Paper Sharks and Fufu

The entire time I was in Sierra Leone I searched for a certain meal I came to depend on while I was in the Peace Corps in Cameroun.  It is called fufu and is a staple dish of many African and Carribean countries.  It can be made from a variety of vegetables but I am partial to the cassava fufu.  It is a pretty labor intensive process.  First you harvest the cassava (aka yuca), a long waxy brown tuber that grows easily in tropical climates.  You then soak the tuber in water for a few days.  It is then pealed and cut up into small squares and laid out on sheets of tin roof to dry in the hot sun.  It gives off a tangy, musty odor as it dries.  Once it is fully dried, it is taken and placed into a giant mortar and pounded with a thick wooden pestle until a thin flour is made.  The flour is then added to a pot of boiling water and stirred with a long wooden spoon or stick until it becomes the consistency of a sticky cream of wheat.  It is balled and served alongside a ground nut sauce with any number of bitter leaves.  You pull off a piece of the ball with your hands and soak up the sauce with it.  Generally, it is a communal meal with everyone eating from a giant ball of fufu and dipping it into one bowl of sauce.  It is more than an acquired taste.  It is an acquired religion.

Cassava fufu is food for the people and prepared in any village in Sierra Leone.  I asked for it from every kitchen.  People smiled, perhaps thinking I was kidding.  Why would this tall, lanky white man want to eat villager fufu?  I saw the pestles in the village on the way to work rise and fall, pounding the dried root vegetable into flour the same way their ancestors have done for centuries.  As my time came to a close in Sierra Leone, I came to terms with the fact that I wouldn't be reunited with fufu this time around.

Dr. Kafoe, one of the Sierra Leonean physicians I befriended, invited me over to the One Mile Lodge where he and several other colleagues were staying on my last day in Sierra Leone.  We had talked about getting together for weeks but with schedules and families had yet to make this happen. Until the day I was leaving.  One Mile Lodge sat at the end of a dirt road that passed through a palm grove. It was encircled by a concrete wall atop which jutted shards of broken glass bottles.  They looked like hot, angry green teeth in the wash of the mid-day sun.  The Lodge is a group of small concrete two story buildings painted in pastel colors that open up into a communal concrete courtyard with a small bar on one end and a deck on the other with small plastic tables adorned with vases holding old, faded fake flowers.  It is much more intimate and African than the Bai Suba where most of us stayed.

I greeted Alusine, our pharmacist, who was wearing a tie in the colors of the Sierra Leonean flag and pressed clothes that conformed to his body perfectly with no excess.  His wife, Michelle, wore a traditional African dress in a semi-glossed print of brown and black, her head covered in matching material.  A Guinean physician, Dr. Bah, soon arrived, belly out front with a huge smile that closed his eyes when it fully expanded to take over his whole face.  There were a number of Kenyan nurses, including Anne, who sat quietly with her legs crossed, eating an orange.  Kamara and Kafoe, my two Sierra Leonean colleagues, darted around in Sunday attire grabbing extra chairs and glasses like any hosts would do anywhere.  Mohammed, another physician from Sudan, and I sat and washed our hands in the bowl of water put on the table as is customary in Africa.  We spoke of his time working in Darfur and of providing medical care when the refugee camp you are working in is getting shelled.  "That is when I started smoking," he said.  There we all were, brought together by Ebola, teammates for the past month and a half, at my final meal in Sierra Leone.  Michelle, it was announced, had prepared the meal for the occasion, a meal typical for most families on Sunday.  She brought out the plates covered by plates.  I took off the top and low and behold.... cassava fufu!!!  Apparently, Kafoe had mentioned that I was enamored by the root vegetable dish and they all had prepared the dish earlier that day.  Kafoe giggled as he showed me the video of the men turning the fufu out behind the concrete wall over a small fire.  I was not only heading home, I was home.  We ate there as a group that had experienced something we may never experience again, pulling off the fufu with our fingers and using it as our utensil to collect the sauce.  The hot African pepper peaked late, was washed down by cold orange Fanta.  We sat and talked and laughed for hours, never once mentioning Ebola.  It was, for once, not the largest occupant of our shared space, having been temporarily minimized by the power of connection.

After thirty six hours in transit, in and out of dreamless airplane sleep, I landed back in San Francisco to find my wife waiting for me, alone, with sunflowers in her hand.  I have been home for three days now and am serving my twenty one days in isolation in our converted garage guesthouse, "la casita."  I call the health department twice a day with my temperatures and meet with them weekly.  Ebola can incubate in human hosts for up to twenty one days but generally will infect people within ten days of their last exposure to the virus.  I am not concerned.  I have the requisite GI issues and a low level nausea that accompanies foreign travel.  And the re-entry phenomenon.  I hide behind the jet lag.  Now I am cutting out sharks from glitter paper with my children to make valentine's day cards for their classes. They tell me I look old.

I run in the cold mountains behind my house when the kids are in school and my wife is at work.  I crawl back into writing, the space between words.  It has always been more about what isn't said.  I cut out more sharks and glue them to clothes pins.  My son glues the googly eye on and opens the mouth up by squeezing the clothes pin.  "Chomp!" he says in a growl.  My daughter recites a line from the play she is taking part in at school called "Into the Woods."  I watch their mouths and bodies move here in our toy room.  My wife keeps them on track so we can finish the valentine's day cards by Friday.  Outside the recent winter rains have summoned a green carpet to the hill's empty field behind our house.  The Christmas lights are still strung up in the trees.  I want to take them down.  Maybe tomorrow.

The number of new cases of Ebola in Sierra Leone has risen for the second week in a row now.

Fufu

Mohammed

Kafoe

Bah

Sunday Fufu Supper Club

Standing Up on Salt and Water

I traveled over ten thousand miles to stand up on my first surf board.

A few of us took advantage of a mutual day off today and headed back to Bureh Beach.  For some of us, it will be our final trip to the coast of Sierra Leone, and to a beach that has been restorative, almost antidotal during our time here.  We piled into an old Range Rover and opened the windows as we sped away from the heaviness of our somber routine.  Today would have been Bob Marley's 70th birthday so a station out of Freetown was sprinkling some familiar reggae tunes between West African pop songs. We past villages once unpronounceable that have been since weaved into our new vernacular.  Mamama.  Masiaka.  Rogbere. We skirted through Ebola checkpoints that have been loosened in the past few weeks.  The roadside hawkers peddled their fares.  It is pineapple season now and the papayas hung like green testicles high above the thatched roof lines.  Augustine, our driver, pointed out that the decapitated palm trees I have often inquired about have died from being tapped incorrectly.  People here, as in other parts of Africa, tap their palm trees in order to make palm wine.  It is sweet and pungent if you drink it in the first day or two after it is tapped but if you wait longer it ferments and becomes acerbic. If you tap it too aggressively the palm tree loses too much of its essential fluid and dies.  The top falls off.  Palm tree trunks stick straight up on the landscape as we drive.  Now I know why.  It is all about keeping your fluids in balance, whether in the Ebola wards or in the palm trees.

Michael, the Australian who runs Australeone, greeted us as we arrived from the hammock that overlooked the soft shore.  He came to Sierra Leone about 10 years ago as part of the UN's war crimes tribunal from Australia.  The trials revealed so many atrocities committed during the civil war. His job was to capture it all as the court stenographer.  He would escape to Bureh Beach as often as he could.  He bought a little property along with a Sierra Leonean friend of his and has created a rustic group of wooden cabins and a thatched bungalow where you can sit and have some fresh fish or crab with coconut rice.  We ordered our food and walked over the the Bureh Beach Club next door.    Michael told us that a reporter from the New York Times recently wrote an article about the surf club (http://www.nytimes.com/2015/01/11/world/no-moon-suits-just-trunks-and-the-healing-surf.html?_r=0).  Kids were already in the water drifting out on surf boards, laying belly down in waiting for a wave to catch.  Smaller kids were running and skiffing on smaller boards in the shallow surf.  As they laughed and ran, it was striking how this was the first time I had actually heard kids being kids, free from Ebola, free from working to sell bananas or peanuts in the streets.  The surf crashed, the sun was  just where it should be and the palm trees leaned into it all.

