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 

Ebola and the Risk to Healthcare Workers

When we reported to our morning shift, we were handed 5 patients; 3 in Confirmed and 1 each in Probable and Suspected Wards-a very light census.  Someone’s parting remark to us was to try not to have a very long day.  It has been ten days since we last have a positive patient.  Faday wanted psychosocial team to go to his house to check on his child who was reported to be sick.

In the late morning after the patients had their meals and nursing care, we started rounding from the outside of the fence.  Patients were mainly stable.  Ishmael seemed slightly better sitting up across from Peter Rabbit, although he seemed to be groaning and whining a great deal.  His mother, Aminata had been encouraged to interact with him.  It was nice to see him lying on top of her belly.  He shook his head when we asked him whether he had such-and-such a symptom and went through a whole list of food trying to find something enticing that he would be willing to eat but he only nodded to peppered soup.

St. John triaging sent a four-year-old girl Asiatu to be admitted to the Suspected Ward and mom and aunt came along.  Mother was none too happy to be sent to the ETC and refused to have anything done to her daughter.  After a lot of persuading and explanation of the risks of staying with Asiatu in the ETC, her aunt insisted on staying with her.  Asiatu’s mom has another baby who is still nursing.

Here in Lunsar I have very little news of the world but some of my colleagues mentioned that a British and an America volunteer have contracted Ebola, both working in Sierra Leone.  The America volunteer works with PIH and is flown back to Bethesda for treatment.  Here in Lunsar we admitted another national healthcare worker working with PIH in the same ETC in Maforki in Port Loko District as the American.  In the span of a few days, there have been three volunteers contracting Ebola, hitting home the fact that we have to be always vigilant with our infection control practices.  It is very easy to let our guard down when the cases are decreasing.  However, I am puzzled as to why the national healthcare worker did not get admitted into the ETC for healthcare workers in Kerry Town.

At one of the weekly round table conferences, we could have brushed shoulders with many of the healthcare workers.  We are in it together fighting this epidemic, when one of us is down, it sure affects us all.

As volunteers here we are also concerned that after such a long period of calm without an American volunteer coming down with Ebola, the media frenzy surrounding this case might throw the public into a kilter again. My brother sent me an e-mail " Re: US care worker down with Ebola" wondering if I might be the one and wished I were safe at home in the US and if not to come home safely from Sierra Leone.

Casting a Wide Net

When I arrived at the front of St. John Hospital this morning, I did not see any patients waiting and yet after I changed into scrubs, the patients continued to parade through triaging.  All of them we cleared to be seen at the out-patient department including a very thin man who had been coughing for about a month with many of the hall-marks of tuberculosis.

Then walked in an ill-looking man who had a whopping of a fever, complained of malaise and anorexia.  He has been traveling from Makeni to Freetown driving goods and staying overnight in Freetown.  Just about a week ago he started to have diarrhea and he stopped his trips to Freetown and returned to Makeni where he sought the help of a traditional faith healer.  He was not feeling any better so he came here accompanied by his brother who wore a black t-shirt with multi-neon-colored words printed on the front” My Money Grows Like Grass”.  There was no psychosocial team to explain to the patient about the ETC which was where we sent him after waiting for the ambulance to be dispatched via the government for at least an hour.  Oftentimes the line at the command center was turned off and the captain either did not answer calls or failed to return calls when promised to do so.  Knowing the tardiness, I made sure he received his lunch and water.

Between twelve and one o’clock, all of a sudden the patients were all triaged.  We had three patients who walked in, including one being brought in by a taxi.  He was discharged from the ETC two weeks ago with two negative tests for Ebola.  He was feeling well the first week then poorly the second.  The only symptoms we could get from him were weakness and poor appetite.  He did not look dehydrated to me.  We decided to send him to be seen at St. John.  While he was being triaged, he was given an energy bar which he devoured eagerly without even unwrapping it; the flame of hunger consumed him.  He did have an appetite; perhaps he was just weak with hunger.

Looking over the book for triaging, there have been very few suspected cases being sent to the ETC and the ones that were sent usually turned out to be negative.

Our lunch from the ETC never materialized.  We were promised a one thirty delivery, then two-thirty, then three thirty but still no lunch.  The WASH shift is on duty till seven in the evening.  They would have to wait to eat at dinner time, a long time to be hungry.

A Week with No New Ebola Cases in Lunsar ETC and the Meteneh ETC in Makeni

It has been eight days since we last have a new Ebola case in the Lunsar ETC.  Many of suspected cases turned out just to be that suspected, which is a good thing.  Yesterday afternoon a 7-month-old baby was admitted with some symptoms and her mother who is not a patient stayed with her.  The negative Ebola patients have been discharged back to their community.  This morning we will transfer two more Ebola-negative patients to Port Loko Government Hospital, one for scrotal abscess and malaria and the other for anemia and hepatomegaly.  RK will be transferred to MSF facility in Freetown for termination of her pregnancy which is rather sad.

