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?

The Day After the Goats Died

When I arrived to Bai-Suba Resort in Lunsar three weeks ago, a dozen or so goats, mostly kids, spared outside the bungalow where we usually gather at night to eat and decompress from the day.  As I started working in the treatment center and became alarmingly familiar with how aggressively this virus drains the lifeforce out of young bodies, I watched the goats play.  I would sit outside on a wooden bench, listening to Jay Mascis on spotify, and watch them raise up, horns first,  in a display of power and youth.  Goat TV with a guitar odyssey soundtrack.  Elemental and raw. Healing.

As the weeks wore on, the goats became less and less playful until finally they were laying down in the tall brush that would later be set on fire, with heads askew.  Their pointed muzzles had that familiar froth, a web of dry saliva and their bellies bloated like ancient tribal drum skins.  They were all dying, the darkness lashing and raking them in and taking them across.  We called and they were taken away- we don't know where or what was done with them.  I hope they didn't end up being consumed, conflated with non-diseased meat in the catacombs of the outdoor market I visit in the center of town.  Shakira, the lamb who sits guard outside my door, was washed in laundry detergent and is now blue.  But still alive.  Blue isn't her color, but today is mine.  I will miss those darn kids.

Hawa, the 18 year old who was about 28 weeks pregnant, died yesterday around 4 pm.  I saw her on rounds around 1 pm as she lay on the concrete floor, trying to stay cool, or more likely, no longer aware of her surroundings.  We gave her some IV fluids through her left arm which we actively had to unfold to expose her IV.  It thumped the mattress like a fat snake.  She was becoming too weak to even hold herself up.  I wanted to, but couldn't, believe her when she told me that she still felt her baby kicking.  I wanted her to believe her baby was still alive, that somehow it  would survive, even if she didn't, and make it out of her alive.  She dreamed her last dream for her unborn.  As I left the confirmed ward, I looked at her in a diaper on the plastic coated mattress the way I have come to look at patients when I am fairly certain I will never see them alive again.  It starts in the toes and rises like a morning mist in the muscles, swings softly from the ligaments, rafts in the wild vena cava, and spelunks in the ventricles of your heart.  Until it finally meets up with condensation from the clouds of your mind in the small recesses behind your eyes and emerges, to take flight one more time in the hallowed, blue sky that separates the living from the non-living.

Fifteen minutes later I was calling out information I collected inside the tents across the orange plastic fence to a nurse when I heard Hawa calling out, "Doctor.......doctor.......doctorrrrrrrrr."  I went back inside to find her twisted uncomfortably on the floor with her head underneath the metal frame of the bed.  I put her legs back on the mattress and then moved her torso by putting my arms underneath her arms.  Then I sat her up and sat next to her on a stool to give her some oral rehydration solution.  We sat there together, me filling up her plastic mug with the salty and sweet fluid, talking little, until she could drink no more.  I helped her lay back down and put my hand on her forehead.  Then I left to take off all of my protective equipment and be washed in chlorinated water until it stung my eyes.

The number of new infections in neighboring Liberia has slowed to a trickle, with only 10 reported cases in the whole country over the past 4 weeks.  Here, in Sierra Leone, we are starting to see fewer confirmed cases as well in the past two weeks.  I hope this indicates a true decrease in the number of new infections and not just that we are no longer finding the cases to bring in for treatment.  We currently have about 15 patients in our unit, but are seeing an influx and efflux of patients daily.  Ibrahim, the 13 year old, who has been in our unit for 21 days, finally cleared the virus from his blood and was sent back to his village today.  He holds the record since I have been here for the longest stay in confirmed ward.  He has been the first one to discover dead bodies, frozen yet warm, in the middle of the night.  He has seen other kids like him make it out quickly and has watched as they danced in celebration on the other side of the fences.  But the deeper the anchor of despair the higher the kite of hope flies.  I could hear the drums starting to thump and clap hollow outside of our meeting and I knew.  I went outside to witness him in the middle of a circle, dancing and smiling as the nurses, washers, kitchen staff, social workers, and now medical staff snapped, clapped or yelled along with the beat of the drums and the blessed cadence of the  locally crafted "Ebola Song."  Out in the gravel, under the early afternoon white sun, the taste of sweat, chlorinated water, and tears are indistinguishable.

Ibrahim is free at last!