We rented a surf board for the whole day for eight dollars.  Julie, another infectious doctor from the Bronx, and I wanted to join the kids and try to catch some waves.  I have never surfed before but Julie grew up in southern California and has some skills.  The kids were not just standing on their boards and riding the waves, they were actually dancing on them!  So we paddled out and I awkwardly tried to stand up on my long board to practice.  And fell. And fell. And fell.  The kids were laughing and showing me how easily they could mount their boards and ride even the tiniest of waves.  I laughed too at myself.  Here I live in Northern California with some great surfing, and I am trying to catch a wave in Sierra Leone.  Finally, after a number of attempts, I managed to stand up for a brief second before the board went flying out from underneath me.  That was enough to whet my appetite, but also enough for the day.

I met a man named Davis who was carving out a pirogue with a modified axe, by hand.  He told me it takes about three weeks to make a boat out of a log from a tree whose name I couldn't understand.  He offered to make me one for two hundred dollars.  I thought of my father-in-law who grew up in a fishing village in Colombia and how he would love to watch Davis claw and chip away to make this fishing boat, just as his great-great grandfather did so long ago here on this shoreline.

There is something about the ocean water here that allows you to float easier.  I drifted on my back, eyes closed seeing only the red of the overhead sun, and thought back to my time here.  I listened to my breathing internally with my ears under water.  In through my nose and out through my mouth, I attempted to empty my thoughts.  The waves raised and lowered me and turned me in the current.  Larger waves rippled my body.  I had to blank out the images of bodies in new death poses.  Get back to the breathing.  The underwater sounds were distant and carried by streams within the ocean before they fell apart.  Buoyant, there in salt and water and sun,  arms spread out to my sides, drifting in a stripped down vessel made of salt and water, pointed towards home.

A Soccer Goal without a Net

I have watched more soccer on television here in the past month and a half than I have ever watched.  It is the African Nations Cup tournament, a time when all the countries in Africa who have qualified over the past two years square off in a format identical to the world cup.  They are each assigned to a group and the top two teams in each group advance to play teams from one of the other three groups.  Starting with sixteen teams in four groups, they are reduced to 8, 4, and then 2 remaining teams.  African players who play for lucrative European teams come home to join their national team for the honor to play for their country.   For their fellow countrymen and women.  For bragging rights.  Much like any sport, the affinity you have for your team is steeped in the story of your team, and when it is a national team in Africa,  the stories have chapters.  Colonization chapters.  Dictator chapters.  Corruption chapters.  Genocide chapters.  Starvation chapters.  Disease chapters.  Independence chapters.  Freedom chapters.  Redevelopment chapters.  Prosperity chapters.  Redemption chapters.  And always hope chapters.  

Guinea qualified for the African Nations Cup despite not being able to benefit from any home field advantage.  Because of the Ebola outbreak that started in Guinea in December, 2013, all its games had to be played in other countries.  They overcame great odds to qualify for the Cup and advanced to the 2nd stage before being knocked out.  Morocco was supposed to host the 2015 Cup but withdrew because of the Ebola outbreak.  Public gatherings to watch soccer are still banned here in Sierra Leone, so we didn't get to watch the matches together but everyone rooted for them and followed along on the radio or on the lobby television.  All of the teams have distinct, overt personalities shaped by the current state of affairs in their country.  Some teams are content with a take-no-chance conservative ball control management devoid of any flare for the dramatic or aggression.  They are stable, status quo.  Others are hungry, young, and aggressive, attacking with long runs that draw on power and individual skill, with a touch of undiscipline.  They want change and don't want to be restrained.  The teams that can find just the right combination of speed, power, and finesse and arrangement in proper spacing are the ones that advance.  Soccer is all about triangles.  And so much more. The "beautiful" sport indeed.

I am nearing the end of my time here.  The stories keep coming in, carried by ambulances from familiar and unfamiliar villages.  The longer you stay here, the more it becomes clear that Ebola is only one of many epidemics continuing to rage.  

Ali, a new driver for International Medical Corps, was interviewed here three weeks ago.  His wife was pregnant and due any day as he left his village to travel to Lunsar to interview for the coveted, yet temporary position.  He wore a full pin-striped suit and carried a brief case he told me as he rode in a "bush taxi" all morning to get here.  He interviewed well and was offered the position.  He was all smiles and couldn't wait to tell his wife.  A few minutes later he received a call from his village that his wife gave birth to a healthy baby girl but that his wife died in the process.  He continues to smile and call us "sir" and "mam" when he drives us to and from the Ebola tents.  Beyond Ebola, Sierra Leone has one of the highest maternal mortality rates in the world.  

Mohammed, a 34 year old construction worker who helped in the construction of our Ebola Treatment Center, was diagnosed with pulmonary tuberculosis back in August and was started on medications at a TB clinic called Lakka just north of Freetown.  He took the medications for about one month and then, according to him, the clinic shut down because of Ebola.  He was offered the job to work for the contractor who won the bid for our treatment center construction and left his hometown to come to Lunsar to work.  Without medications.  He was brought into our center 3 days ago because of shortness of breath and fever.  He was felt to be a suspected case of Ebola but it was clear when we saw and talked with him that he had progressive lung disease from TB.  He had a small head that sunk down between his shoulders and a flat, sculpted face that reclined slightly to expose a large patch of  forehead.  His arm musculature was defined in that way manual labor develops muscles-- without gross exaggeration of biceps or triceps.  His fit chest expanded and contracted in short, shallow breaths.  Sweat beaded at his adam's apple and streamed down the muscular mid-line canal that ended in his navel.  He was confused and restless due to the fact that his oxygen level was 75%, normal being over 95%.  He died six hours later.  Beyond Ebola, tuberculosis rates in Sierra Leone are the highest in the world.

We received 10 new patients over the past two days from several separate outbreaks from different villages.  I was giving a talk about fluid resuscitation for all the nurses and doctors yesterday in our canteen when we heard three ambulances were arriving simultaneously.  Ishmail and his 1 month old daughter Isatu, were admitted to our probable ward.  The wife, and mother, died from expected Ebola earlier in the day at their home in the village.  Ishmail refused to believe the news and lay in his bed with his head covered by the blanket as his IV fluid bag hung like a jelly fish from a make shift IV pole.  I came to see him last night and, through the Temne translator, tried to give him sympathy and encouragement at the same time.   His eyes were red and his two day stubble implied it had been a rough couple of days.  Isatu was on a padded table as three nurses in PPE hovered over her like space monks tapping her tiny hands, looking for veins.  Her skin was paper bag dry and stayed tented up when you pinched it.  The little soft spot on her head, the anterior fontanelle, was sunken in- all implying severe dehydration. The baby sucked on one of the Ebola survivor's fingers who would be assigned to her for the night as they tied off her arm with a tourniquet and tried repeatedly to find a vein to put an IV in.  A tube to be put in a tube.  The baby cried but wasn't able to produce tears.  Finally they found a vein on her forearm the half the size of  a coffee stirrer and were able to put an IV in it.  We gave her fluids and some formula as she hadn't breastfed in 5 days.  The father, Ishmail,, was too weak to get up to hold her.

Mariama, a one year old baby girl, lost her mother and father to Ebola and was in our suspect tent just last week.  She was discharged as Ebola negative but because of her family exposure, and now lack of family, was placed in a temporary orphanage where she could be watched for signs and symptoms of Ebola.  She was brought back in yesterday after developing a fever and is now positive for Ebola.  Armed with a stuffed animal my son gave me before I left, I went in to see her in our confirmed ward.  She was sleeping, her soft nose flaring and her tiny lung pumps working hard to breathe out carbon dioxide to balance out the acid level rising in her blood.  She had lost weight and was vomiting earlier.  I put the stuffed animal under her blanket and put my hand on her head and kept it there while I looked at her.  Yes, she could be  the first child under five that makes it out of here alive.   Yes, we got her in early didn't we? Just after the fever started, right?? You can do this Mariama. You can do this.  You can.  You.