Ishmael continues to refuse to eat and pulls out his naso-gastric tube, his persistent diarrhea dictates continuing his IV fluid.  He is our sickest patient.  Last night the ETC had a movie night.  A screen was set up at the back of the three wards and patients could watch it from the backyard.  My Temne nurse and I donned around 11 pm, by then most patients were in bed except Aminata, Ishmael’s young mother who curled up in a chair watching the movie.  In the wards, while patients were trying to sleep or already deep asleep a few patients had their radio music turned up at full blast.  Surprisingly none of the other patients complained.  I had to turn it down so I could talk to them.

For the rest of the night, all was quiet.  We were able to take a nap on cots or mattresses placed on the floor, a sleeping arrangement far more superior than that of Bong ETU.

The Meteneh ETC

My one day off is now after a night shift which really should be a day to catch up on my sleep but a colleague and I wanted to go to the beach, however as always we could not find a vehicle early enough so we drove to Makeni, an hour away in the Bombali District.  There we paid a visit to the 100-bed Mateneh ETC built by the UK military.  This was where a resurgence of cases came and many of the staff form Lunsar ETC was moved here.  So it was nice to be welcome by many familiar faces.  We could really feel the impact of the full sun here without the shade of the corridor that we have in Lunsar.  The very friendly person that took us around evidently is very proud of the center.  Many of the confirmed patients who were on the road to recovery sat outside in the covered corridors waving.   Today they have a total of 34 patients, 15 in Confirmed, 11 in Concalescent, 5 in Suspected and 3 in Probable.  Because of the bigger patient load, the medical staff split up their duties.  Their mortality rate is about 50% and like us, lately they are seeing a lot more hemorrhagic cases.  They also had 5 births, one of whom was from an Ebola-infected woman but the baby who initially tested negative but then became positive, eventually passed away at a few days of age.

Celebration with Hand Print on the Wall

Today also they celebrated 2 discharges; we were able to witness the happy discharge of a young man who proudly planted his hand print on the wall signaling a new beginning for him.  Then they all marched out of the ETC to the psychosocial tent, with singing, dancing and drumming.  There he would receive his Ebola-free certificate.

Market in Makeni

Downtown Makeni was abuzz with outdoor markets selling slippers, cell phones, and clothing but I did not see fresh fruits.  We stopped at the supermarkets and right outside I bought some mangoes from a young girl and from St. Mary supermarket which only had a few pineapples and corossoliers; I bought a corossolier for a treat and to remind me of home in Malaysia.

A Corossolier

March is reputed to be the hottest month here and the sun’s ray has been so intense that my clothes get dry in less than two hours! In Bai-Suba where the generator is turned off during the day, those of us who have the day off try to cat nap rather fitfully, sweating all the while.

Ebola is Real

In the morning I went into the market in Lunsar center.  The same blaring radio was on and I wondered if the locals have grown so used to it, they are just background noises.  Someone called me by name and when I turned I saw a face with a wide smile and she asked if I was shopping.  I said yes and would like to buy some cucumbers.  She then asked me if I remembered her name.  “What is my name?” has been an on-going game here.  The nationals often query me whether I remember their names. It is hard enough for me to remember everyone’s faces and their names but I have done quite well.  I told her that her name was Aminata and she broke into the happiest and widest grin.  She helped me to buy some cucumbers.  I went into the crowded market and picked up some lappas (wrappers) and then a tin of sardines.  While waiting for the driver to come to pick me up, several persons greeted me, pronouncing my name accurately.

Abu Bakar came to pick me up.  He has been instrumental in teaching me some Temne.  He has asked me whether I went to the market to interact with people and expresses his sentiments that many expats keep to themselves, tight-lipped and do not interact.  He asked me what I would miss most when I leave Sierra Leone.  I answered, “The people.”  As I said that a man came right into the path of the cruiser barely looking at where he was going.  Abu Bakar laughed and said people paid little attention on the road.  Life in Sierra Leone is hard and people are poor and hungry, always searching for food and employment.  Ebola does not make it any easier. 

He blamed Ebola for his wife’s death a month ago.  After giving birth to their third child, she began to bleed but there was no one who could help her for fear of getting Ebola as it is largely believed that infected pregnant women have a high viral burden.  His wife did not have Ebola but no one dared touched her.  Abu Bakar said she fell and died. As he held her in his arms, he wondered whether this would happen if there were no outbreak of Ebola.  We reached the ETC when he finished telling me his story.  He was so grief-stricken that he could hardly contain himself.  He covered the pain on his face with his hands; no tears flowed from his eyes.  I knew we were not to touch skin but I could not help but reached over to touch his shoulder gently.  Another vehicle with a fellow driver drove from the opposite direction.  Abu Bakar composed himself and nodded in acknowledgement.

