The President

The harmattan has moved through Lunsar and the banana trees stand still now in shiny droops of bending attention.  No more wind.  The tuxedoed magpies flap through the stillness and caw atop headless palm trees and swoop down to pick through the garbage pile that is not far enough away from where we live and eat.  The west African dwarf goats lock horns on the side of the dirt road and refuse to mix with the lambs who tend to be more solitary and conserve their energy (or are more in touch with their fate).  I think back to when I was six years old growing up in Vermont.  I thought then that the arc of the universe would bend according to my will.  I wonder if children here think anything is possible for them??  When I ride into work in the morning or take a walk into town, their smiles enter through my eyes and are converted instantly by the organ machinery I was born with and the blood enzymes I have brewed unfiltered over the years, into a universal antidote.

The streets today were lined with local soldiers wearing light blue camouflaged pant-shirt sets and red berets and policemen in green, tucked in, bearing crude rifles.  Women wore vibrant printed wraps with matching head scarves and lipstick, their babies wrapped tightly on their backs.  Motorcycle taxis flanked the main street in town.  It had the feel of a local high school football star returning home from war.  But, in fact, President Ernest Bai Koroma was coming to visit our Ebola Treatment Center today.

Koroma, from a nearby town, was an insurance executive who was elected in 2007 and speaks the local language, Temne.  He is serving his second term and is generally well-liked but I get the sense that even if he wasn't, given the brutal recent history here, contrarian voices would remain silent.

I had the day off today but couldn't resist the opportunity to meet the President and hear a pep-talk style speech to all the workers at our center.  Even if it was political parlance, African style. Even if it had gratuitous photo opportunities with Ebola patients behind the fence.  What I really wanted, though, was to ask the President to say hello to the kids in our confirmed ward, even if it was through two fences and 15 feet away.   I wanted leadership in action in this time of great crisis.  I wanted charisma, confidence, and heartfelt concern.  I wanted vision, a sun-drenched, concise path to lead the country out of despair.  After waiting for him for 5 hours, we received word that he would not be able to make it.

The embers in Sierra Leone turn grey and then into dust.  There is no wind here tonight to fan them. But in the morning, when the roosters squawk and peck around the swept dirt courtyard, the embers will grow radiant once again, and the pot that is placed on top of them will be waiting like a giant stemless chalice for water and the reconciliation that comes with bright, sweet yams.

(For the video  taken by one of my colleagues, Joel, of our WASH team going in to get Martin ready for discharge please go to www.bit.ly/ppedance)

Judas

Shakira

Me with the guys from WASH

Shift Change

A thick haze hung in the air this morning as I got up at 5:30 to go for a run.  The morning sky arrived for her shift early before the night sky was done with his restorative duties.  The result was a smoky, seemingly benign but somehow foreboding reaction in the air.  Like a wall of e-cigarette vapor.  I greeted Shakira and used my mini-mag lite to cut a beam through it and started my morning routine.

When I arrived at our Ebola Treatment Center (ETC), I changed into scrubs and put on my rubber boots and prepared for shift change.  The medical tent at this time is full of nurses and doctors ready to go home from working the night shift and abuzz with the uproaring chatter of the new staff  greeting them.  It is crowded, loud and animated.  Everyone in dark blue scrubs and ink black rubber boots.  Imagine a throng of car wash workers.  Then I noticed the master board with a list of all our patients.  I scrolled down to see "RIP" next to a patient named Mohammed we admitted two days ago with pulmonary tuberculosis and possible Ebola.  He had been on TB medications for 5 months now and came in complaining that he never really improved and now had continued shortness of breath, at rest and walking.  He was found dead with his prayer book on his chest and the radio still playing early this AM.  There are expected deaths and unexpected deaths.  He was more in the latter category. 42 years old.

The average life expectancy for a male in Sierra Leone is approximately 48 years, one of the lowest in the world. Infant mortality is equally as abysmal.  The public health infrastructure prior to Ebola was terribly inadequate but since Ebola arrived here in December, 2013, the whole healthcare delivery mechanism has seized like an old transmission.  Routine medical care for non-Ebola patients has disappeared.  Patients come to our treatment center even if they don't have Ebola symptoms just in order to receive some medical care.  Unfortunately, we are not resourced to provide much else beyond Ebola care, which in and of itself is supportive for the most part.