The night noise outside our giant white tents is a relentless cricket screech and fat buzz of giant flying insects as I try to catch a few hours of sleep before morning rounds.  I only have four more days here in Sierra Leone.  I put my headphones in to take control over the noise.  I put on an album by Elephant Revival and close my eyes.  I am wide awake.

Boxcars

We currently don't have internet available so I came up to an office to enter some observations before going back home after work....

The number of people admitted to our treatment center continues to fluctuate.  Currently our numbers are back up.  Nobody wants to be busy here.  When we are busy it means the virus is still busy.  And it continues to be spread in demonstrations of love and culture.  Caring for one another.  Sending off a loved one into the afterlife with sacred rituals.  Yesterday we admitted a family of four from a quarantined home in a distant village I wasn't familiar with.  A mother and her two children and her brother.  Children.  Before I departed for Sierra Leone I thought often about how I would cope with child suffering. And death.  I concluded there is no way to prepare for it.  A test you cannot study for. Concerns about personal safety, the inhospitable working conditions, the lack of resources  and every other fear of the unknown all taken together never posed a formidable challenge in my mind to that of dealing with child suffering.  This continues to be the case.

As my time winds down here, the cumulative effect of watching this virus poison and drain the life out of young, healthy bodies has not diminished the effect from every new case I see.  And they come fast.  You have no doors on your car.  It all rushes in and you hold up a small flame to expose it, and then  in protest.  You hold it up again.  And again.  And one day it burns a little longer until it is phosphorescent.  Your hope builds slowly and is kept inside.  Then she gets better and you carry that light until the next one is admitted and there you are again driving off road with no doors and it all rushes in again.  This is repeated every day in every shift here.  The wind and the flame.

Boxcars carrying birds out to the sea.  And there you are, riding on top, leaning over to look inside to see if they are still there, trying not to fall.

Hawa (a new Hawa, it is a common name here), is a 10 year old girl who was admitted along with her sister, mother and uncle from a quarantined house.  They are all critically ill.  This strain of Ebola doesn't cause as much bleeding as previous strains, but when it does it is ominous.  She was in the back corner of our probable ward, laying on her side uncovered.  Colorful beaded little girl bracelets circled her wrists.  A larger beaded necklace hung from her tiny neck and disappeared underneath her old, non-descript t-shirt. Dried blood flaked at the corner of her mouth.  The nurse and I had her sit up and gave her a cup of oral rehydration solution to drink.  Even through two pairs of gloves I could feel the heat transfer from her bony back into my hand.  It traveled up to my brain and then pooled in my heart.  I breathed in and out of my mouth through my duck-billed mask. Her lips were dry, cracked.  Her eyes were red and injected, and not looking at anything.  We waited as she drank and then her throat twitched.  Out came a long, arcing stream of bloody vomit. And then another, And another.  She was hemorrhaging and vomiting up dark clots of blood and fresh bright red blood.  Projectile vomit.  Explosive release.  We jumped out of the way and let her finish.  She was shaking, her feet twitched.  She didn't say a word as we cleaned her up and laid her back down.  We gave her some IV fluids and some medications to try to help with her vomiting.  We don't have what she needs here.  Even if we did, it would likely not stop the process that has started.  The virus has put the boxcar of birds on the track and sent it downhill to the sea.  It laughs as it opens the doors.  I don't want to be a part of any of it.  I don't want to ride on top again and peer in to see all the wedding cake white birds flapping  into one another before spilling out into the wind-stream.  Every day I pray in a slightly different voice, that this is the last one.  Maybe someday soon it will be, but not now and now is all we have here.

A white feather no longer carried by the wind falls gently on the side of the tracks, waits to be covered up by the night as the stars blink on in every pew of the sky.

Night Shifts

I worked the night shift last night.  Going into work as everyone is going home feels like you are going against the natural current of things.  Working at night is more spacious and tends to be a bit more mischievous.  It feels like trespassing.  I haven't worked nights in a long time until I arrived here.  The same night work vibe materialized.  Except it remains hot and well lit at the Ebola treatment center.

I have been reading enthusiastically about the drop in the number of new Ebola cases in Guinea, Liberia, and Sierra Leone but they don't dilute the individual cases we continue to see.  They also stir a unique set of emotions for our national staff.  Every single Sierra Leonean will tell you that Ebola has been a scourge and has shattered life here on every imaginable level.  But getting a job working for an international relief agency has given them something often unattainable in Sierra Leone- a steady job.  Even those with advanced degrees in engineering or business administration sat unemployed for years after the war, making ends meet with odd jobs here or there for which they were terribly overqualified.  They are now drivers, warehouse managers, and security guards for our American-based non-governmental organization (IMC).  And they get paid reliably and mostly on time.  When Ebola is driven back to the jungle and the international disaster relief agencies start to withdraw from Sierra Leone, they will once again be entering into the pool of overqualified, underemployed folks akin to those who drive cabs in Bangladesh, sell used phones in Dakar, or work as nurses in Freetown in government hospitals that pay little and often sporadically.

Some will have a chance to go back to the work they did before Ebola with the money they have saved working for IMC.  Michael, a driver who takes me in a Toyota van to work regularly, owned a small sporting goods store in town before Ebola shut him down and wonders if and when he may be able to open up again.  He has a mouth that looks like it is always smiling when he talks.  He drives safely but fast and looks at you when he is talking/driving.  "The people here don't have any money.  And when they start to get that money again, I don't think they are going to come buy footballs."  The economy here will bounce back, like a deflated ball here, an inflated ball there, and likely end up where it was after the civil war and before Ebola- leaving its citizens on the bench.  It is no wonder that so many of the brightest, or luckiest, or most connected, when given the chance, choose to leave Sierra Leone for the United States or Europe.

The national staff working in our organization, from Yusef, a talented sketch artist who never finished school because of the war and then Ebola, who works security at the front gate , to Isaac, who lost almost all of the elder men in his family to the war and then 4 of his cousins to Ebola, who works on the WASH team disinfecting the grounds and us, to all of the nurses who leave their children and homes to come work in our treatment center from far away, there is a lot vested in battling Ebola and a lot of uncertainty about what they will do for a living after Ebola.  They endure with grace and humor.  I am filled and affected by their spirit.

"We all require devotion to something more than ourselves for our lives to be endurable.  Without it, we have only our desires to guide us, and they are fleeting, capricious, and insatiable.  They provide, ultimately, only torment."  So wrote a philosopher named Josiah Royce in 1908.

I read that quote in a book I am reading called Being Mortal.  

(Now that would have been a good title for the instruction manual they forgot to give us at birth.)

Exchange Rate

The market in the center of Lunsar is about a thirty minute walk.  We try to go early before the sun elevates and burns through the morning fog that is mixed with the burning of tree trunks and stumps. They light the bases of the uprooted trees on fire and cover them with dirt.  They smolder and a pungent earth aroma leeches out from the smoke as it  sifts into the fog to become one gaseous vapor.  The burnt wood is cut up and sold in giant bags, covered with banana leaves, on the side of the road as a type of charcoal used in cooking.  I ran by such a burning mound last night at dusk, just after a field was cleared by setting it on fire, the terrain blackened and sepulchral under a socketed sun whose exit was unceremonious from the day.  This morning the heaped pile of dirt with the burning tree inside still emitted smoke as we walked by on our way to town.

