Bundibugyo, Where the tears never run dry

This was a newspaper headline in the days of the ADF war, and it popped into my mind today since my tears flowed freely. Luke then brought it up on his phone call this evening, so it seemed an appropriate title to the day of the burial.

Dr. Jonah was buried today. It was so unlike any other burial I have ever been to in Bundibugyo (and I’ve been to a lot) that it doesn’t seem quite real.

9 am: To the airstrip where the CDC team landed, the kindness of one of the doctors (Dr. Jordan) with whom I’ve been corresponding by email about Jonah brining up the first tears of many for the day.

9:30 am To Kirindi, where Jonah had owned a small farm of land and built a small house. I pulled up in the morning sun, and as I approached the house the wailing reverberated out to draw me in. There sat Melen on the floor of the tiny front room, and I could see she had slept there. Banana leaves topped by a thin scratchy layer of dried bean pods/chaff/grass were her bed. I went in and sat down and just wept, saying nothing. My sobs and her wails and his mother’s from an adjacent bedroom joined in waves of grief, then his sister Sophia came in to cry with us. For a long time that’s all we did. Melen’s grief, and Jonah’s mother’s, consisted of traditional mourning, a lament, a loud protesting litany of what has been lost, my doctor, my son, my husband, our hope. It enveloped us. When the waves subsided Sophia began to recount her version of the illness, and later I talked extensively to Jonah’s brother. So I think I have a pretty accurate view of what happened.

THE STORY OF THE FINAL DAYS
Friday November 23 is the day Jonah believed himself to have been infected. That was the day he and Scott examined Jeremiah Muhindo. In between two of the times they saw the patient together, Jonah went in alone and arranged a face mask of oxygen onto the dying man, hoping to provide some relief or comfort. He was not wearing gloves because he could not find any at the hospital at that moment, and he felt that his friend needed the oxygen. That was his greatest exposure.
Sunday November 25 Jonah traveled to Kampala. He had some business there regarding land he leased during medical school, and planned to see his children and moonlight a few days for extra cash.
Wednesday Nov 28 he began to notice a headache, and wondered if he was getting malaria. (5 days from last exposure, though of course he’d had earlier ones too).
Thursday Nov 29 the EBOLA epidemic was announced. Jonah’s headache persisted in spite of first line malaria treatment, and he vomited twice. He instructed his family to wash the floor with bleach, to not touch him, and to not share his food or drink. He picked up his oldest daughter Masika from boarding school, and by the time they came home he was feeling weaker and worse, slumped over on his young brother’s shoulder.
Friday Nov 30 he had two malaria smears at a private clinic up the road from his house, one positive and one negative. Though he still hoped his illness was malaria, he talked to a doctor friend who encouraged him to be admitted, so they hired bodas and both rode to Mulago. There he was put in an isolation tent.
Saturday Dec 1 a blood sample was taken to test for the virus.
Sat to Monday he was mostly up and talking during the days, still having fever, vomiting, and some diarrhea. Then his urine output slowed down, so the staff began to give IV fluids, but in retrospect he was not dehydrated but rather in renal failure. He was thirsty, and at times hungry. He remained optimistic until Monday that he would recover. His family would come and see him from outside the tent flap, talking loudly to communicate but not touching. The Mulago doctor assigned to his care supposedly fled, but MSF Spain doctors checked him a couple of times a day. His young brother sometimes entered the tent to care for him when no nurse or other medical person was available. He was alone much of the time.
Monday 3 Dec he began to have chest pain. He told his family this was a bad sign, that he had seen patients and when they had chest pain they were getting much worse. His brother describes finding him reading a medical text and thinking through his symptoms and what was happening. He told them that he would die for others, and read them some Bible verses.
Tuesday 4 Dec his chest pain became worse. He could not always talk because of breathlessness, taking several breaths to get words out, so his brother just kept quiet. He also felt a lot of abdominal pain and weakness. He told the staff he was going to die. His young brother was finishing A levels and left to take his last exam. When he returned he found that the MSF team was in the tent and they told him to wait somewhere else. Later he saw Jonah’s body. I think the hardest thing for the family was that Jonah died without any of them around, alone in that tent. That’s hard for us too. And that his body lay uncovered for a while, that seemed to be a very upsetting detail. His brother and the Mulago staff decided that it was best not to tell the family that day, they should keep it under wraps until the morning. But I blew that cover due to direct information from MSF, for which his wife and sister were very grateful.
The picture I get is somber but not desperate. He knew what was happening to him. He followed his own symptoms and watched them unfold. He knew the choices he had made to care for patients might cost his life. It was five days from exposure to illness, and six days from the illness to death.

12 pm: Back in Kirindi . .. Jonah had the small house and farm there, but usually he and his family stayed in town in Nyahuka where he had build a larger building where he rented out some rooms and Melen ran a nursery school. But they were told to quarantine themselves in Kirindi (by MOH). By my estimate only his youngest brother and his mother had any exposure, touching him or cleaning up from his sickness. But the entire family is being ostracized as dangerous. As I sat there for three hours I realized I was the only visitor. There were a half dozen family members, and that was it. No neighbors, no colleagues, no church friends, no one. If Jonah had died any other way there would have been hundreds of people at his home, and maybe a thousand at his burial. Really. Instead there was me. I realized they were going to feel very uncomfortable in Nyahuka town, so I drove a sister back with me to collect mattresses from their rooms so they wouldn’t have to sleep on leaves on the floor again. It was surreal. No one greeted her/us. The building was empty. We collected four mattresses and a few sheets, and then stopped at our house where I filled a basket with about 30 kids’ books for the girls. Three weeks of isolation . . . I put some games in too.

2pm: Up to Bundibugyo. Well, it turns out the district leadership wanted to honor the hospital workers by burying them on site. This may have also been a way to contain spread? Not sure what they’re thinking. But I found out this morning that they planned to drive his body from Kampala to Bundibugyo and bury it with no ceremony, no attendants, not even his wife. Scott and I strongly objected. There is no danger to standing a few feet away and watching the MSF team put the coffin into the ground. I took Melen, the three oldest girls, sister Sophia, and mother, to Bundibugyo Hospital. When we arrived the other two staff were just being buried. Scott is posting pictures of the space-suit team doing the burials. Some hospital staff clustered around, but after those two everyone but us wandered away. We sat in the grass, waiting, crying some, talking, waiting.

3:30pm Dr. Sessanga wandered down from his house to the hospital. Yes, Dr. Sessanga!! He is on day 13, afebrile for two days and so considered no longer contagious (though we found it a bit alarming to see him). He had just heard that Jonah died, and so he decided it was time to come out. I respect that. He was thin, and walked a little unsteadily, but it is so good to see him recovering.

4:30 pm: The truck from Kampala arrived, with the MSF burial team. Masika (15 year old) started to hyperventilate and pass out and had to be carried (by people wearing gloves) to recover in the grass. The rest were crying, on the ground. Scott called the DDHS thinking someone from the district should show the courtesy of attending the burial, and he and the LC5 came, as well as a handful of medical staff and a dozen or so other people I didn’t know. I asked Melen what she wanted, she only wanted to be sure that someone prayed. We circulated looking for someone who was willing to sing, and thankfully found a Red Cross mobilizer who led hymns while the coffin was unloaded. Again people tried to keep Jonah’s family away, but there was no reason for that. Because Jonah’s body was decontaminated and enclosed in Kampala, the infection control protocol for his burial was less than for the two who died here. The team merely wore gloves, and MSF allowed the girls and relatives to stand by the side without touching anything. When the coffin had been lowered on ropes, Scott asked for a pause. He took out a Bible and read from John 12:
But Jesus answered them, saying: The hour has come that the Son of Man should be glorified. Most assuredly, I say to you, unless a grain of wheat falls into the ground an dies, it remains alone; but if it dies, it produces much grain. He who loves his life will lose it, and he who hates his life in this world will keep it for eternal life. If anyone serves Me, let him follow Me; and where I am, there My servant will be also. If anyone serves Me, him My Father will honor.
Jonah fulfilled this description as well as anyone we have ever known, not loving his life too much, being willing to die for the good of others. Scott talked about Heaven and God’s honor, and then about our friendship (with tears), and then against fear and isolation. He prayed. I was really proud of him at that moment, without his leadership there would not have even been that semblance of a service.

5:30 pm: Back to Kirindi, then back to Nyahuka.

I think my tears have run dry now. Back to the numbers, the epidemiology, the science later. For today it was just about grief and friendship.

Jonah Kule, 1966-2007. He was 41 years old.