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.