We passed a boy carrying an oil drum horizontally on his head, wearing a faded red v-neck t-shirt that read "San Francisco Does it Better." Children came out to the road to greet us with the familiar "Ah-patto!!!" , "white man," in the local language, Temne.  It remains irresistable for them.  We wave and respond with a few greetings in Temne and they laugh at our pronunciation and tongue-tied and likely tone-deaf efforts.  Jon is a family physician from Alabama whose wife was struck by lightning and killed 6 years ago.  He was here visiting his daughter who was working as a missionary in a children's home in Freetown last year when he met his now fiancee.  His daughter introduced them.  He is a gentle soul who lives guided by his Menonite beliefs.  He takes lessons in the local language a few times a week and plans on staying here for a long time, even after Ebola has receded back into the jungle.   We passed by the creek where women using wash boards cleaned their clothes by force, wearing open back tank tops that exposed each muscle involved in the process.  Children ran pushing inner-tubes with a stick that never lost speed.  Everyone was doing something and a lot of it involved labor.  We were walking with backpacks into the market to get some fruits and whatever else we could find.

First, I had to stop to exchange money with Kabia, an old Muslim man who owns a small hardware store.  I have changed with him before.  He pretends that he has just called the banks in Freetown to determine the daily exchange rate.  I pretend to believe him.  We have imputed his falling exchange rate to the fact that there are more of us exchanging money here in Lunsar.  It is a matter of a few dollars and I prefer to exchange with him rather than the banks who give a much lower rate.  So I exchanged one hundred dollars and walked down into the market.  Women sat on wooden stools behind their mounds of salt they sell by the small cup that sits on its peak.  They sit behind neatly arranged piles of dessicated fish that no doubt never imagined a condition in death so at odds with how they once lived.  I push through and find the young woman I buy peanuts from laying down on a rough day bed made of bamboo.  She perks up and doles out two cans of roasted peanuts and ties them in a plastic bag for me.  Her smile is genuine and young.  We find some fat cucumbers and knobby carrots and buy them all.  Yusef, a teenager wearing a loud shiny necklace and sunglasses sells us popcorn in that insouciant teenage kind of way you could find anywhere in the world.  Voices project and intermingle with the Zouk music blaring out of what looks like a 1970's Peavey amp sitting next to a cage full of chickens.  The market is the lifeblood of a village and I was being transfused.  We filled our backpacks with bananas, bread, and some rope for a bee box Jon had made and plans on suspending from a tree next to several log bee hives.

As we walked home, the same children yelled out to us "Ah-patto! Ah-patto," in their chirpy sweet voices, as they gathered on the hills and in the fields of their childhood, to watch us go by.  The musical memory of them there, cheekbones and elbows and lips highlighted by the morning sun, I cut out to paste later into the Missalette, unedited, to face the page of Mohamed's song, their voices rising up above the smoke and fog to that space where the sky drifts in cool blue pools.

Counting

We have a tendency to count things.  We count up.  We count down.  We count how many of one thing make up a larger thing.  A dozen eggs.  A six-pack of beer.  And we come to expect that number to remain true, a constant. And then we count repetitions.  How many games have been won, or lost, in a row.  We start to look for numerical patterns or sequences.  We then start to collect, organize, analyze, interpret, and then present numbers.  Statistics.  Numbers are powerful.  They can change the world for the better or for the worse.  My children are counting the days until I get home, at least that is what my wife tells me.  I have been counting my blessings.  I count on the people who spray me with chlorine and help me in and out of my moon suit to keep me safe.  Others may count on me to provide good medical care.  Yesterday, I started counting the number of deaths in our center since I arrived 30 days ago.  Twenty-five.

William Faulkner once said, "there are the facts, and then there is the truth."  Many numbers are tracked in the Ebola epidemic here and reported out by several agencies on a daily basis.  And they are put forth as facts.  And we desperately want to believe them when the number of new cases is reported as dropping precipitously.  But there are always other things at play.  Recently, the Ministry of Health stopped paying the surveillance workers again.  They are the teams that go out to the villages where cases have been documented and establish quarantines, and return to monitor individuals under quarantine for evolving sickness.  If they are not working, we don't have a way of effectively getting people sent expeditiously to our treatment centers.  So when they didn't get paid and didn't work, the number of cases referred to us dropped drastically.  Now they are back working and we are seeing a spike in cases again.  In the last two days, we have had at least 10 new patients admitted to our center.

One of the 10 patients came in yesterday.  His name was Mohamed and he was 4 years old.  He came in with his aunt Ramatu, who was 12 weeks pregnant, and his older sister, Hawanah, who was 8 years old.  I didn't work yesterday so when I came in to make rounds on the patients today, the doctors on the shift before me gave me an update on those most critically ill.  Mohamed was brought in from a quarantined house in a remote village.  We took care of three women from his village who contracted Ebola during a burial ritual.  They all died in our tents last week.  There are two patient characteristics I don't want to see on our patient board when I come in to work.  Children under five years old.  And pregnant women.  Death from Ebola comes in predictable and not so predictable patterns.  We have yet to see children under five or pregnant women make it.

The air in our medical tent this morning reminded me of a roadside produce tent in a rural Tennessee town in the middle of August whose flaps had been rolled down during the rain.  The air did not move and what air you took in seemed to have just come out of someone standing next to you.  Bodies were fragrant and too close.  The charge nurse admonished several of the arriving nurses for
being clamorous as they swelled around the main work table.  Sweat dripped from under my arms.  The heat has a way of making you irritable followed quickly by the shame of being affected by something so benign.  So you drink water and center yourself.  Transcend the transgression.  And drink more water.  You start to think about who needs what form of hydration in the treatment tents.  Is Mohamed taking anything by mouth?  Were you able to start an IV on him overnight?  Reports are given on buckets filled up with bodily fluids.   If you have ever carried a full plastic bucket of liquid patient waste to disinfect it and discard it into a dug out pit latrine, you will understand how the shifting sway of the bucket's weight steals your hope.  You don't want to allow it to, but it does.  

This morning I worked with a family practice doctor from Vermont named Jean.  She has three children under the age of eight and spent time in Africa as a child and later as an adult.  She couldn't answer "no" when she asked herself about coming to join in this fight.  We finished the paperwork we needed to do, drank some more water, and put on our gear to go inside to round.  Before we had even put on our hoods and aprons, there was a message from one of the nurses inside that Mohamed had died.

We started as we always do in the suspected cases tent, those with the lowest probability of having been infected with Ebola.  Jean and I, perhaps through our young parenthood connection, seemed to both be taking an extra amount of time in the suspect ward.  I examined a 44 year old man who looked  like he had TB or AIDS or cancer, his body contracting and involuting, pulling itself  inward through its'  bony cage leaving only the surface skin and dying hair follicles  visible amongst the bony outcroppings   I put my hands on a 60 year old woman's muscular shoulder and told her everything was going to be okay as if I somehow could promise that.  I found myself talking to patients about hope and faith and courage.  And other not small things.  We washed our hands and left the suspect tent and walked on the concrete passage to the probable ward, where Mohamed was.  I stepped in the chlorine foot bath and took a deep breath.

Someone had wrapped Mohamed's body up in a colorful blanket.  No part of his body was showing as he lay there in a long bundle the length of a doorway.  I kneeled beside him.  Jean and the nurses stood above me.  I unwrapped the blanket slowly to find that beautiful boy laying on his side, his hands under his head in a final pillow.  I didn't need to open up his blanket to know if he had died.  I needed to open up that blanket because all children's deaths need to be felt.  Not counted but felt. Each and every one of them, everywhere, every time, needs to count.  I ran my hand over his head, over his tiny shoulder, and prayed without prayer before covering him back up.

We still had the confirmed tent patients to see.

It was probably not even noon.

The Road to the Mine, and back

Every son, to some extent, is the son of a preacher.