As the morning sun chased away the haze, I went into the treatment unit to check on Sarah, a 40 year old pregnant woman who presented yesterday with Ebola symptoms.  Her 16 week fetus was halfway expulsed yesterday when I saw her, a purple flesh balloon sticking out from her vagina.  We have strict protocols here about not doing any extractions or vaginal exams in pregnant patients given the high risk for bleeding and exposure to our healthcare workers to massive amounts of Ebola virus.  So we gave her medications and hoped she would pass it on her own.  Given her risk of infection, we put her on antibiotics as well.  When I rounded on her today she had passed the fetus but was in a lot of pain and began to show signs of bleeding and shock.  We attempted to put in another IV as her first one was blown but she had the all-too-familiar sunken veins of dehydration.  She died one hour later.

When a patient is actively dying their eyes have a wide glossy shine.  Their last light  burns out like a ship's lantern as the ship bobs and sinks completely into the sea at night.   A wild calm.  We are trained to "pronounce" people after they die by listening over their heart to make sure there is no audible beating.  And watch for the rise and fall of the chest for respirations. To feel for a pulse.  But I cannot help but always start with the eyes.  They speak of mysterious passages in a language of salt and electricity.

Fatmata, a 25 year old woman with agricultural biceps and a wide, lean torso was admitted about 4 days ago.  She knew our treatment center because her baby died here on Christmas Eve.  She went back to her village and started showing symptoms of Ebola and was finally returned to us.  Too late.  She developed massive diarrhea and started bleeding from her gums.  She eventually became disoriented.  When I rounded on her yesterday she thought she was back in her village.  I imagined her drifting in and out of consciousness thinking about holding her baby in her arms and slicing potatoes with her sisters and laughing as they sat in the open air kitchen by the fire on wooden stumps.  I pronounced her dead today at 1:50 PM and we put up a small blue partition so the patient next to her would not see what she already knows.

The afternoon steam intensified even outside the tents and my black boots felt like bird shaped tires.  I was finishing up for the day. And I was finished.  The treatment center noise seemed far away, punchless.  I wanted to stay forever.  I wanted to leave forever.  I wanted to call my son and hear about red power rangers.

Just as I was about to catch the minivan back to my room I heard some clapping coming from the showers outside the confirmed tent.  Then some laughing.  The sound of hands striking drums shot through our compound and I knew at once it was the discharge celebration for a patient named Yakadiatu who had outrun Ebola and was now free!  The chants and percussion then became a small parade to walk her out, feet dancing as she weakly left, the wicks of her eyes awash in holy, wet light.

 I went back to my room, took off my shirt and my shoes, and closed my eyes and waited for sleep.

Hands

Sierra Leone has been portrayed in the media in a number of ways in the last several years.  I have listened to the music of Sierra Leone's Refugee All Stars but have never seen the documentary.  Similarly, I never saw "Blood Diamonds," a film starring Leonardo Dicaprio, which documents the alluvial diamond trade in Sierra Leone.  Both attempt to given an account of Sierra Leone's brutal and         complicated civil war which lasted from 1991-2002.  I have started reading the book "Blood Diamonds" recently but do not purport to have a handle on all the billigerents that played a role in this bloody reign of terror that is estimated to have killed between 50-300,000 and displaced 2.5 million during its 11 year span.

Suffice it to say, at the center of the uprising that involved multiple coup d'etats and several groups vying for power, was the control over the country's diamond mines which are located in the Southern and Eastern regions of the country.  Many children (from both Sierra Leone and its troubled neighbor, Liberia) were recruited into the Revolutionary United Front (RUF) and were reportedly drugged and coerced to participate in atrocities against their fellow countrymen.  Child soldiers.  The book "Blood Diamonds" starts off  with Sierra Leone's president, amidst continual confirmed reports of mass atrocities being perpetrated against civilians, asking the people of Sierra Leone to all "join hands in peace." He woke up the next morning at his presidential palace to find that dozens of severed hands were dumped on his doorstep. Campaigns such as "Operation Pay Yourself" and "Operation No Living Thing" were carried out by a collection of  desperate youth, soldiers, and civilians who enlisted into the RUF.  The country had reached a boiling point after years of corrupt diamond smuggling, unfulfilled government promises to improve the quality of life of the ordinary citizen, and the young, impressionable, displaced youth from neighboring Liberia who were recruited to fight with the RUF in return for medical care and money.

