimes in any NGO, expats seem to enjoy better working and living conditions than the nationals and one wonders whether the nationals feel like a second class citizen in their own country. On the PIH website that is a caption that reads “The idea that some lives matter less is the root of all that's wrong with the world”.

We all hope this patient well and our prayers go with the patient every single day. 

To be the Infected

Our census is not staggering; seven in total, one patient is to be discharged as he does not have Ebola.  The 4-year-old Asiatu sat on a chair looking at her mother who came to visit her sitting in the visitor’s tent across from the orange fence.  The separation might as well be like a vast ocean. She did not look very happy and neither was she very ill.  However the national nurses came and picked her up to give her medicines which were more or less forced into her tiny mouth and in the end she threw them all up.  One of the nationals told us that that is how children are given their medicines here.

In the Probable Ward was a 14-week pregnant woman who was picked up yesterday from a quarantined home, bleeding form her womb.  While sitting on a stone slab in the village she fell backwards and hit her head.  This morning her breathing was labored, dry blood coated her nostrils, she had expelled her fetus during the night but her placenta remained.  She had a swollen left side of her face with a huge bruise, and bleeding in her conjunctiva.  Whether her vaginal bleeding had led to shock with her fainting and falling yesterday and resulted in possible head trauma, we would never know.  She was drawing her last breaths and died shortly in the morning.  Her Ebola test was just sent.  If she were positive, there would be a lot more people potentially exposed in the quarantined home.

Ishmael still refused to eat.  The kitchen did not cook his peppered soup.  He continued to have diarrhea but he had no fever this morning.

The healthcare worker who contracted Ebola walked out of the ambulance into the corridor of the Confirmed Ward yesterday, walking the lonely anxiety-provoking walk, greeted by the fellow healthcare workers.  I am sure every scenario had been gone over to find the very act of potential breach.  To have seen and cared for so many Ebola patients, their ups and downs, their horrendous outcomes and triumphs and now to be on the other side of the infected must be quite surreal and scary.  We spent some time to dispel the notion that the patient was not to impose blame but to think on the positive.  We as the caretakers would do our utmost to help the patient but the patient would need to have faith.  I reached out to give a parting pat on the thigh and looked into the hemorrhagic eyes; there was fear, reassurance, gratitude, and a sense of unity.  For a brief moment as I walked from the backyard into the ward, my eyes were moist from trying to put myself in the patient’s shoes; would I fare any better?  This is every Ebola fighter’s nightmare, to contract the very agent that one has been trying so hard to save the patients from killing them.  To date, 840 health workers have tested positive for Ebola in West Africa with 491 reported deaths.

Today all of us seemed to pay a little more attention to how we conducted ourselves in the ETC.

Jenni Marsh from the South China Morning Post based in Hong Kong interviewed me a few weeks ago and here is a link to their magazine publication.  My son's in-laws in Hong Kong said it is the cover story of the magazine: Behind the Mask, One Doctor's experience on the Ebola Frontline.  It is nice to have the Ebola story reached Asia.

http://www.scmp.com/magazines/post-magazine/article/1736695/ebola-diary-dr-kwan-kew-lais-harrowing-journal-her-time