I have been reading a book called "Gilead," about  a multi-generational family of preachers in American Civil War times and this popped into my head this morning, eyes closed still ,after I woke up.  Maybe it is because I have been thinking about my parents a lot lately.  It is their wedding anniversary today.  Or perhaps it has to do with all the kids I have seen lose both parents to Ebola.  Of course, family structure as it is here, the children will be raised by aunts, uncles, sisters,brothers, cousins and so on who live in the same village.  Every parent is haunted by the thought of leaving their children behind or their children leaving this world before they do.

Some kids are born into families with little wilderness.  Everything is provided.  And controlled.  Others are born into great wilderness.  Parents are not involved for whatever reason from the start.  Or part way through go missing.   Or disappear during the crucial years.  And then there are children who are born with the wilderness in them.  I know how my parents would comment if posed this question.  Tonight, I think of Kadiatu, who lost both her parents here with us to Ebola, and was placed in the Children Fund's temporary orphanage after testing negative to be watched the requisite 21 days to make sure she doesn't start showing signs of Ebola.  She will go back to her village but has little family.  I wonder how the wilderness quotient will play out for her.

I went for a run this morning on the road to the iron ore mine.  It is a hard-packed red clay dirt road with occasional ribbed areas that are less than affectionately referred to as "washboards."  The road is wide enough for two articulated dump trucks to pass easily.  Iron ore is used to make pig iron and ultimately steel.  It is arguably the world economy's second biggest player behind oil.  Sadly, the mining company is owned by a Swedish firm.   Lunsar, as a community, shows no overt signs of benefiting from this precious mineral harvest.  At the end of the road there are box cars that are loaded up to be taken by rail for processing and then exportation to China I am told.  The mine operates 24/7 and I can hear the lorries wheezing and rattling from my room as I lay in bed reading.  I picked up a piece of rock that had an argent glaze on it that rubbed off into my hands like the glitter my daughter dusts onto glue to "spice up" her pictures.  It looked pre-historic like it had been taken out of a formation that had been made by a drastic event that shook the earth to its core and was not  witnessed by any higher functioning creatures besides bees.  I stuck it in my pocket for my son and kept running.  Up ahead I saw a man walking in his Sunday clothes carrying a machete in the way that a man in Detroit might carry an umbrella, tucked under his arm but still able to strut.  A lorry downshifted to make it up a hill and coughed up a cloud of exhaust that drifted like a black veil off the road and was suspended briefly in the early morning air before diffusing.  Banana tree leafs drooped with a thin, red dust that took away their waxy lustre.  The industrial effluvium reminded me of running in medical school on the banks of the Kaw River in Kansas City, Kansas behind the Colgate-Palmolive factory.  There was a sweet, synthetic scent to the air then.  We called it the "Industrial Run."  I suppose this one here on the road to the Sierra Leonean iron ore pit would qualify as an industrial run, the soot and the particulate dust sticking to my skin as if I were a lollipop dropped on a wood shop floor.  But when the trucks all passed and the morning sun poured through the palm trees and the birds cawed from high up on ancient mango tree branches, I inhaled the landscape as a whole and it filled me with power and light and a transient equanimity that made who I was or where I was blissfully irrelevant.

Our psycho-social team often goes out to provide support to families who have lost loved ones to Ebola.  Anna, an Australian, has spent the past four years working in South Sudan and Bangladesh in international relief work camps.  She is quiet and has a sadness about her that is more than situational, almost a settled, habitual sadness.  She flowers when she is working with families in that way that some people are better suited to weep with those who are suffering as opposed to those who are better suited to rejoice with those who are rejoicing.  Today, I rode out with her to a village where an 18 year old girl, Hawa, contracted Ebola before being sent to our treatment center.  You may recall her from an earlier entry.  She was 24 weeks pregnant and believed up until her last breath that her baby was still kicking.  I met her husband and all of her immediate and extended family from behind a small plastic green rope that was tied between the trees that surrounded their house in the village.  To keep them as effectively as the wind, under quarantine.  We talked about her death, expressed our sorrow and delivered the bereavement package donated by the World Food Programme which consists of 50 kilos of rice, a large sack of what looked like lentils,  a sack of  enriched corn meal, cooking oil, and some laundry soap.  I brought along some crayons, pens and pencils for the kids.  We reminded them to guard the death certificate that certifies that Hawa passed from Ebola as it will entitle them to certain small governmental benefits down the road.  I watched the kids watch me as I watched them.  They all came out of the house and stood quietly in flip-flops.  Mothers in tank- tops hipped babies.  Charred aluminum pots cooked cassava leaves  and fish stew over open flame branches.   We had come to talk about an eighteen year old pregnant woman's death and have some sense of dignified closure.  When we finished we sprayed our boots with chlorinated water before getting back into our vehicle.  We are so close but we are not out of the wilderness yet.

For 3rd Graders Only

My daughter asked me to write a note for her that she could read to her 3rd grade class, so here goes...

Dear Jasmin and Ms. Griffin's 3rd grade class-
Hello from a country in West Africa called Sierra Leone!  I had to take 3 airplanes and make 5 stops to get here.

We are 8 hours ahead of you.  So if it is 12 noon in San Anselmo then it is 8 pm here.   I get to see the sun rise and set before you do!  We see the same moon and same stars too, but the stars are a little different.  There are over 6 million people in the entire country here.  That is like taking the population of San Francisco and multiplying it by 7.  So it is not a very big country.

Everybody in Sierra Leone speaks a language called Krio, which sometimes sounds like English but most of the time does not.  When I meet someone I will say "Aw yu du?" which means "How are you?"  But there are a lot of other languages people speak here.  It depends on where they were born and raised.  We are living in a town called Lunsar and the people here talk Temne.  When I meet someone who speaks Temne I say "Topeh moi?" which means "How are you?".  Or I say "Endiray" which means "good morning."  The languages sound a bit funny at first until you hear them a bunch.  Then they start to sound like music and are beautiful.  Jasmin, you already know one word in Temne- "Momo," which is the name of your friend in Portland, Oregon.  It means "thank you" in Temne.  Isn't that cool? I bet Momo doesn't even know that!!!

The people here are so nice.  They teach me a bunch of things every day about their way of life.  I have made a lot of friends.  Sometimes you don't even need to speak the same language to talk!!  The children here have not been able to go to school for almost 9 months now.  That would be like all of you missing an entire year of school!  Sounds fun at first, but the kids really want to go back to school.  They listen to a teacher on the radio when they can so they don't forget how to spell or do math.  All of the schools were shut down because of a really bad virus that can make people sick.  You can get the virus, called Ebola, even by just touching someone who is sick.  Can you imagine not being able to touch anyone for almost a year????

Me and a nurse called Mbalu

Two boys in front of their house

Me and another doctor with a nurse and her family

Every market here is a farmer's market

People here eat a lot of rice and fish.  They also make chicken, yams, corn, plantains, egg sandwiches, and lots of other stuff like stews and greens (kind of like spinach).  They drink juice and soda but mostly water.  Most of the food is cooked outside on a fire.  Like how we do when we go camping.  People make their own houses in the village out of mud bricks and cut down trees.  They are really good at it.  It is always hot here so they don't need a heater.  They like to sing and dance and have parties just like we do.  People everywhere want love and happiness.  We may have different stuff or talk different languages but we are all pretty much the same.  You would like the kids here.  They are creative and make up a lot of games and run a lot.  They make a lot of their own toys out of sticks and recycled stuff like cans.

There are a lot of animals here.  I see dogs and cats just about every day. There are goats, sheep, and chickens but not a lot of cows.  I haven't seen any horses.  They have chimpanzees and gorillas too but this virus has been getting them sick.  We hope that this virus is finished soon because it has been a terrible thing for the country of Sierra Leone and other countries in Africa.  Your daddy takes care of people sick with the virus.  I have to wear a special suit that looks like a space suit so the virus can't get me.  I am really safe here.  But it is important to come to places like this to help people.  It is like helping friends or brothers or sisters who are sick or sad.  We live in one world and everyone is our sister or our brother.  The more we help one another, the better the world will be.