The civil war ended only a little over 12 years ago.  The village I am currently staying in, Lansur, was completely decimated by the fighting.  Schools, churches, and gas stations were looted and burned to the ground.  A whole new group emerged from the barbarous conflict- amputees.  They are visible here.  Handless.  Legless.  A constant reminder of how this country suffered the unimaginable for over one decade, hiding in fear from an enemy supported by corrupt diamond trafficking, hiding from an enemy who looked just like them.

The stoicism I have witnessed in the Ebola ward has roots perhaps in the culture, in general, as well as this recent callous atrocity.  Trauma has been woven into everyday life here even before the civil war.  Even before Ebola.

Adamsay, a 60 year old woman from a neighboring village, speaks only Krio, a de facto national language that came from the Krios who were descendants of freed slaves sent here from the West Indies, Great Britain, and the United States (mostly Georgia and South Carolina).  It is very similar to Nigerian Pidgin English.  She has been laying on the floor on a mattress in the confirmed ward ever since I started working here.  She has languid eyes, a defiant grimace, and a chiseled jaw ridge that, when all taken in together, give her the countenance of someone who has seen more than you will ever see and acts from within regardless of the situation outside of her.  The civil war and Ebola have taken freely from her.  Aunts, Uncles, cousins, children, grand-children, nieces, and nephews.  All part of her quotidian life in the village one day and then snatched in an instant by an unprovoked enemy, be it a misguided rebel or a virus that started in fruit bats before jumping into humans, hijacking their cellular machinery and driving them quickly towards death.  To call her a fighter or a survivor seems insultingly inadequate.  Maybe you endure and overcome because that is what you have repeatedly done.  We are what we repeatedly do.  We are....what we repeatedly do.

Adamsay has been in our confirmed tent for over two weeks now.  When I look at her hands and feet, they are strong but somehow soft, every articulated bone and tendon warmed over 60 years by the fires she has tended are in beautiful repose, even here, laying on the unblanketed mattress on the floor. She, and only she, will write the ending.  I think she will make it out.

Isaac is 25 years old and works in the WASH department, responsible for chlorinating every inch of our treatment center, day and night.  He is from Freetown and is still trying to finish high school.  He lost his father and his brother in the civil war.  Yesterday, he showed me where I could order an omelette in town and we shared a coke together before he had to board the bus for work.

The more you unravel the history of Sierra Leone, the more people you meet, the more magnified their beauty becomes.  In fact, Ebola isn't the biggest enemy they have encountered.  Nor is it the only invisible assailant they have battled.  But it has the stage now.  We are the stagehands.  The world light is bright here. The props are shiny.  All of the actors are playing themselves, as they will continue to do long after the audience has gone.

Shakira

There is a lamb that sleeps outside my porch.  When I get up early in the morning to run she greets me before the sun does.  If I leave my front gate open she will sleep on my porch.  Her droppings are neat islands of pellets that are mysteriously cleaned off the tiled deck every evening when I come home only to be there again in the morning when I open the door.  I leave the gate open now for her.  We lost our canine savant Orville in October and I am not used to being without an extra four legs at my feet to ground me.  I have named her Shakira after my daughter's favorite singer.  She doesn't move much but when she does, the hip gyrations are refreshingly kindred to that of the Colombian goddess.

The government of Sierra Leone has lifted the curfew now that the holiday season has come to a close.  The markets are alive again with color, volume, and denisty.  Hawkers carry around the world on their heads, random objects like sunglasses, toilet paper, and spatulas dangle from the plastic buckets that are more wide than deep.  Motorcycles lean and dart through the crowds driven by teenage boys in sunglasses who show off for girls carrying bags of papaya, cassava leaves, and baggies of salt.  Music rises and falls out of clapboard store fronts.  Water sluices in a ditch along the main market road, just enough for tiny birds to wet their wings.  A boy gets his hair quaffed as the other barbers play a dice game and gesticulate fervently.  Yes, the market, the source of life in this rural village, has roared back colorfully to reclaim the air.

When a patient survives Ebola in our treatment center and is ready for discharge there is a recognizable crescendo of elation in all of our staff.  Yesterday, a young boy named Martin was finally going home.  The WASH team is responsible for escorting him to a chlorine shower where he will shed all of his clothes and belongings and decontaminate his body before re-entering society.  If he wishes to bring anything out it will need to soak in chlorine for a set amount of time, usually less than 30 minutes.  That includes cell phones, most of which do not recover from such an assault.  After the chlorine shower he is able to take a shower with soap and water.  He is given new clothes and then emerges triumphantly to reclaim his life.