I had the afternoon shift with 11 patients signed out to two doctors, a luxury compared to yesterday when I worked alone.  As the death marching order of Ebola continued, Emmanuel Senior and Rosemarie passed away, unable to stem the surging tide of death.  Ishmael seemed a little better, we urged mom to encourage him to eat.  Mom lost her grandfather, Emmanuel Senior this morning.  I asked her how she was coping.  She said when her baby died she was quite ill herself and she felt “mixed and confused feelings inside” and when her 2-year-old died two days ago, she cried inside her heart.  She has also recently lost her husband to Ebola.  At age 22, she has 2 children left, a 7-year-old in Freetown and Ishmael in the ETC with her.  So much tragedy in such a short period and at such a young age! 

Her young caretaker then told us a similarly tragic story.  In October when many Sierra Leoneans still did not believe that Ebola was real, her husband died of Ebola while in Port Loko Hospital and he bled all over.  When she saw all that blood she became convinced that Ebola was real.  She and three of her children became sick and all perished except her and now she is a caretaker for other Ebola patients in the ETC. She also lost her mother.  

The 4 year-old Abu cried all afternoon for his papa who brought him to the ETC 3 days ago and he left him here.  Abu cried until he was so tired that he finally fell asleep on the lap of his caretaker.  The psychosocial person would get in touch with his father to pay him a visit.

RK with her 10-week pregnancy is still waiting for a negative Ebola test.  She has been advised to terminate her pregnancy and arrangement has been made for her to be transferred to an MSF facility.

It is so ironic to think that when Ebola was rampant here in Sierra Leone last fall, many Sierra Leoneans did not believe that Ebola is real and it kills.  When Ebola reached the shore of America, in the person of Mr. Duncan who later infected two more persons, many panicked that Ebola would spread like wild fire and that drastic measures should be imposed including quarantining the asymptomatic returning volunteers for 21 days and preventing any incoming flights from West Africa from landing in the US!       

Marching to the Order of Ebola

It was morning shift for me with 17 patients handed over to us and by the end of the shift, 2 more new patients were admitted to the suspected ward, full at the beginning of the morning with no one for discharge so these two might end up in the Probable Ward.  Most of the patients in the Suspected Ward had one negative Ebola test and hopefully their second test would remain negative as well.

The Temne–speaking nurse and I did the majority of our rounds outside the fence as most of the patients in the Suspected and Probable Wards were stable and were sitting outside after their breakfast.  With us asking questions over the fence would mean there was no way one would pass HIPPA in America. The two patients I sent from St. John yesterday looked well, although one of them remained anorexic.  We donned PPE to round mainly in the Confirmed Ward.

The three sickest patients were in the Confirmed Ward.  The 22-year-old Aminata who lost two of three children; 5 month-old baby and 2 year-old Emmanuel again did not look as devastated as I would imagine her to be; she did not like the food served and asked for fufu and peppered soup.  She looked so young that she could almost pass for a teenager and she behaved like one.  Her 4-year-old Ishmael struggled with diarrhea, thankfully no longer bloody, and pulled out his naso-gastric tube a few times.  Her father Emmanuel Senior struggled with his breathing and we finally helped him to bring up a thick mucus plug and raised the head of his bed higher; he seemed more comfortable.   In the next room, the 70-year-old Rosemarie only responded to verbal stimuli, now only subsisted on IV fluids.  She seemed to have lost her will to fight.

Again we seemed powerless against the marching course of Ebola infection despite treating the patients symptomatically.  We would need to have an antiviral or to have an armamentarium that would boost the immune responses of the patients against Ebola.    

The Chiefdom Entourage

It was a very slow day at triage at St. John, perhaps because it was a Saturday and the outpatient Department only opens for half a day.  There was just about half the number of patients waiting on stools outside the hospital this morning as compared to the last time I was here.

We did send two patents with suspect cases of Ebola to the ETC, one of them was not such a strong case but following the Ebola Triaging Protocol, she fulfilled the criteria.  The other patient took paracetamol before coming to the clinic and his temperature remained flat but he had a number of symptoms.  Despite his denial of ever visiting the sick or attending a funeral, the nurses did not believe him.  However it took almost two and a half hours and numerous phone calls before the ambulance finally came to pick them up to go to the ETC.

As we waited for more patients to be triaged, all of a sudden a big group of traditionally dressed men in Boubou or Agbada , women in Boubou and head pieces, and section chiefs in white traditional clothes looking rather distinctive and elegant; came to the triaging area. These were the community leaders including the Paramount Chief identified by a pendant medal he wore. Later I spotted them roaming the outpatient and inpatients areas.

Fatmata, the severely dehydrated baby was much improved, awake, alert, and had been nursing well.  She was lying in bed playing with her foot.  Soon her mom could take her home.

The village was strangely soporifically quiet.  The stores closed by twelve noon on Saturdays because of Ebola.  Some women gathered under the shades of trees cooking, washing clothes, hair-styling; some just bared their chest because of the heat.  The men congregated together over their vehicles and little shops, away from the women.  Goats roamed around eating small sprigs from short bushes.  One man wearily said Ebola has destroyed their commerce and he was tired of it.  He gave a sigh that said it all; he could not wait to return to life before Ebola.