Taking off the suit we wear

My laundry drying where I stay

Shakira

I think you are old enough now to come with me next time to Africa Jasmin.  Anyone else in your class ready to travel to Africa????  Awa-woo! (Good Bye in Temne)

The Beach

Palm Tree Sunset

A Day Off Poem

A pressed hospital gown
hangs
in
the closet
like a thin white ghost.

The generator
convulses
on its concrete
platform
one final time,
goes silent.

You learn after a while
to keep the shades
drawn
and not open up
the refrigerator.
To keep it all from escaping,
Or breaking in.

Days off
are like uncapped syringes
on the confirmed ward floor.

Outside the Kenyan nurse's
room
a man takes a machete
to the ochre chaparral.
It crinkles
then slouches.
No different in death than life.
For now anyway.

It could have been different.
It could have been seared,
leaving ashen stalks
on red earth,
the memory
of black plumes
rising
from the funeral pyres
that once incinerated
the virus
and all the cloistered dreams
from amygdala
to spleen
in a pit lined with stones
too large to be called gravel.

The smell of singed hair
is back to the smell of molten plastic.
The sun turns a pallid eye,
and has been confused for a hot moon.

Acronyms form and then scatter
in what few night clouds remain
in neither holy nor unholy trinities-

WHO.
NGO.
IMC.
CDC.
APB.
IMF.
CNN.
NFL.
MLK.
DNA.
PCR.
CPR.

And
RIP
written
in
dry
erase
red
on
our
whiteboard
in
the
white
medical
tent
next
to
a
name
given
three
years
ago

Routine Water

Much gets routinized here.  In the month I have been here in Lunsar, I wake up around 5:30 as the roosters just over the fence outside my window give their throaty serenade to the sun gods.  Contrary to my normal waking reflex, I am able to be awake here for several seconds, or sometimes longer,  before making the conscious decision to open my eyes.  It is like deciding when to press the "record" button.  I have come to enjoy this form of waking and don't attempt to control what I think about there in my bed, in the dark, with my eyes closed.  I often have the images of my children conjoined with the images of the children I have met and cared for here.  I take quick survey of my body- no fever, no headache, no joint aches.  Relief.  It is with gratitude that I slowly open my eyes, put on my glasses, and reach for the day.

I brush my teeth with bottled water, cup and splash tap water onto my bearding face, wash my hands and put in my contacts, left always before right.  I gather my black shorts and KC Royals t-shirt from the balustrade of my front patio, put them on, lace up my old sneakers and stretch.  I grab a small flashlight my colleague from Sebastopol, Mary, gave me and enter the morning darkness that is just being infiltrated by the slow blush of the morning sun.  And I run.  In a zagging loop around the perimeter of our lodging compound.  Past the garden Thomas has put in since I have been here.  The rows of squash with their core yellow bugles announcing the largesse to come.  Past the heaping rows of soya beans.  Past the stalky teenage growth of pepper plants.  I used to throw the flashlight over all of them to see if the goats got into them overnight.  Now, with the goats gone, I illumine them to mark their growth and the passage of time.  A few days ago Thomas showed me the well they dug in the middle of the field.  A man stood at the bottom of a 30 foot reinforced well filling buckets of moist soil.  Two men at the top used a pulley to hoist up bucket after bucket.  All done by hand down to the water table to bring water in the dry season up to the fields.  Later in the morning a farmer walks with a watering can up and down every row like a priest carrying an aspergillum to sprinkle holy water on his congregation.

I continue my run past the generator shed that rumbles and hums.  I pass the garbage pile and the magpies fly off.  I cross the wooden plank across the dry ditch and start another lap.  Sometimes if the  guards at the gate are awake, I leave the compound and run on the iron ore lorry route next to a large rice paddy field.  But not all that often.  I don't mind running in circles, really.  I process what I am doing here by speeding up my heart rate, pulling it into my lungs, locomote, and pour it out in sweat and exhalation.  Take it in, strip it down, and be sure to let it out.  Time after time.  Near the end of my run I turn off the flashlight.  The sky fills with a soft, iridescent  light that starts at the periphery of the horizon.  And without knowing exactly when, the night has been relieved by the understated dawn.

I take off my running gear and hang them back on the balustrade in the same place I removed them from earlier.  Sweat.  Cold water swallowing.  Morning ablutions.  Continued sweat.  And when the post shower sweat has slowed and my body has cooled, I get dressed and head down for hot Nescafe and white bread with butter and bananas for breakfast.  Every day.  Routine.  Blessed routine.

I was on track this morning to start the day like every preceding day since I have been here.  I woke, kept my eyes closed, and didn't hear the roosters.  I kept my eyes closed.  And then I heard the wind pick up velocity and write about it in the trees.  Leaves shook, trees leaned.  And then leaned back. I imagined.  I opened my eyes, got up, and went to  the door.  Ink black.  Rustling of leaves and the sense of movement in the dark.  The world in dark is a foreign world of sensation.  Not having to work today until the afternoon, I slept in.  So the light came sooner than usual.  I went through my routine and laced up my sneakers.  As I stepped outside, Sharkira was not there to greet me.  The air smelled of suspended moisture and mineral dampness.  Something outside of the morning routine was being plotted.  I began my run and before I even reached Thomas's vegetable fields, the rain began to fall.  Drop after warm drop it fell onto the ground in front of me.  And onto me.  RAIN!!! In the middle of dry season, an unexpected early morning rain.  The red, dusty road was tempered and lay now like a sheet of old red velvet cake.  Rivulets of pink and brown ran downhill like a mixture of pink and chocolate milk.  The rain came down in individual drops and never coalesced into sheets.  It fell straight down and didn't slant.  Nobody else was outside as I ran and ran under it.  In it.  With it.  I thought of Father Garcia Viejo and the unopened missalettes in the darkened pews of San Juan de Dios.  I thought of how kindness and faith can dilute even the most evil of assailants.  Routines are routines and meant to be broken.  For the sake of new, better routines.  The squash bugle flowers filled with water, lap after lap.  Soon the bees would come to drink from them, yellow on yellow.  The whole earth was being baptized anew.  For the first time, I knew Ebola was truly receding. And a new routine written in water awaits me.

San Juan de Dios

In September, 2014, four months into the Ebola crisis here in Sierra Leone, Dr. Manuel Garcia Viejo, a Spanish priest and physician at San Juan de Dios hospital in Lunsar said his morning prayers with his staff in the small concrete church on the hospital grounds, took a cup of tea and assumed his customary role seeing patients in the busy outpatient department.  The missionary hospital was started in the early 1960's as a midwifery ward  by a Spanish nun who died from burn wounds suffered after an accidental gas stove immolation.  The Spanish Catholic priests who came to Lunsar for her funeral decided to expand the operation into a full hospital, which opened in 1967.  It continued to offer more and more medical services including an operating theatre, a 100 bed inpatient hospital, a lab, x-rays, and a full maternity ward.

Dr. Garcia Viejo started working here in 2002.  The hospital built a strong reputation throughout Sierra Leone and beyond.  People would travel from Freetown and from as far away as Guinea and Liberia to receive their care here.  On this day in September, 2014 several patients who came to be evaluated had high fevers, headaches, and joint pains.  He saw them all, taking some personally into the hospital to minister to them as they unexpectedly deteriorated rapidly.  They were all young, healthy, and followed a similar, sinister path towards death.  One of the staff reportedly cautioned Dr. Garcia Viejo about the possibility that these patients could have the deadly filovirus, Ebola. "I am an old man and if I contract Ebola and die, then it is the will of God."  Within several weeks Dr. Garcia Viejo and 8 of his nursing staff died of Ebola.  The missionary hospital that attracted patients from Liberia, Guinea, and all over Sierra Leone was in essence attracting Ebola sufferers from the most affected locations on the planet.  And it wasn't prepared in the least to protect its patients or its own healthcare workers.