As the WASH team was heading into the ward to get him yesterday, they all spontaneously started dancing in full PPE (video forthcoming in future posts!), shaking their booties, swirling their hips, and lunging their chests in one fluid rhythm to make one wonder if they actually had bones.  All the seconds, minutes, days, and weeks of not knowing if Martin was going to make it exploded into a rhapsody of relief and injected our whole center with a much needed infusion of hope and gratitude.  Later, when he emerged from the soap and water shower, there was another celebration with djembes, traditional dance and chanting to send him back with all that he may have lost temporarily while he was awaiting his fate inside the hot, white Ebola tents.  Godspeed Martin!

Infrequent as they are with a case fatality rate approaching 60% in our unit, these fetes are what keep everyone going.  I imagine back to the days of the plague, or of the pandemic influenza outbreaks, or even before the advent of antibiotics, when people just held on and summoned the deepest of faith, forged the widest freeways of hope, and prayed the prayers of the dying because there was no cure to what had seized them.  For us this is now.  Ebola has no cure as of yet. No vaccine as of yet.  To have personally overcome Ebola here in West Africa is to have glimpsed the face of God, a visage now recognizable by Martin in all that he sees in the world.

Now that Martin is heading back to his village out there in Port Loko district, I think about what his future holds.  It doesn't take a village.  It takes a village with running water.  It takes a village with access to affordable, quality health care.  It takes a village with quality education.  It takes leaders who resist corruption for the sake of social justice.

All these things and more.  May it be so.

Touch

You come to feel like you are always wearing gloves after a while.  Purple nitrile gloves go on first when you are preparing to enter the treatment center tents.  Then surgical gloves.

Elastic as hope.
Impervious as reality.
Gloves.
Barriers of protection against a thread-like virus that is 1/100th the size of bacteria.  Mere nanometers.  Unseen.  Ungodly.  Double-gloved hands defile touch.I feel a need to touch all the patients in the ward here regardless. To let them know we are both human.  That something in all this suffering and fear can be revealed as faith. And, sadly, because we have little more at times to offer.

This morning a surgical oncologist and I did "fluid rounds." We went from bed to metal bed underneath the open expanse of the white Unicef tent making sure patients who needed them had IV's and intravenous fluids.  Fatmata, a 28 year old from a nearby village, was having voluminous diarrhea, cholera level diarrhea, and needed an IV.  So we put one in and hung a solution called lactated ringers in a 500 ml bag. And then hung another. And another.  You try to keep up with how much fluid patients are losing by giving it back to them in oral rehydration solution (a mix of salt, sugar and water) and intravenous fluids.  This storm of loss and replenishment can result in massive electrolyte shifts.  This, I am afraid, is what kills people just when you think they have beat Ebola and are getting better.  And currently we have no way to monitor this.  Unicycling in the dark.

After our shift we ate a fish stew over rice from the kitchen at the back of the compound, near where all the boots, gloves, and aprons are washed in 0.05% chlorinated water and hung out to dry overnight.  Lunch cost 1000 Leones, about 20 cents and we eat in a separate canteen tent with all the staff in staggered breaks.  I think of my children ringing the meditation bell at home before we eat to show gratitude for what we have in a moment of silent reflection.  I do the same here without that bell, before the first sip of cold water restores my lips and travels downward.  I am aware of it until it splashes into my stomach and is now part of me.  Until I sweat it out again later.
Holy water.
Holy salt.

Before I left I asked three of our Ebola survivors, who are now employees of international medical corps, if I could interview them briefly about their experience.

They graciously agreed and I learned how Miriatu worked at a hospital nearby as a cleaner and became infected with Ebola in October after her sister and her young niece both died. She spent two harrowing weeks in the Ebola treatment center but walked out cured.  Once you clear the virus, you are completely immune, meaning you can come into direct contact with the virus again and not become infected.  She works in the treatment center taking care of young children who have no family in the treatment unit or are too sick to care for them, or ,as is often the case, have died.

Then there is Isata, a beautiful woman with a childhish smile and eyes that dance.  Ebola took hold of her husband and daughter and never let them go, and she herself endured a tumultuous 30 days in the treatment center where she thought she was never going to walk out alive many a day.  This was early in the epidemic, early August, and medical staff wouldn't even enter the unit at times for fear of getting the virus.  They would leave the food and oral rehydration solution at the door and walk away.  Unlike 70% of others, she survived.

