Jan 1 and Dec 31, beginning and end of the year

Today we spent with Jonah’s family, trying to give them a breather from mourning, a bit of green grass and sunshine and pizza and coke. Julia the jewel entertained with soccer and Speed Uno, and by the end of the afternoon the bigger girls were at least smiling and the youngest giggling. I realized that we began 2007 with Jonah’s family at his house—a year ago (Jan 1, 2007) we celebrated the 10th anniversary of a previous New Year’s Day feast (Jan 1, 1997) by visiting at their farm for the day, including slaughtering a goat and eating together. That day we thought we were entering a new decade of partnership . . . Today however we brought closure to the grief of this year, and reaffirmed our ongoing friendship and commitment in spite of Jonah’s death. We took a pause in the pizza fest to ultrasound the new baby, who is growing perfectly on schedule for a March 19th arrival . . . and looking rather male (Scott's 95% sure) which made me cry and Melen too, after five girls. We’ll see. Love breaks through and finds a way even in the greatest of losses.

None of my kids want to leave tomorrow for our Team Leader retreat, a meeting scheduled a year ago for Austria, tickets long paid for, and a break we think we need. I understand their longing for home at this moment, and it is not without a good helping of guilt that we will leave for two weeks. The hospital is just beginning to get busier again, and it is hard to leave the staff struggling. But 2008 will begin tomorrow with transience and travel, reminding us that we are sojourners at best, longing for true Home.
------------------------------------
Post-Script:
For those who surf for the sake of the Ebola numbers...

Current Admissions: Bundibugyo Hospital 3 currently admitted; 1 of which was a new admission--there were 5 discharges. Kikyo 1 current admission and 1 one discharged.

Total cumulative cases: 146
Total cumulative deaths: 36

Contacts, total: 767
Currently being followed: 275
Those who completed the 21 day follow-up: 408
Visited today: 263 (95%)

Au revoir and Happy New Year!!!

Last day of 2007

2007, a year of blessings and sorrows, a year of life, in review. . . . .

BLESSINGS OF 2007
Blessings in Health

• New Paediatric and Maternity Ward opened officially
• BundiNutrtition:  God provided the funds, Stephanie’s work in sustainability, more goats, and miraculous recoveries
• Kwejuna Project reaches 10,000 pregnant women, funding extended, Pamela’s connection with TBA’s
• Opening of the Butogho water line serves the neediest part of the district
  

Blessings in Education

• Christ School football and track both took teams to nationals, boost to student morale
• Leadership development made great strides at Christ School; Kevin’s discipleship of teachers
• Process of re-opening school after disturbances (see below) strengthens community support
  

Blessings in the Church

• The book of Acts in Lubwisi was dedicated in June
• The church responded to the Ebola Epidemic with fasting, prayer, and grappling with God’s word in a healthy way.  
• National leadership growing in grace and spirit.
  

Blessings in Expansion of the Kingdom

• Two team trips to Sudan led to the Massos sensing a call to that nation, being approved as team leaders, and determining an initial location!
  

Blessings in the Team Community
God sent us the right people at the right time:  

• Sarah Reber and Ashley Wood, two new teachers for our missionary kids
• Larissa Funk and Scott Will, short term medical help
• Bethany Ferguson, intern leader and friend!
• A great group of summer interns
• Ministry to the team by Stu and Ruth Ann Batstone and Donovan Graham, pointing us to Jesus just when we needed it most
• Emergency care from Dan and Gini Herron when team evacuated
  

SORROWS OF 2007:  War, Disease, Death, and Goodbyes

• ADF incursions led to insecurity early 2007
• CSB near-riots led to temporary school closure and slow process of reconciliation
• Annelise Pierce long illness and thyroid surgery, four month HMA unexpected
• Two team families making decisions to move on from Bundibugyo, good process but painful anticipation of separations
• End of term for Kim, Amy, Scott Ickes, and Pamela
• Gray’s abrupt departure to pursue evaluation for Chase, great loss
• Ebola Epidemic
• Death of Dr. Jonah Kule
  

PRAY FOR THE MYHRES AND THE BUNDIBUGYO TEAM:  looking ahead to 2008

• For godly grieving.  The Kingdom is a dangerous business.
• For courage and perseverance.  Pray we would not give up.  
• For wisdom and leadership through a year of extreme transition.
• For our family:  unity, love, recovery, educational plans for kids.

Ebola Bundibugyo, Not Going Away

The Sunday night numbers while not huge continue to cause concern... I failed to reach the Task Force Meeting due to mechanical motorcycle problems, but got the report second-hand from a very reliable CDC source... Current Admissions: Bundibugyo Hospital, 5; of which there were three new admissions. All of the new admissions managed to somehow filter through the Triage System and were admitted to the Bundibuygo Hospital General Wards. After displaying symptoms suggestive of Ebola (high fever, vomiting and diarrhea) each of the three were subsequently transferred to the Isolation Ward. Patients seem to be hiding their symptoms and/or history of contact with cases because of fear of admission to the Isolation Ward. Consequently, more health workers are being inadvertantly exposed to Ebola. This is a huge problem that has eluded a definitive solution. Kikyo has 2 current cases. Total Cumulative: 146 Deaths, Cumulative: 36

Mourning the passing of a loyal companion

Our dog Angie died last night.

In the grand scheme of ebola and eternity, the death of a dog may not seem important, but to the hearts in this home it is the final crushing blow of 2007. Angie was nearly 12 years old, which is a long life for a large dog in the toxic environment of a tropical jungle. Over the last year she had slowed down considerably, but in the last few weeks she could barely walk and finally she was unable to even stand without help. It was time for her to go, but that does not make it much easier.

Angie was Scott’s idea. In 1997 we had three children age 4 and under . . . So adding a dog to the mix was far from my mind. But he saw a notice in one of the first little grocery stores frequented by foreigners in Kampala (for such luxuries as ketchup and mustard) offering a 1 year old mixed yellow lab to a family because the physician owner was finishing her term in Africa and moving back to England. We searched her out and brought her home to Bundibugyo. And never regretted it. Angie stuck with us through war and evacuation. When the ADF attacked us that year and we were running for our lives, Scott took the time to get her on a leash from the line of fire on the front porch and bring her along. She was denied passage on the military helicopter that eventually airlifted our family out, but stayed with Rick Gray in Bundibugyo until we could be reunited. She was never very fond of soldiers after that.

Over the decade she killed her share of snakes and rats, once nabbing a cobra just before Julia walked by it. Our house was never broken into during her tenure, in spite of numerous thefts plaguing other mission houses. When Scott traveled and I was here alone with the kids, I had no fear sleeping at night, knowing she would alarm me to any dangers. In 2001 we brought home another yellow lab puppy, Star. But Angie always remained the top dog, the level-headed one, the trustworthy one.

Her greatest value to all of us was that she represented home. Our kids live as outsiders in an insular culture, slightly out of step no matter where they are in Africa or America, except this little plot of ground. Angie was a force of continuity, unconditional acceptance, faithful love. She was a constant in their lives of tenuous transitions and frequent loss. Whenever we were away, they longed to be back with her, and as we would drive into the yard they would burst out of the doors of the truck to greet their beloved dogs. Her life span fills their conscious memory.

They said goodbye before they went to bed last night, sobbing and stroking. I do worry about the impact of this month on their hearts, this death following so closely upon the frightening separation from us during the worst days of the ebola epidemic. They have seen first hand the groaning of creation, the pain of the Fall (Rom 8). We talked about the New Creation, about Jesus’ words, Behold, I make all things new (Rev 21). We long for that day in a new way this morning, firmly believing that creatures like Angie will be part of that new and good world.

Ebola Bundibugyo, Friday Night Numbers

The Ebola Task Force daily briefing was tense and long. The death of a patient who was errantly admitted to the Female Ward of the Bundibugyo Hospital, later recognized as a Ebola supect, later confirmed and then died...after having exposed at least six health workers to the virus--has left the hospital and district anxious and angry. Current Cases: Bundibugyo Hospital, 5 - of which 3 are new admissions (no discharges, no deaths). Kikyo Health Unit, 4 - of which 1 is a new admission (no discharges, no deaths). Total Cumulative cases: 143 Total Deaths: 36 Case Fatality Rate: 25.2% Contacts: 667. 362 finished their 21 day follow-up. 240 visited today. Please continue to pray for an end to this scourge. PS Check out this trailer for the 20/20 feature this evening which may include Dr. Jonah (the trailer does!)... the ABCNews 20/20 trailer

On being home, and on counting the cost of Ebola

I realize how much our souls have been imprinted by the geography of where we live—mid day yesterday Pat and I both experienced such tiredness.  I think that in spite of the fact that we are told to get away and take breaks . . . There is a certain amount of tension associated with displacement and transition, and real relaxation comes when we’re back home, back in familiar surroundings with familiar people, back where I know what drawer to open to find a spoon and how to use my stove, which allows a release and a wave of tiredness to wash in.  Even though this place is associated with grief and loss, those are only a small aspect of the depth of experience.  So it is good to be home, to prepare a meal, to celebrate our family (plus) around our own table together for the first time in over a month, Christmas candles burning, quiet music, all telling our “highs” and “lows” of the day (the former mostly relating to the fact of being home and the thrill of our mountain pass plane ride; the latter mostly related to the illness and decline of our beloved dog Angie).

We came home because we wanted to be here, and wanted to spend a few more days in the fight.  But an unexpected side effect has been the confidence boost to the community.  I did not anticipate people stopping us and telling us with great sincerity, thank you for coming back, for brining the family, for loving us.  I’m glad for that, the simple act of being present translates into the message that we are still part of this place, that we have not given up, that children can still live here too.  Public opinion is fickle but we’ll enjoy this little surge of connection and community while it lasts.

This morning I went back to Nyhauka Health Center with Scott Will.  We found a half dozen inpatients on most wards (Paeds, maternity, male, and female) and about 30 outpatients.  Though many nursing shifts are remaining uncovered there are a core of faithful people at work.  We learned that six children have died there this week—of anemia, of waiting too long to come for treatment.  The Ebola impact is so much greater than the 36 deaths recorded in the official toll.  The fear that keeps people from coming to the hospital, the fear that keeps staff from working, the isolation that impacts our blood bank supply, these things are more difficult to measure.  Another child left against medical advice in the night, and will die at home, with signs of meningitis according to the clinical officer.  There is no system to track non-hospital deaths, so no way for us to know the true cost of Ebola.  The loss of medical staff, the reluctance of those remaining to work, the loss of confidence in the medical care system, these will have an enduring and devastating effect upon the health of Bundibugyo long after the last case of Ebola.

Ebola Bundibugyo, the Thursday Night Numbers

Yesterday, the delight of anticipation of the end of the epidemic emerged. With only one Ebola patient resident between the two Isolation Wards, the end was in sight. Today, however, reality crashed in. Bundibugyo Hospital Isolation Ward had two new admissions and the one previous patient died. Kikyo had three new admissions, bringing to five the total number of suspected cases admitted to the two Isolation Wards. The one patient who died proved to be a laboratory confirmed case, the one who had been mistakenly admitted to Female Ward. There is a long list now of health workers who will be monitored for 21 days because of their exposure to that patient. The total cumulative cases: 139 Total deaths: 36 Case Fatality Rate: 25.9% Contacts to date: 643 Number who have completed their 21 day follow-up: 330 Number visited today: 235 A new reported statistic being reported: date when the most recent contact will finish their 21 day follow-up and the epidemic will be considered over: ~ January 17th.

Iconic Images of 2007

ABC 20/20 plans to air a year-end review that will possibly include Dr. Jonah as one of their “Iconic Images” for 2007. The show will air tomorrow, Friday, at 10 pm EST (but different schedules will apply to other areas). We are praying that their take on his story and the images they were able to obtain from our summer intern will bring the story of self-sacrificing love to a wide audience, both as challenge and inspiration. We are not certain yet that he’ll be included, but if he is in the show it will be towards the end.

Back in Bundi

We are so grateful for the rich experience of family and team immersion for Christmas, from a white dinner under the moon in our rented yard in Kampala to the the fun of surprising each other with simple gifts and resting far from patients and crises.  This morning Garrett from MAF treated us to the best ever flight into Bundibugyo, threading through some unexplored Rwenzori folds as we topped the mountain passes and looked down on bamboo and heather, rocks and streams, dropped thousands of feet to float to a stop on the grass airstrip.  It was spectacular.  Not quite so fun to get home where a dead rat was decomposing by our bed (!) and one of our beloved family dogs is now so old and arthritic she could not rise to greet her devoted fans.  On the aistrip Scott met with some CDC people who confirmed that a woman with a miscarriage just before Christmas turned out to be positive for Ebola, and exposed numerous hospital staff by denying her history of fever and exposure to known cases.  Sigh.  Back to reality.  More later today, but all of us are grateful to be back home for a few days.

Ebola Bundibugyo, the Sunday night numbers

Two steps forward, one step backward…the first Ebola death since December 13th. Cumulative cases: 134 Cumulative deaths: 35 (Case Fatality Rate, CFR = 26.1%) Case Fatality Rate among Laboratory confirmed cases = 12/34 = 35.3% Current admissions: Bundibugyo Hospital 5, with no new admissions, no discharges, no deaths. Kikyo 2, with no new admissions or discharges, but one death. Contacts: 587 of which 148 have finished their 21 day follow-up period. 321 were visited today. Tomorrow, I will fly out with Pat and three others from MSF to spend Christmas with my wife, my kids, and my Team. As much as I am bursting to see my kids again…I also don’t want to go, to leave behind my fellow soldiers fighting the war against Ebola, against death. As Jennifer mentions below, our Net access is limited at best in Kampala. Funny, but we are better connected to the world in rural Bundibugyo than in Uganda’s capital. May your Christmas celebrations be filled with the Life and Light of the World.

Dispatches from Displacement: Kampala at Christmas

Being out of the ebola zone is a respite and a sorrow all at once, a relief to be safe and yet an ache to be away from home, especially for Christmas, especially when leaving behind others who have no respite options.  My heart is in Bundibugyo with Scott, yet another part of my heart needed these days to hug my children and absorb the care of living in the community of our team, to weep over Christmas carols and corny Christmas movies, to sleep deeply and eat well.  Yesterday most of us attended the Kampala Pentecostal Church’s Christmas Cantata, a 150 person choir, a couple of dozen dancers, a live band, actors, costumes, color, sound, vibrant life and Gospel truth.  I sobbed through the first half hour, just the reality of Christmas joy washing over me in spite of the bitter losses of the epidemic, the African life beat of dance and song bringing the familiar story into a new focus.  The Spirit is so clearly present at that church, if there was advance seating in Heaven I’d want to be somewhere near the KPC section.  Then today we visited a local church, the other side of worship, not the exciting music but the solid rock of truth. The preacher told me after the service that he was a little 10 year old boy who met Jack Miller 30 years ago when he was picking up trash in the Owino market and doing evangelism!  Now Gerald is a gifted preacher, and today he looked at Mary’s story.  His message:  God brings change, His plans are never straightforward and simple, He chooses ordinary people and gives them grace, always calling forth faith, sometimes risky and painful.  Mary could have been stoned for adultery . . . But God favored her, chose her, and brought redemption through her flesh and blood.  I found that reminder tremendously encouraging as our ideas about our future in Bundibugyo, gradually giving all our work over to Jonah, were clearly not God’s plan.  Like Mary, here we are, in an unexpected shelter, with many miles of trials still ahead, and much sorrow already around us, hanging by faith to the character of God, holding on no matter where He takes us.

Tomorrow we will pick up Scott and Pat from the airstrip, the last pre-Christmas act of MAF kindness to fly them out.  We will sing and cook and thank God for reunion, open gifts around our little team tree.  The list of gracious people who have loved us in concrete ways this month is absolutely amazing.  Dan and Gini Herron dropped their lives as Europe field directors in Granada and flew in to shepherd the team through crisis, MAF connected us with a house to rent and the practical details of life in Kampala as well as flying all the responsible organizations in and out of Bundibugyo, our mission’s office staff sent money to treat us to a day off of fun and swimming at a resort, Redeemer Presbyterian in NYC let us know they will fund the Kwejuna Project food for pregnant HIV positive women for the next year, 50 people have bought goats, over ten thousand dollars (with pledges up to 20) has come into the Africa Response Fund (goal 100K), people whom we’ve never met send us encouraging words.  I’m not sure I’ll be able to post for the next few days, so let me close with a deep note of thanks, and a wish for a fresh encounter with the living God this Christmas, be it merry or crushing, I pray that we would all cling to Him.

Ebola Bundibugyo, Saturday Night Numbers

The Saturday night numbers…

- Cumulative cases: 134
- Cumulative deaths: 34
- Current admissions: Bundibugyo Hospital 3, with one new admission and one discharge. Kikyo 3 with one admission and no discharge. No deaths in either ward.
- Contacts: 584 cumulative, with 125 finished their 21 day follow-up and 379 visited today.

Issues discussed in the Task Force Meeting…

Most significant and distressing. A woman presented to the outpatient department of Bundibugyo Hospital yesterday with symptoms consistent with a miscarriage (vaginal bleeding after a period of amenorrhea). Because of her bleeding she was questioned about the presence of other symptoms related to Ebola (and any history of contacts). She denied such. She was admitted to the Female Ward as a run-of-the-mill spontaneous abortion. A few hours later she developed bloody vomiting with nose bleeding. She was promptly transferred to the Isolation Ward where she is being handled as a suspected Ebola case.

As you might guess, the hospital staff has been thrown into a “fresh panic”, and rightly so. The triage system failed, possibly due to misrepresentation or deceit on the part of the patient in an effort to avoid admission to the Isolation Ward or possibly due to an error in judgment on the part of the triage staff. Hard to say with my limited information. Triage protocols are being reviewed and the staff is being counseled. The situation reemphasizes the reality of the risk of accidental Ebola exposure to general health workers in Bundibugyo. Those NASA-like space suits completely protect health workers from Ebola virus in the Isolation Wards who are knowingly exposing themselves to Ebola, but we can’t live our lives wearing those suits. Sadly, this dark cloud of doubt will probably linger in the minds of Bundibugyo health workers for months (or years) to come. Whenever a patient presents with fever and vomiting, nurses and doctors will wonder if Ebola is possibility. It’s frightening.

On a brighter note, the biggest Bundibugyo market of the year, the Nyahuka Saturday-before-Christmas Market occurred today. A frenetic rush to procure new clothes, shoes, sodas, and other party provisions (goats, chickens, and palm oil…egg nog and ice are not on the list). Excitement (and perhaps are bit of desperation) seemed to be the prevailing emotion of the day…rather than fear…and for that I am very thankful.

Ebola Bundibugyo, Friday Night Numbers

Today's numbers...
-Cumulative cases: 132
-Cumulative deaths: 34 (CFR 25.8%)
-Current Admissions: Bundibugyo Hospital 3, of which 1 is a new admission, no discharges and no deaths. Kikyo Health Unit has 2 inpatients, with no new admissions, 1 discharge and no deaths.
-Contacts: 577 total, 124 completed their 21 day follow-up, and 379 (94%) were followed up today.

Issues of the evening briefing (see the picture of the Task Force meeting above):
- 5 dogs were found dead in Bundibugyo Township today causing general panic due to fear that the dog deaths could be caused by Ebola. CDC experts assured everyone that Ebola has never been known to be found in dogs (collective sigh of relief).
-70 herbalists were sensitized/trained today. Not sure exactly what that means or how effective the training will be.

The pictures above...
-The Bundibugyo District Ebola Task Force meets in a Unicef tent every evening from 5:30-7pm (avg attendance ~ 50).
-The Kikyo Health Unit MSF Isolation Unit is now a finely tuned machine, terraced and complete with brick-lined crushed stone sidewalks.

The RDC reminded everyone to be vigilant as we approach the Christmas celebrations.
Vigilant...watchful, observant, attentive, alert, eagle-eyed, hawk-eyed, on the lookout, on one's toes, on the qui vive; wide awake, wakeful, unwinking, on one's guard, cautious, wary, circumspect, heedful, mindful.

A biblical reminder for sure...

Ebola Bundibugyo, Thursday numbers

A small milestone. The last death occurred one week ago, 13th December. The beauty of the line graph above is the flattening of that slope on the right. A whole week without an Ebola death...that's a cause for celebration.

Today's numbers:
-Cumulative cases: 131
-Cumulative deaths: 34 (CFR=25.9%)
-Current admissions: Bundibugyo Hospital 2, with 1 new admission, no discharges and no deaths. Kikyo Health Unit has 4 inpatients, with no new admissions, 1 discharge and no deaths.
Contacts: 571 of which 432 are being followed-up. 94 have completed their 21 day incubation count-down. 89% of contacts were seen today.

Issues discussed in the evening briefing:
-World Food Programme will be giving a generous package to the families of all Ebola patients: 75 kg of corn meal, 11 kg of dry peas, 3.7 kg (one can) of vegetable oil, 14 kg of corn-soya blend, and 3 kg of sugar.
- The Batwa (a.k.a., the pygmies) have appealed to the LC5 Chairman because they are "bad off" because of Ebola. They claim that they depend on the income generated from tourists who have stopped coming to Bundibugyo because of Ebola and that they are starving. In fact, the Queen Pygmy has deserted her husband, the King, because he is not providing for her. Abdicating the throne because of hunger...things are bad in Bundibugyo. The Task Force requested that their request be redirected to other donors so as not to confuse our mandate which is to treat and prevent Ebola infection.
-The Democratic Republic of Congo has closed the border to incoming traffic. Congolese citizens may enter Uganda freely, but not re-enter the DRC. Congolese nationals who want to re-enter their country from Uganda are being admitted to Isolation Tents whether they are sick or not. Unnecesary, extreme, mis-informed.

Jonah's wife, Melen, and her family returned from their outlying farm to their small concrete home in Nyahuka last night. Melen, Sofia and Jonah's mother wept all evening. Pat slept with them and read Scripture to them all morning until the stream of visitors began which lasted all day.

Ebola Bundibugyo, Wednesday numbers

One of the World Health Organization experts told us that in the best case scenario we would see the number of cases cut in half each week. The admitted caseload peaked at 40 about 2 weeks ago, so with the current admissions numbering 6, things are looking pretty good.

Today's numbers:
- Cumulative cases: 130
- Cumulative deaths: 34 (CFR = 26.2%)
- Current admissions: Bundibugyo Hospital 1, with no new admissions, 3 discharged, and no deaths. Kikyo has 5 current, with 2 new cases (both identified from the pool of contacts who are being visited daily), 1 discharge and no deaths.
-Contacts: 571 total of which 450 are being actively followed (77 have finished their 21 day incubation monitoring and the remainder were lost to follow-up). 86.4% of the contacts were visited today.
-Lab confirmations: of the 108 samples sent for testing in the CDC/UVRI lab in Entebbe, 32 have been positive (29.6%). Of the 32 positive samples, 11 died (CFR = ~34%, slightly higher than the overall clinical CFR mentioned above)...probably closer to the "true" CFR of the Ebola-Bundibugyo strain (Btw, still waiting on that name to be officialized).

The District Task Force meeting continues to chase administrative details rather than medical or epidemiological questions. Today's issues related to the number of individuals of a village health team who could receive renumeration for assisting the surveillance teams and who would distribute food donated by the World Food Programme. Every confirmed Ebola case will receive a month's worth of food for a family of six.

My favorite anecdote of the meeting came out in the Surveillance Committee report. When a patient is discharged from either of the two MSF Isolation Units, they are asked to surrender all of their properties for incineration. Their mattress, their clothes, their toiletries...up in smoke -- along with any residual virus. Well, one patient was asked to surrender his cell phone (any studies out there on the duration of Ebola virus viability in a cell phone?)...which he relinquished without complaint. However, he did follow-up over the next couple of days with a couple of calls...and found that his phone is still in use! The surveillance committee is pointing the finger at the Isolation Ward staff for poaching the infected cell phone.

"Burn it or give it back," the patient has asked (he's not afraid...he's immune now).

Tuesday Night Numbers-Still in Bundibugyo

Dueling posts? Jennifer has posted this evening from Kampala because she flew out of Bundibugyo with MAF this afternoon to re-join our kids, capitalizing on her first opportunity in 14 years to sit in the co-pilot's seat. Flight protocol states the plane must be loaded heaviest in front, so Jennifer has always been relegated to the rear with the small kids. As the only passenger on today's return leg to Kampala, she had no competition for the premium seat.

This evening's District Ebola Task Force Meeting revealed a continuing tapering of the epidemic...

- Cumulative Cases: 128
- Cumulative Deaths: 34 (CFR = 26.6%)
- Current Admissions: Bundibugyo Hospital 4 ; with no new admissions, 1 discharge, and no deaths. Kikyo also with 4 inpatients; 2 new admissions, 3 discharges and no deaths. Of the 8 currently admitted to the Isolation Wards, they hope that 6 might be discharged tomorrow.
- Contacts: 535 have been listed with 426 actively followed (the remainder finished their 21 day waiting period--the Jonah family will hit their 21 day goal tomorrow). 85.2% of the contact list were visited today, a huge and punishing task in the unrelenting sunshine today.

The most intense discussion of the evening again revolved around the issue of "traditional healers" , also known as "herbalists", "traditional herbalists", "alternative practitioners","witch doctors" or "jujus". The lines between these practitioners seem indistinct, and in fact, they appear to jump back and forth between the roles depending on circumstances. Hundreds of these healers prescribe their concoctions of locally gathered substances (77 different tree sources) in drinkable teas, smearable pastes, or otherwise unspeakably applied mixtures for all sorts of common illnesses...and now they are taking credit for the successful treatment of Ebola patients.

Where does the Task Force draw the line between challenging engagement versus tacit endorsement? Clearly, this group is out in the community on the front line of caring for people with illness and cannot be ignored. However, their practices and pharmaceuticals have not been scientifically studied and cannot be endorsed. They commonly make small incisions to "let bad blood out" and to promote the absorption of their smeared herbs, a practice that could put them at extremely high risk of contracting Ebola themselves or promoting the transmission of the virus to others. Thankfully, reason prevailed and the Task Force unanimously agreed today that this group should be strongly discouraged from treating any Ebola patients. Whether they can be convinced is an entirely different question.

In Kampala

I flew to Kampala today, and am now with my four children after two weeks and one day of separation.  Thanks to the many who prayed.  Now Scott will be updating the blog from Bundibugyo.  It was amazing to fly out over the epicenter today, seeing the white MSF isolation tents like mushrooms sprouting around the Kikyo health center.  Smoke rose from forest-clearing fires, the ridges shone with the diamond glitter of tin roofs reflecting the afternoon sun, and the line of the forest where the elusive viral reservoir hides was clearly visible.  All so orderly and peaceful from the air . . .

21 Days! Ebola Bundibugyo on Monday Night

Today we are celebrating emerging from the danger zone, though the joy is heavily mingled with the deep sadness of those who lost their lives, particularly Jonah.  In the dark hours after his death we truly thought we might not be writing this today.  So we should thank God that for His inscrutable reasons He has ordained that we remain symptom free for 21 days, and in the clear.  Melen and family reach their safety zone on Wednesday.  In our daily visits I sense a slight lightening of spirit, a hope.

Tonight’s meeting saw the RDC, the LC5, the DDHS, and the CAO (chief administrative officer), the four most powerful men in the district, all back in place.  The RDC opened with the statement that the enemy has just made a tactical withdrawal but is not defeated, so don’t relax.  The struggle continues.

• Cumulative cases:  126
• Cumulative deaths: 34 (holding for DAYS now); CFR 27%
• Current Admissions:  Bundibugyo 5; with 2 new admissions, 1 discharge, and 0 deaths.  Kikyo also 5, with 1 new admission, 4 discharges, and 0 deaths.  More discharges expected tomorrow.
• Contacts:  487 have been listed, with 408 being actively followed (others like us have reached the 21 day limit).  Today 88% of those were evaluated by energetic mobile teams, now boosted by five young MPH students from the Institute of Public Health, all Ugandan doctors who have joined the CDC in their efforts.
• Complaints:  tribalism surfaces again, with the Bakonjo claiming that the social mobilization teams are speaking only in Lubwisi . . . Which prompted a LONG discussion of the mobilization effort.  Are the Bakonjo areas just harder to reach (steep, scattered), or are the complainers angling for jobs and pay, or is there really any problem at all?  Much emphasis was put tonight on using the LC1 system, the political organization of the country, to address communities.  I think they ended up deciding that various big men should volunteer to train LC1 chairmen to reach every community.
• Dissension:  much discussion again of local herbal remedies, with some herbalists now spreading the word that certain recovered cases only recovered due to their medicines . . . And not so surprisingly, many of the people in the task force are not so sure, the power of the belief in traditional medicine is widespread.  A couple of brave voices asked for science to interpret the results, and warned that if herbalists are invited to participate as part of the official task force then we will be inadvertently authenticating their claims.
• Money:  there is now a 2 billion shilling plus budget, but the Ministry has to approve it.  Refreshing moment: In contrast to all the grabbing we see in the political sphere, we were handed a document today by one of the translators who works on the Lubwisi Bible project, who had taken the information about Ebola and translated it.  Unlike everyone else we have encountered, this man wrote at the bottom:  translated at no cost, for the good of the people of Bundibugyo and the glory of God.  Amen.
  

And the emotions of the day for us:  relief, and eager anticipation of going to Kampala tomorrow (Jennifer) to see the kids.  At this point we are still planning that the non-medical team stay out, and Scotts and Pat join the rest for Christmas.  But our kids call several times a day asking when they can come home, and why not for Christmas.  Now that the epidemic has slowed in its relentlessness, we are torn.  We don’t want anyone to be exposed.  But the chances of that are remote for those who don’t see sick patients.  Our kids’ friends, who are flocking back to our house, asked today, when are they coming, and why not now if you are safe?  Once again, we are torn by our care for these kids, and the painful reality that our standards for our kids and team are different than our standards for local people.  Unfair, and stressful when you’re here facing reality.  Actually most of the rest of the country and the world is probably more uptight about Ebola than the average person in Bundibugyo, and for good reason.  If you aren’t here, then Bundiubugyo = Ebola.  If you are here, then you see that 99% of life is about other things, the normal human interactions that constitute a day.  Pray for wisdom for us and our mission leadership, who have to buy into the decision on when to sound the all clear.

And tonight, to close, a little reminder of life going on.  Dear team mate and friend Heather Pike Agnello is in labor with her first baby, while a few hours from now dear team mate and friend Rick Gray will celebrate the milestone of 50 years (Dec 18!!!).  Happy birthdays.

Dr. Jonah's ship...out of our sight...

Fellow WHM colleagues in Ireland passed on this poem to us. A poignant image of death as merely transition... I am standing on the sea shore, A ship sails in the morning breeze and starts for the ocean. She is an object of beauty and I stand watching her Till at last she fades on the horizon and someone at my side says: "She is gone." Gone! Where? Gone from my sight, that is all. She is just as large in the masts, hull and spars as she was when I saw her And just as able to bear her load of living freight to its destination. The diminished size and total loss of sight is in me, not in her. And just at the moment when someone at my side says, "She is gone", There are others who are watching her coming, and other voices take up a glad shout: "There she comes" - and that is dying. An horizon and just the limit of our sight. Lift us up, Oh Lord, that we may see further. Bishop Brent 1862 - 1926

Ebola Bundibugyo: Sunday night report

Today, the non-medical side of Ebola . . . Or the real-life, long-term side of it perhaps. After Scott did his very public thanks and contact-greeting with survivor Fred, Pat gave him a Bible, and he came to our house for a coke and sandwich. Meanwhile a reporter for a Christian Dutch news service who had traveled to Bundibugyo showed up at church too, so he took advantage of the time to do interviews with the nurse, then with Scott, and briefly with me. He lives in Kampala but earns a living by writing stories and radio shows for the Netherlands. He was just leaving when the CDC team came, we had invited our fellow-Americans to cheer and encourage them with pizza and a break from the front lines. It was one of the hidden blessings of the outbreak, to enjoy the company of these young doctors, swap stories, and send them back into the battle a little fortified. Also the evening briefing is a bit more palatable after a good meal . . . The medical side continues to improve:

• Cumulative Cases: 123
• Cumulative Deaths: 34 (stable number once again); CFR 27.6%
• Laboratory: no news, no planes on Sunday, so no new samples analyzed.
• Contacts: reporting was a bit more fuzzy, the teams are definitely out there tracing, there is a concerted effort to add contacts of new cases to the list. The surveillance team seems to find questionable people on a daily basis who have some sort of symptom, but rarely get admitted, so then aren’t counted as cases. There seems to be a gap between contact tracing and case identification, hard to tell from the briefing but we might be missing some people, or focusing attention on people who aren’t real contacts, because the stakes are high. Either mistake is potentially costly, to leave infectious cases in the community, or to distract resources towards non-Ebola sick people.
• Admitted to Bundibugyo Isolation Unit: 4. Quite an improvement since last week! 0 new admissions, 1 discharge, 0 deaths.
• Admitted to Kikyo Isolation Unit: 8. 1 new admission (was a support staff who worked in isolation, so yet another health care worker contact falls ill), 1 discharge, 0 deaths. There was also a readmission of a previous Ebola case but he is a man with chronic hypertension, so his readmission was judged to be due to this chronic problem and not to Ebola.
• Politics: The entire two weeks we’ve discussed the lack of a vehicle for Kikyo to serve as an ambulance. They are supposed to have two separate trucks, one to bring patients in (ambulance) and one to go out and bury the dead. Every day the hard-working staff complains about the lack of a vehicle. Every day there is a different person to blame. It is broken, it is in the shop, the district hasn’t paid the bill, the fuel wasn’t available, it is back in the repair shop . . .and today’s explanation: the driver could not be found. It seems that drivers signed up for the extra allowance of being Ebola-response team members, but none actually want to go anywhere with Ebola, so Kikyo is not a preferred route. WHO suggested that drivers only be paid AFTER driving. Sounds good to me too.
• Cultural issues: a doctor from Kampala warned that Christmas might be a risky time because the local people would want meat and therefore poach wild animals from the forest, accelerating the epidemic. While isolated cases of this hunting probably did trigger the initial transfer of the virus from the supposed animal reservoir to humans, the entire district certainly doesn’t go poaching for Christmas. I guess I’ve lived here long enough that I felt personally offended by the underlying cultural superiority of the comment, people from other parts of Uganda look down on Bundibugyo people as primitive. I wanted to raise my hand but had already been attacked for a previous question, so I waited and was actually quite happy when our own DDHS very politely explained that as the senior indigenous person present, he wanted them to know that this is a season for cocoa, and the local people get money for their cocoa and use it to buy beef, goat, pork for Christmas, they do not go poaching from the parks. There was also a suggestion that circumcisions be deferred until after the epidemic. This was agreed to be a wise move. Usually Dec/Jan is the main season for circumcisions, boys are off school and can go through their initiation in groups. Some years seem to be more popular than others. Any procedure that involves blood and is not urgent should be delayed. So next year might be a better choice.

Today’s sermon was on Elizabeth and Zachariah, on God bringing joy into a situation of barreness. We so easily criticize Zachariah for his lack of faith, but I sympathize with him this year. This is a bleak season for health and the Kingdom in Bundibugyo. To see God’s work here takes faith, and I’m sure I’d be tempted to point out the facts to an angel. Praying for hope, for the nine-month view ahead to what God will do.

Ebola Heroes

Today Scott stood up to introduce Fred Lubwasa in church—Fred is a UPDF soldier and nurse who volunteered to work in the isolation unit back when we didn’t understand the epidemic, then stayed on when he knew it was Ebola. We first met him three weeks ago, the first time we were examining patients there. His exposure led to infection, and he battled for his life. Now discharged, he thanked Scott for the prayers of the people, so Scott invited him to church. As they stood together, Scott put his arm around him and shook his hand to show that post-Ebola patients are not infectious and should not be ostracized. He pointed out that God looks at the heart and in God’s kingdom this nurse is a “Big Man.”

We are also posting some additional pictures today of the other Heroes of Ebola.

Rosa Crestani, the MSF Medical Coordinator who led the advance team, moving in to create order in the chaos, passionately caring, with that core of steel that allows her to do her job even when criticized by politicians (and she’s had plenty of that in the meetings!).

Dr. Yoti Zabulon, the energetic and patient young doctor, who survived the Gulu Ebola epidemic of the year 2000 and then pursued a career in Infectious Diseases with the WHO in Uganda, flying to every trouble zone in the country to offer service, leadership, and wisdom.

Our Resident District Commissioner Sam Kazinga, who represents the President's Office to the District, with his commanding presence and insistence on work, pulling all the agencies together and keeping the Ebola District Task Force focused on their task, dispelling rumor and insisting on excellence.

Monday Julius, the Clinical Officer In-Charge at Kikyo Health Unit, who has been caring for Ebola patients at the epicenter since it began, seeing more Ebola patients than any other person in the district...and who has managed not to get sick with the disease!

And there are many others, the fresh faces from CDC who track contacts and draw blood samples and diagram transmission chains. The voices of experience from WHO and elsewhere who have seen this all before and know what to do next. The doctors from Ministry of Health who left their homes and families behind to shore up the devastated medical system here. The committed and competent field workers from the Red Cross who scour the district for contacts and cases.

Dr. Ian Clarke writes a weekly column, and in today’s he praises two doctors in Kampala working with paediatric AIDS. In that same spirit we applaud the heroes we’ve seen here. Just when one is tempted to despair over Uganda, these people remind us that God has his people everywhere, fighting the good fight, showing mercy, using their talents to serve others.

Ebola Bundibugyo: Saturday numbers

Encouraging statistics from today:

• Cumulative cases: 122
• Cumulative deaths:  34 (same as yesterday, no new ones!)
• Admitted on isolation wards:  Bundibugyo 4 . . . 0 admissions, 4 discharges, 0 deaths.  Kikyo 8 . . . .2 admissions, 4 discharges, 0 deaths.
• Contacts:  423 identified, 327 being followed, 286 seen today (87%).  42 people moved off the list at the end of their 21 days.
• Surgeries Scott performed today: 3.  He was called this morning by the police surgeon from Fort Portal who said he needed to go home for the weekend, so could Scott be on call. . And a few minutes later the first emergency C-section call came.  So Scott and Scott spent the whole day at Bundibugyo hospital, once again the only people seeing non-Ebola patients.  This pinch-hitting is very stretching for them, dealing with cases that come very late and very sick . . . Thankfully a healthy baby boy was delivered by C section, an 18 year old bleeding excessively from a miscarriage had a d and c, and another lady’s life was saved when she came with a retained placenta.  Before and after all that Scott was dealing with airstrip maintenance.  It’s a lot of work to be here these days.  
  

Best comment of the day:  Dr. Sessanga’s son.  It is a privilege to be a source of information even for Ebola patients’ family members in Uganda, to encourage prayer and hope.  A small way in which this crisis bridges cultural barriers and connects us all.

Ebola Bundibugyo: Friday Night Numbers

Two weeks and one day since the diagnosis of Ebola was made public.  Two weeks since the MSF preparation team came, 12 days since the first real medical staff, and 10 days since the overall organized response took shape.  In that time it is good to think about what has NOT happened.  Ebola has NOT been confirmed anywhere outside of Bundibugyo.  Hundreds of new cases have NOT materialized.  Health centers in addition to the two primary foci have NOT been swamped with cases.  It has been a stressful and uncertain two weeks, and a time of great loss and sorrow.  There were many points at which it seemed we might be reaching the potential beginning of the end of life as we know it, with diffuse spread of the infection and overwhelming fatalities.   Thankfully that has not happened, but now the weariness of grief is beginning to catch up with us, the change in pace to the long-haul.  And with that shift comes the district and ministry wrangling over money, power, and control.  Scott spoke up in tonight’s meeting on behalf of compensation for health workers who were infected and recovered, as well as the families of those who died, concerned that these people were getting lost in the scramble for the money flowing in.  He was immediately attacked by at least three people who sensed a threat or challenge to the proposal of huge allowances for all numbers of people, some of whom are quite peripherally involved. Sigh.  I think it is a small reflection of the kind of pressure Jonah faced.  If we aren’t a threat to the way things are, we shouldn’t be here.  And so it goes.

• Cumulative Cases:  120.
• Cumulative Deaths:  34 (CFR 28.4%)
• Admitted:  Bundibgugyo 8, 1 new admission, 1 discharge, 0 deaths.  Kikyo 10, 1 new admission (a health worker sadly), 0 discharges, 0 deaths.
• Confirmed cases by lab:  32 still, but now we got the information that 11 have died, 7 are still admitted, and 14 have recovered.  If those 11 are the only ones to die then the CFR among laboratory confirmed cases will be slightly higher than the overall, at 34%.  The numbers are small, and this CFR could be falsely lowered by the fact that the sickest patients did not survive to get their labs drawn, or falsely elevated if we go back and test lots of people for antibodies since we’ll only find the survivors.  Still it is the best number we have, and would suggest this strain is less lethal than other strains of Ebola.
• Contacts:  345 (17 were removed from the list for reaching their 21 day limit, a milestone we look forward to next week!).  Over 90% were followed up today.  
• Interesting stories:  the two biggest clusters of related cases  have been mapped out.  There do not appear to be multiple sources of this infection crossing from the supposed animal reservoir to humans.  This is excellent news, since it was certainly possible that Bundibugyo might have had lots of little mini-epidemics all cropping up in this time period.  Most cases seem to be directly related to each other.   However not all are testing positive, which may mean that we are looking at not just another strain of Ebola but something else as well.  We continue to be thankful for the excellent and inquisitive minds who are focusing their energies on this.
• Sad news:  there was a massive turn over in staff today, especially WHO, including three of the men whom we have grown to really trust and respect over the last ten days.  They will be missed.  Dr. Yoti promised to come back.  Other sad news was that a mission house was broken into, the thieves dragging a safe a long distance and then sledgehammering it to pieces.  They were probably disappointed to find it was pretty much empty.  Sad for all of us that people would use this time to take advantage of others.
• Happy news:  The UPDF nurse Fred, whom we met in the Bundibugyo isolation unit the first time we went to investigate patients, recovered.  
  

Some men that Scott lived with in college, 25 years ago, let us know that they are coming together to pray for us.  A dear friend whom I have known since I was born, and almost never had an email from, wrote today.  We continue to be humbled by the outpouring of love and concern from the amazing network of friends God has blessed us with.  We even had a call today from the National Forestry Authority official who nearly arrested us last Christmas when we cut down a pine tree (with permission, but it turned out that the permission was not from the people who had authority to give it . . . ).  He wanted to be sure we are OK, and asked us if we had our Christmas tree yet for this year!  For the first time in my memory I have not done any preparations for Christmas at all beyond packing a hurried trunk of things for my children when we sent them off.  But the team in Kampala had tree and decoration plans for tonight, so we politely declined the NFA friend, though we appreciated the thought!

Ebola Bundibugyo: Thursday Night, Living on the Edge

The facts:

• Cumulative cases: 118
• Laboratory confirmed cases:  32, all still from Bundibugyo
• Cumulative deaths:  34 (28.8%CFR)
• