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.