San Juan de Dios was shut down by the local government when word got out that staff and their families were dying en masse.  The village of Lunsar, who trusted this medical institution for over 45 years, was thrown into a complete panic.  If their hospital couldn't stop Ebola, then surely they themselves couldn't stop Ebola.  The hospital gate has been locked since September, 2014.  Until this past week when it slowly and deliberately opened its doors in the outpatient department.  My organization, IMC, was asked to help prepare for this re-opening by building a labyrinth of partitions and installing a chlorinated water system to effectively triage possible Ebola cases.  If they screen negative then they can see the Nigerian doctors who staff the hospital now until the Spaniards return. If they screen positive then they are sent to our treatment center for testing and care.  I went there today for the first time to help make sure everyone was following infection control protocols and help with the triage process.

Hawanatu and Aminata sat in a small triage room with a plastic window through which patients were screened using a series of questions to assess their risk of having come into contact with, or had symptoms of,  Ebola.  One after another, patients came to the hard plastic window complaining of vaginal bleeding, complaining of cough, complaining of neck pain.  But not one today screened positive as a suspected Ebola case.  On the concrete walls were colorful murals depicting African life.  A mother nursing her baby while she cooked a pot of greens over an open flame.  A boy in flip flops carrying his books to a one room schoolhouse, the red dirt carpet in front at the foot of a giant mango tree.  A photocopied picture of the departed Spanish priest was taped up just underneath the right bottom corner of an African version of the last supper and included the handwritten letters "RIP Brother Manuel."  I talked to Abdulai, a recent physician's assistant graduate, about the African Nations Cup games played last night.  He made flirtatious comments to Hawanatu between patients and she attempted, unsuccessfully, not to smile. Hope, and life, were now returning to San Juan de Dios.

There is a definite transition happening here now.  Institutions and establishments are starting to discuss when they will open their doors and unshutter their windows again.  Schools have not announced when they may follow suit but people are starting to think about stepping back into their lives again.  The UN choppers overhead are less frequent.  The markets have more colorful produce.  But we are still seeing new cases everyday in our district.   Smoldering coals can re-ignite.  This is the biggest public health fight Sierra Leone has ever faced and complacency and crisis fatigue are not an option.

As I finished work at San Judas de Dios hospital today, I could feel the absence of Dr. Garcia Viejo on the grounds.  The concrete fountain with a statue of a monk tending to children looked like it had been dry for years.  The grass behind the admissions foyer grew up onto the wrought iron fence.  The operating theatre table slumped like a dusty leatherette cross alone in the windowless daytime dark.  The autoclave door was ajar in the recovery room.  The doors were all closed in the hospital and the silence interrupted only by overhead birds, perched on the corrugated tin roof.  Beyond the birds I saw the solar panels tilted toward the afternoon sun, patiently waiting to be of service. A few vehicles unloaded medical supplies.  A nun behind a desk smiled as a little girl peeked into her office from between her mother's skirted legs.  Men gathered around a transistor radio placed on a tree stump to listen to a soccer match.  The smell of roasting plantains wafted through the iron gate. A resurrection was underway.

Dirt Road, Paved Road

At the end of the ulcerated dirt road from our hotel complex, the dirt gives way to a crested paved road.  Used blue jeans hang from a make-shift bamboo rack on the corner.  The girl I buy hard-boiled eggs from every week, Mabenty, sits under a palm leaf thatched swath of shade on the side of the street.  Mohammed flanks her, selling dense white bread rolls the size of an iphone, and carries a jar of mayonnaise that for some reason obviates the need for refrigeration.  In case you want to parlay your purchases into a fine egg sandwich.  Across the street, miners from the nearby iron ore pit dismount from a large, open air transport truck wearing hard hats and bright orange vests.  Their faces look weary from working until exhaustion deep in the earth.  The gas station behind them has Nigerian pop music blaring out from somewhere and the tin of the treble is swept away like iron dust by the magnetic whoosh of passing land rovers, motorbikes, and ambulances.  I had the day off today and was heading north to a town called Makeni.

Makeni, during the civil war that ended just over a dozen years ago, was the base for the rebel group called the revolutionary united front (RUF).  They orchestrated a reign of terror that tortured and killed fellow Sierra Leoneans over more than a decade.  It is also the hometown of the current president, Ernest Bai Koroma.  It is a 40 minute drive from our town and has a small grocery store with a restaurant on top that is well known to ex-patriates in the area.  Judging by the absence of gaping potholes, the road seems relatively new.  Mud brick and concrete houses ensheath the road on both sides with baskets of oranges, bananas, plantains, and cassava for sale in hard-packed dirt front yards..  In the distance shirtless men shape mud bricks from a small clay colored pool of shallow water and line them up to dry in the sun.  Hand-held hoes glimmer and slice in the distance as fertile fields are prepared for the rain-squalls that will come in a few months.  I thought about the civil war here and how the landscape must have looked when villagers were running through it for their lives, having left their hands behind.  I thought about a painter we knew in Nashville who wrote that "all war is civil war" as part of a show he did with paintings he made from American Civil War photographs in a studio just behind the minor league baseball stadium.  Germain, a Congolese physician colleague, snored next to me as I stared out the window, the images all fusing together until we reached an area with wide open grasslands whose emptiness was swept by the wind of forgiveness.

We went through two checkpoints where we opened our windows and leaned forward to have our temperatures checked by thermal scanners.  Our International Medical Corps emergency response pass taped to the front window allowed us to pass through the other military checkpoints with only a glare from the armed guard in fatigues who pressed truck and bush-taxi drivers for proof of tax payments in a long, slow heated grind.  The outskirts of Makeni didn't look all that different from Lunsar, despite its claim as being the 4th largest town in Sierra Leone.

Avnad's was in a small African-style strip mall with a red dirt parking lot.  We entered through the glass door and were greeted by a Sierra Leonean who took our espresso order as a Lebanese man smoked out front and talked pressingly on the phone.  Most of the major stores in Sierra Leone, our driver told us, are owned by the Lebanese.  They have been long involved in the diamond merchant business here and are reportedly often the middle-men in diamond dealings, even now that restrictions have been put in place regarding the "clean" exportation of diamonds.  I drank my espresso eagerly.  I have been drinking Nescafe since I arrived and have had a low level headache I am coming to beliefve is related to the drastic drop off in caffeine consumption since my arrival.  That and the pound of salt that precipitates on my skin daily from being in PPE.  The aisles were full of sweets imported from Lebanon, wine and liquor from France, England, and South Africa, and even a solitary bottle of el Patron tequila from Mexico.  There were snack crackers from China in long oblong packages, brightly colored soups with Arabic characters scrawled across the front and many iterations of vienna style canned sausages and spam.  I bought Sierra Leonean cheese puffs, Thai potato chips, and a small bar of soap made locally to wash my clothes.  Others in our group stuffed their basket with Pringles, Skittles, and Argentinian red wine.  After we paid we went upstairs to the Lebanese restaurant that looked out over the hills of Makeni.  It was empty and rather formal with plastic over ornate table clothes and pleated upholstered chairs.  We ate Falafel and were just content to have a different variety of food, and a new view.

The driver needed to pick up a large toaster from a similar Lebanese owned grocery store down the road.   We waited for him in the van.  The still humid air made an invisible curtain of heat.  And then the suffering.  A little girl, probably my daughter's age and half her size, using a t-shirt as a skirt, and shirtless, peered into our van with the most beautifully sad eyes and held out her hand.  An older girl, perhaps 14, pedaled up in a home-made wheel chair that had a bicycle sprocket shaft drive she could turn with her hands because her legs were shriveled up and useless.  She too, held out her hand.  Soon a procession of blind men and women, with hands on the shoulders of children whose duty it is to shepherd them around begging for alms, crowded the open sliding door to our Toyota van.  I called over to a peanut vendor and bought peanuts for everyone.  And did it again for the next wave.  We sat there for what seemed like a heart-wrenching eternity, each silently under the hot spotlight of moral interrogation. As we backed out and climbed back up onto the paved road, a group of the children were gathering around an older child who was banging a coconut on a rock.  It may as well have been my head.

Threshing Ebola

A worm the size of a pencil, the color of the pencil eraser, was on the floor next to Marie's bed yesterday.  When a person has worms compounded by a high fever they naturally want to get out.  She vomited it up.  It was a type of worm called ascaris by appearance, the so-called roundworm seen in the tropics, usually in children.  We treat it with medication and when the worms die off they often are excreted in the feces.  When the burden of worms is very high, however, they can clog up in a mound in the GI tract and cause an obstruction.  This can be an emergency and require an intervention, sometimes surgical, to be fixed.  Combine this with Ebola and you have a volatile, tropical sickness.

Today when I rounded I drew blood on patients.  Men and women offered their tough, leathery arms with tendons bulging out like fleshy violin bows.  Most of the patients did not even wince when the butterfly needle punctured the skin.  One of the babies, Kadiatu ,was very dehydrated and I couldn't find a vein plump enough from which to get blood for her Ebola test.  I had to get it out of a large vein called the femoral vein which is in the groin.  The caretaker, herself an Ebola survivor who now helps by staying with the children without the need for PPE in the ward, had to hold her hands and legs as I stuck her in the groin, careful not to go through a superficial infection she had in the region.  She cried very little and, because of her dehydration, produced no tears.  Her mother had died of Ebola in our unit a few days ago.

Marie, the woman who vomited the worm, was in attendance at a recent funeral as were two other women now in our confirmed ward.  When the dead are buried here in the village, they often use a rice paste to cleanse the body in preparation for the afterlife.  An Ebola corpse is highly contagious and continues, despite a public education campaign, to be a significant vector of new infections.  

I hung a liter of IV fluids for Marie when I saw her and, because of severe abdominal pain, gave her morphine through her IV.  People here have never had any narcotics.  I watched as I pushed in the morphine as her breathing became less labored and the wrinkles on her brow relaxed.  It didn't last long, though, and she appeared uncomfortable by the time I left the tent.  She was found dead two hours later, her pain and fear shut off at last.

It is said that for every one Ebola patient we identify there are at least 2 more who contracted Ebola from that person.  I don't know how true that is.  Frankly, I don't know how true any of the numbers the government is releasing are.  If we are to believe them, then the epidemic seems to have slowed over the past two weeks.  Our organization's focus has shifted to reflect this, at least in planning.  We are opening up several "screening and referral units"(SRU's) which will function to screen all patients entering a local medical facility for Ebola before they can be seen.  If they screen positive they will be sent to our center.  If they screen negative they can be seen by a local medical team for whatever afflicts them.  This is how the medical system is gradually going to open its doors.  Safely and deliberately.

The most extraordinary people I have met here are the national staff we work alongside.  I have gotten to know many of the nurses well and am blown away by their courage, trust, and love.  A few days ago I was out walking in the village and ran into one of the nurses, Mbalu, who was threshing her rice , separating out the rice from the husk, or chaff.  She has two children back in Freetown but came to Lunsar to take one of the few, precious jobs available in the region.  Another woman was pounding away with a giant pestle to pulverize cassava in the wooden mortar.  Children ran around kicking a tin can, laughing.  Papaya trees, no taller than me, already boasted green bosoms of fruit.  The sound of flip flops fell in a muted ricochet off the pile of tin roof sheets leaning up against the mud brick house.  There were so many village scenes in one visual field, all resonating off one another, there in the fading afternoon sun, like a stage set.   I thought of my time in the Peace Corps so long ago.  I saw the birth of my children in soft, holy light and how, eyes closed, they rooted for Sandra's nipple.  I saw my parents on their first date in New Bedford, MA at a soda fountain where my motherworked.  I thought of how at peace this moment is right here, at this very place, at this very second.  We do what we can, when we can, where we can.  And when we do, the whole universe seems to be threshed from the limiting grip of its husk and we are granted passage into the inner sanctum, where the golden mystery of all mysteries was conceived.  Only to  leave again, our steps untraceable as air.

Mbalu and Me, Lunsar 

Undiagnosis

We are accustomed to making decisions based on a constellation of data points.  We connect the dots, essentially, to give us the complete picture.  In developed countries these data are are increasingly refined.  In medicine, we have complex imaging to peer inside the body, thousands of blood tests to tell us what travels in the body, all the way from genetic defects to sinister pathogens.  Our investigations more and more magnify the microscopic world.  So much, at times, that we no longer listen to or touch the patient.  Technology in medicine is exploding.  This is not the case in the majority of the world.  Nowhere is this more evident than in our Ebola treatment center.  We have vital signs, a brief history through an interpreter that speaks Temne, and an awkward exam performed by double-gloved hands ,through fogged up goggles as the time we can withstand the heat and sweating slips by.  Fortunately, Ebola follows a fairly characteristic mortal arc.  High fevers with headache, lassitude, and body aches.  Followed by diarrhea, vomiting, lack of appetite and dehydration.  And finally shock, confusion, hiccups (thought to be irritation of the diaphragm or possibly neurologic), respiratory distress, occasionally bleeding, and then death.  As the epidemic has matured, we are seeing fewer and fewer confirmed cases of Ebola in the past two weeks but an increase in the number of patients being referred with similar symptoms as Ebola.  We triage them according to a pretty subjective protocol and they are often brought in out of an abundance of caution.

If we can identify all new cases and isolate them with us here in the tents, then we can break the chain of transmission.  But often they have other conditions.  Malaria, TB, HIV, etc.  The difficulty lies in not being able to run any other tests here.  They are often discharged with a letter stating they are Ebola free.  As far as what they have, they walk out undiagnosed to seek care elsewhere in a country with no resources for those who cannot pay for testing to determine what it is that is wrong with them.  Factor in the complete lack of an economic base to provide jobs, very few diagnostic tests even for those who can afford them, absence of immunization campaigns, and corruption --and you have the reason for the limited number of years a young Sierra Leonean can expect to live.

How would you live if you were a 25 yr old man who could expect to live only another 20 years??  You would likely live in the moment, and only in the moment.  (Not in the moment like we strive to live in the moment when we are tempted by the endless combination of possibilities afforded to us in the future.) You may not make decisions that would affect the landscape of things in 30, 40, or 50 years down the road.  That is what happens here. People live for the day.  Every new morning is a triumph, more singular than part of an optimistic procession of time.

The goats, like most people here apart from Ebola, died undiagnosed.  There wasn't a veterinarian.  There were no tests.  There were no drugs.  Most people in the village thought that the goats were poisoned by jealous neighbors or were the victims of a "juju" or form of African witchcraft cast upon them.  We are uncomfortable and restless with whatever we cannot diagnose.  Because we have grown accustomed to answers.  Answers which have generated more questions.  Which have led to more answers, which have led to more questions.....  This is suspended here.  Not because you give up or stop asking.  The pursuit is subsumed into a reluctant acceptance of things.  Temporarily.  Like the chunky gulp of cough syrup you took as a child after over-thinking how bad it was going to taste.
It was better not because it helped the cough, but because it was simply done

We grow superstitious here.  I, like a baseball player at the plate as he steps into the box-adjusting his batting gloves, digging his feet into the dirt, pushing his helmet down tighter-, have a ritual here when getting into the PPE.  I do everything exactly the same every time.  And there are several beds in our confirmed ward, C1, C2, and C18 that seem to have held a disproportionate number of bodies that have died, eyes wide open.  My heart sinks when I see new names on the board in those beds.  I quietly lobby to move them to other beds.  Superstition is sometimes all you got.  Vespers, like the treatment center's stadium-esque white lights that corrupt the African night sky, beam up in the distance.  A holy incandescence.  Diagnosed or undiagnosed, we still walk together in the light.  Prayers, after all, are only prayers when written in the first person. Right?