And then there is Mariata from whom Ebola has taken 10 family members in the last 6 months.  Unlike HIV which causes people to often grow increasingly thin and waste away over time, Ebola takes young healthy bodies in their primes out in a matter of days or weeks in a violent maelstrom as they drift in and out of consciousness, drained of their life fluids, alone in a ward with others in varying stages of succumbing, tended to by moon suits with only eyes to identify them as human.  And then she lost her only daughter.  "God liked her more than he liked me," she told me as we talked from plastic chairs in the still afternoon air as others ate fish stew out of  heavy duty green plastic bowls.  She now works in the psychosocial unit which provides emotional support to patients and families.

I often think that there are things from which we never really recover.

All three of these women are my heroes.  They are the ones who should adorn the cover of TIME magazine.

As I left for the evening, the harmattan winds stirred a bit of red dust and I reached out to touch it but it was already gone.

Distributive Shock, Port Loko Province

Just as the sun fell exhausted
behind the field
blackened
by    slash  
and    burn
creeds
put in place
when local really meant local,
I began to run.

A pregnant African mutt
came out the charred field,
pendulous,
ascetic,
ran in front of me for a dozen yards,
then dashed off into the unburned
tall savannah grass
above which appeared the moon,
clouded like the sclera
of a smoker smoking
and gazing out of the morning tavern window,
small like they always are,
to keep yourself from peering in
and finding you there.

We evade oursleves in a million nifty ways
as our joints rust,
our minds scar and dement,
until once irretrievable, we start to let go
and what we always thought we would become
is almost visible in the unharvested corn stalk
torso,
all that remains in the ashen field
into which we forgot what we were supposed to sow.

Chasing Bananas, Finding Rice

I work the night shift tonight from 8 pm until 8 am so it gave me some time to walk into the town.  I set out to find bananas.  The food here has taken a hit as well.  All the roadside markets and produce vendors that are typically commonplace everywhere you look are conspicuously absent here.  But surely I could find a regime of bananas.  I greeted the children playing in front of their houses with sticks and whatever they could fashion into a ball.  Barefoot feet kicked palm kernels and then chased them towards the creek, clotted green with organic and not so organic waste.

In the center of town, a half-finished concrete mosque had a sign on the front that read "closed for Ebola".  Ebola has risen to an evil deity here.  Something lurking invisibly everywhere, casting yet another spectre  of fear across the land.  But still the Sierra Leoneans smile.  I was greeted with kindness and smiles everywhere I walked.  I met a high-school chemistry teacher, Benjamin, who was hung over from the preceding night's New Years Day celebration that it turns out could not be stopped from occurring after all.  At the hotel we are staying at, the Bai Suba, there are a number of circular buildings with bamboo and thatched roofs.  We take our meals there and it also serves as a bar for the neighborhood that can afford the expensive beer by Sierra Leonean prices.  Last night when I went down there for dinner there were colored lights spraying across the dining hall and loud music I could hear from a good 300 yards away.  The WASH team (the group responsible at our Ebola Treatment Unit for washing and decontaminating everything) was having a fiesta.  Their bodies moved like liquid trees to the west african beats, swaying and flittering like leaves who hadn't felt wind in way too long.  They drank Cody beer imported from Germany and, for a brief time, celebrated just being alive.

Woody Guthrie has a song entitled "It takes a worried man to sing a worried song."  Since I have arrived I haven't heard the faith songs I have been accustomed to hearing when in Africa.  I don't know that there are many songs to sing at a child's funeral or when a whole family dies at the hands of a cruel virus.  That there probably are in certain cultures hollows me.

I met a woman named Bula as I was walking back on the empty streets.  The wooden market stalls sat like scaffolding holding the emptiness just behind her.  She was drying rice kernels on one side of the unused street.  They reminded me of something my children play with at aftercare called fusbees which are small plastic beads kids can arrange into shapes or figures and then have ironed to stay together.  The rice kernels were all a golden wheat brown and baked in the overhead sun.  Bula is a nurse at our treatment center and also a subsistence farmer, mother, wife and aunt to many  I asked her where I might be able to find bananas.  "Not today," she responded, adjusting her  floral serape.  "And maybe not tomorrow, but you will find them soon."

I can wait for the bananas to come back.  I have rice after all.