World Wide Webs

The internet at our housing site has been down for two days now.  I type this post from the medical tent that is smothered by the humid breath of the afternoon heat.  It seems to be a much bigger blow for most of the ex-patriates here than the generators being on the fritz.  We have had an influx of new staff in the last week with nurses arriving from Canada and the US, and a retired infectious diseases doctor who is now in charge of training all incoming staff in infection control.  There is a transient hierarchy here with a constant revolving door of medical staff with a vast, heterogenous global cache of experience.  Fortunately, there are a number of folks who sign on for extended 3,6, or 9 month contracts in addition to the country directors who are on yearly contracts.  Most of the newly arrived, myself included, have questions and suggestions surrounding existing protocols which are handled gently.  It is hard to change protocols that are set up by the WHO and CDC and are couched in the local limitations.  Our mission is very concrete with impervious boundaries- we are here to treat Ebola and only Ebola.

Ibrahim is a 10 year old boy who was brought from an outlying village after he collapsed when leaving the pit latrine.  He was brought in by an Ebola ambulance to our treatment center and was unconscious.  His body lay limp on the gurney, awash in a sweat that beaded on his forehead like mercury and then coalesced to pool at the small cave formed where his bird-like clavicles merged at the base of his neck.  He fulfilled the definition of a suspect case of Ebola based on family reported symptoms and a fever.  But we didn't think this was consistent with Ebola, but rather cerebral malaria, literally malaria that crosses into the brain.  It can carry a high mortality rate if not treated rapidly.  We started an IV and administered IV artesunate and fluids to rehydrate him.  Pulling down his eyelids, it was clear he had malaria for some time and was anemic, as the ordinarily beefy-red eyelid linings were as white as his teeth.  His chest rose and fell rapidly, exposing a rib cage that spoke of the lack of excess in his life.  He looked about the height of my 1st grader.  He had a significant chance of not making it through the night.

A former Ebola survivor was assigned to his bedside in case he had seizures and fell out of the bed.   We pumped him full of intravenous fluids and waited for the anti-malarial medication to take effect.  When we rounded on him in the morning, his eyelids opened with the slowness of a child trying to pull up a steel garage door.  But he was awake nonetheless, a good sign that it was malaria and that he was responding to treatment.  We all celebrated cautiously.  Malaria still kills more children here than Ebola, yet another fight that has been put on hold because of all the attention diverted to Ebola.  Ebola kills in many indirect, insidious ways.

The 18 year old woman who is ostensibly 28 weeks pregnant was face down on the concrete floor next to her bed when I rounded on her yesterday.  She has the increasingly distant stare I have come to fear  here and her voice trails off as if the power to supply her breath is short circuiting.  Her intricate system of nerves, blood vessels and pumps, I am afraid, is succumbing.  The viral insurgency, in wave after countless wave, has the palace surrounded and is preparing to enter without a sound, its mission totalitarian.  The boy whose bed is next to hers, Ibrahim, just today tested negative for Ebola after being in our center for 19 desolate, traumatic days.  One more negative test in 48 hours and he will make it out.  All analogies here seem to center on war jargon.  Understandable.  Enemy combattant.  Battle.  Defeat.  Surrender.  Inhumane.  Attack.  Assault.  Terror.  We retreat, first physically then emotionally, from it all in silent bursts of self-preservation.

I sweat it out on my morning runs and afternoon walks out into the restrained jungle that overtook this area during the civil war and is now groomed by hand into rice paddy fields.  As I walked yesterday on a road used by lorries transporting iron ore from the local mine, I felt a striking serenity.  A field of cassava was being prepared in crested rows of earth by women hunched over effortlessly into that familiar angle of labor in the bleached out noon sun.  The women were singing.  The coconut trees were displaying their encased treasures in neat rows, and judging by their height, were planted in the aftermath of the civil war.  At the end of the path I was given a ride by one of our IMC vehicles to meet the village Chief of Lunsar.

The village chief retains a position of social and political power in Africa.  I went to meet with him to introduce myself and thank him for giving me the opportunity to serve here, as is customary with any outside "dignitary" when entering a new chiefdom to work.  As I entered his home I was greeted by his four year old daughter who was no doubt perplexed with my appearance and loose smile.  She quickly retreated behind an entertainment center.  A stereo sat on the middle shelf with multi-colored lights inside the speakers that book-ended the shelves.  A cardboard white santa- claus hung from a sole nail in the wall above thick leather sofas.  We spoke for about 10 minutes about the current Ebola epidemic and his fear of what will happen in Sierra Leone in the future as all of this medical attention recedes.  His major wish was better training for the traditional birth attendants in his chiefdom to improve infant mortality.  His cell phone rang incessantly during our chat.  Outside a welding shop in his courtyard sparked and sizzled.  Chickens pecked at the edges of things.  The chief was gracious and laughed often, each time shaking his belly like a small earthquake.  We bumped elbows as I left, the new handshake in Sierra Leone, as his daughter peeked out from the hallway.

time, on a cross

A friend of mine likes to use the term "bending time," which I have stolen from him and now myself use, giving him credit of course.  Here in Lunsar, we are indeed able to "bend" time.  The minutes and hours expand and contract as I read, write, run, talk, and work.  Time is malleable here.  It takes on a protagonist or antagonist role.  It even fights you, drags you slowly on your belly through dusty savannah trails with tall grasses.  A hot itchy car wash.  Then at times it puts you on a bucking bull, cinch belt tightened, and lets you out into the ring with clowns, barrels and adoring fans who want to see blood.  But most of all, it is navigable. Put your paddle-less canoe into it's gentle currents, ease back, and watch as the cathedral of trees overhead open and close on a world of inner possibilities.

Yesterday I went into the center of town at high noon in search of a soccer ball, peanuts, and local currency.  The transport of goods, when not packed away in shipping containers or 18 wheelers, can be herculean, awe-inspiring, entertaining, and sad.  But it is visible.  Down to the 5 year old child selling hard boiled eggs with cedar red powdered hot pepper from a tray on top of her head, a colorful bandana holding it firmly in place.  I watched as the world went by on heads, perfectly postured gaits and flip flops below.  I found a peanut vendor rather easily.  A large red plastic bowl held a mountain of roasted peanuts.  An empty plastic mug sat on top.  "How much for your peanuts?" I asked.  "One-thousand seven hundred," the girl replied, no older than 13 years, eyes cast down with lips holding back a smile.  "Okay, I will take them," I said, not wanting to bargain here even though it is customary in the market.  It is less than 20 cents.  Money is, and is not, the answer here.  Since the discovery of diamonds in the 1930's the people of Sierra Leone have not benefited from the hundreds and hundreds of millions of dollars generated from their often clandestine and violent sales.  I smile at her and make some flat joke about the beads of sweat that drip off of my greying beard and say good-bye.

Lunsar Market

We found a place called "David's Nightclub and Restaurant" across from the market and stopped to inquire about lunch.  "We don't have anything prepared today," the woman said as she washed clothes on a washboard in a cavernous courtyard with scattered plastic tables upon which sat old, cloth floral arrangements.  "How about some omelettes," I inquired.  "Yes, I can do omelettes with chips for you," she responded as she showed us to a table near an old concrete stage above which hung revolving colored spotlights.  Grass grew up in the cracks of the concrete floor.  The night club was ordered closed by the local government since Ebola hit the area in May, 2014.

David's Nightclub

As we waited for our meals, a group of young boys, probably around 7-8 years old, sat cutting plastic bags with a pair of scissors.  We walked over and started grilling them with addition and subtraction problems.  They haven't been to school in over 6 months now and closed their eyes when they responded, mostly accurate, to our math games.  Teachers were supposed to conduct lessons on public radio but apparently weren't paid or not enough kids had access to radio.  Anyway, it appears to have stopped.  Another, girl, a little person named Elizabeth, 15 years old, walked slowly towards our table, stopped and said,"I don't have a mummy or a daddy."  And stood there.  My colleague, Richard, a surgical oncologist from the area in Northern California, was in the midst of counting the money we just exchanged.  Haves and have nots in an empty night club waiting for eggs and fries.   Time on a cross.

We ate and paid and emerged back onto the dense, serpentine market place street.  I spotted a soccer ball hanging up from a a crickety wooden stall.  "How much is this lovely ball?" I asked the girl who came running over when I stopped, her 5 year old legs with energy to spare.  "Five thousand," she said, shyly with a smile that seemed to start on one corner of her mouth before running to curl up the opposite side.  I thought of my daughter wanting to sell breath mints at the end of our driveway to passerbys.  "Will you take six thousand," I replied, the smile now flattening in confusion.  "It is five thousand," she reiterated.  Her mom then came over and I gave her six thousand, we both smiled, and we were on our way.

I took that soccer ball to work with me last night to give to Ibrahim, a thirteen year old boy who has recovered from Ebola but still has detectable virus in his blood.  So he cannot be released yet.  He has been with us for 18 days now and has seen his father die in the bed next to him and has witnessed countless children die since he has been there.  When I left, he was sleeping with the ball underneath his blankets.  All of the flood lights remain on in the white tents at night.

I worked with a young Sierra Leonean doctor last night named Kafoe.  He is quiet and efficient.  His hair line has retreated creating a more prominent forehead that gives you the impression of more active contemplation.  I hadn't worked with him before and got a chance in the middle of the night to talk with him about his life.  He informed me that he is one of 70 practicing Sierra Leonean doctors in the country, a country with a population of 6 million.  He detailed the non-existence of health care in Sierra Leone, even well before Ebola.  He balanced his fears for his country with his fear of not being able to make a living once all the international medical groups leave.  His languid eyes harbored the distance they often do when the road has been long and hard.  The look eyes have when they have borne witness to massive casualties.  Dry, forlorn. We shared some protein bars that I brought along and I found out that he is applying to a residency program in Cameroun where I have worked intermittently for a number of years since I served there in the Peace Corps.  We have acquaintances in common, it turns out.  Kafoe has been caring for Ebola sufferers since it first came to Sierra Leone.  He showed me pictures on his phone of loved ones he has lost.  His corners brightened as he told stories about them.  Later, as I lay down on the cot in the medical tent, I heard him unzip the tent and walk outside.  I had no idea what time it was or where he was going.

Generating Nirvana

At the Bai-Suba compound where we stay they shut off the generator every day around nine in the morning.  Air conditioners, televisions and radios take their last beepy breaths and go blank, motionless.  I work the night shift tonight from 8 pm until 8 am so I read the novels I brought (currently "Americanah"by Adichie and "Blood Diamonds" by Campbell) and try to keep what cool air there is from escaping my room.  Later, I will walk into town and change some US dollars to Leones for the week.  You can have as much solo time here as you desire.  You can tell who finds solitude useful and who finds it unbearable.  The experience here in the Ebola Treatment Center can swing from thick, murky, and inchoate to pure holy water.  Solitary time allows you to put it in a mason jar, turn it upside down, shake it, or just sit and look at it all interact.  Otherwise it all spills away.  Even without the availability of all of our modern distractions here you can still easily distract yourself.  Consciousness becomes digitized.  If knowledge is power then self-knowledge must be nirvana.  Nirvana, in sanskrit, literally means "blown out" as in a candle.  Here, in the stifling humidity of this epidemic, you try to blow out your ego, desires, delusions and reach for mindfullness.  Everything you attempt to do at home but with one glaring difference: time to take the mason jar out of the shed and hold it up to the light.

Going back to work tonight, we have another pregnant woman, Hawa, who is 18 years old and 28 weeks pregnant by history.  Her belly shows more like 24 weeks.  There have been no documented fetuses who have survived when the mother has Ebola.  It has to do with the placenta harboring a high level of Ebola virus and the mother's antibodies not being able to cross the placenta to help the baby.  Insert image of  a dump truck trying to cross over a raging river on a 2x8 plank.  The woman often spontaneously aborts and the fetus is delivered stillborn.  The beautiful freeway of nutrients and building blocks from mother to fetus, sprinkled with the magic of creation caves in and is no longer open for passage.  And the woman continues to fight for her life with a high risk for hemorrhage when she passes the fetus.  Maternal mortality from Ebola is higher than the general population infected with Ebola.  If the woman doesn't spontaneously deliver the fetus , we have medicines to help this process along.  But awaiting the delivery of a dead fetus with Ebola is an act without a metaphor.  It is just that- awaiting the delivery of a dead fetus.  In the waiting rooms of our minds here, there are rows and rows of prayer candles, all lit by sanguine souls, their voices as quiet as dry season windfall.  And waiting is dynamic.  Her wait, alone in the metal treatment tent bed, staring at the flood lights that almost ignite the white ceilings, is different than my waiting.  Which is different than her mother's waiting.  Which is different than her father's waiting.  Which is different than your waiting.  This is the value of life experience, the flavorings we drip into our consciousness through our experiences and our processing of experiences.  All shaped by some framework of what we think we are doing here and where whatever we are goes when we cease functioning.  And so we wait, some of us fidgeting with ourselves, some fidgeting with science, some fidgeting with gadgets, but all waiting for IT to happen.  We write our personal scripture in our deeds.  True.  But who is reading them??

Thanks to everyone for reading this blog and adding your comments  I had no idea what to expect when I started writing it.  I thought it would be a good way to convey what was going on over here.   And it is, but I apologize if it drifts from what is going on OVER here to what is going on IN here.  I have received so many insightful comments and emails and regret that I cannot answer them.  Please know that they are appreciated and I look forward to reading them everyday more than you can imagine.  They connect me back to you and remind me how grateful I am to have such community.

And, by the way, the generator just turned on again....

Fire and Brine

Given that a few of us had a day off together, yesterday we had one of the drivers, Mohammed, take us in a toyota minivan into Freetown.  It is about 80 miles west of Lunsar.  There are a number of Ebola and police check points along the way.  Mandated stopping points result in a bustling throng of petty hawkers who set up transient rickety wooden booths just before and after the makeshift gate.  Just in case you want a boiled egg, flashlight, bag of charcoal, or a large regimen of plantains.  Most of the toll arms are mere pieces of rope with tied colorful plastic bags that hang like dirty synthetic prayer flags.  The rope is attached on either side to a thick tree limb stuck into the ground and, once granted passage, is let down on one side so you can drive over what was never a barrier.  If it is an Ebola checkpoint the policemen will point the thermometer gun at your forehead, look at the International Medical Corps logo on the van door, and let you pass.

The entire road to Freetown is a live organism with many shifting systems of cement trucks, bush taxis, bicyclists, walkers, motorcyclists, dogs, goats, and sheep all mounting and dismounting the road in time with a schizophrenic metronome.  The village life is on display in frames of young girls getting their hair braids pulled tight underneath a stick and limb framed hut, in frames of boys with long bamboo poles trying to dislodge green papayas.  Faded billboards featuring "Mr Condom," a cartoon character smiling underneath the latex bubble of a condom, urge us to prevent HIV and sexually transmitted infections.  The song, "I've Been Everywhere Man," by Johnny Cash, comes to mind.  I re-write it in my head with all the names of the villages I see in a passing blur.  Minor intrusions have not altered the basic subsistence of villagers here for centuries.

The closer we get to Freetown, the more dense and industrial the landscape becomes.  Buildings in varying stages of construction and destruction add more than a touch of grey to the green palette.   All the "modern" houses are made of locally made cinderblock and cement pillars.  The scaffolding is made of well positioned tree limbs and has a unique combination of emptiness and danger.  Codes, if they exist, can be circumvented with bribery in most African settings.  Mohammed tells me that a lot of Freetown was destroyed in the civil war and has been being rebuilt now for over a decade.  There are dirt roads that cling tightly to the waistlines of mountains in the heart of the city.  The city itself is a collection of steep hills and circuitous streets congested with the constant transport of goods and humans in a dizzying display of ingenuity and disregard for potential catastrophe.  One motorcyclist was sitting atop a twin mattress that spread bilaterally in a horizontal direction as he weaved through the traffic.  Another motorcycle passenger carried at least a 10 foot 2x6 plank.  Another a hand-crafted dresser replete with a mirror.  Toyota corrolla wagon taxis dragged along so overloaded they had to be strapped with rubber fasteners to keep the hatchbacks somewhat closed.  A far cry from our sleepy Lunsar and showing no Ebola driven slow down, the city buzzed in a cacophony of beeps, shouts, and songs so intermixed you couldn't tell where all the noise was being generated.  It just became a unified wall of sound, behind which the smoke-hazed outlines of the mountains could be glimpsed.

We traveled to a point called "River No. 2," which is on the coast about 30 minutes out of Freetown, a spot popular with locals and ex-patriates alike in a village called BawBaw.  It is a small patch of white sandy beach equipped with a small bar/restaurant and several umbrellas.  We had a group of 9, mostly American, Russian, and Sierra Leoneans.  The water was see-through clean and warm but refreshing nonetheless.  My body floated out as the waves raised and lowered any sadness or anger or confusion I may have been harboring from the work here, each time massaging it all out and using the undertow to take it all out to sea.  All human constraints seem to dissolve when you get to the ocean.  And it isn't until you are there that you realize how much you needed it.

We swam (watch out for giant Man O Wars!) ate shrimp and chips, and watched a group of children play soccer on the wet packed sand.  We didn't speak of Ebola or what we have seen here.  We kept our feet in the sand and listened to the reliable breaking of waves.  Communion.

The others stayed in the city while I headed back with Mohammed to Lunsar late last night.  Brush fires sliced along the mountains at night, leaving gushes of orange blood visible from afar.   The road back had less traffic, but the cars, people, and animals that were out were more hidden.  It was not hard to see why traffic fatalities here still far outnumber Ebola deaths.  I stayed awake and talked to Mohammed about the Civil War, his three children, and the politics of Sierra Leone.  Beach tired and sandy, I felt like the heavy industry of self had had an oil change.  My underground chambers had been sprayed out clean, windows in the long, chalky corridors had been opened, and secret stairways were given light.  As Mohammed and I sat in silence, whizzing through the African night, after a while the road grew emptier and there were no fires visible on the horizon.  There was peace in the darkness, the stars up above in quiet salute.  I would be home soon.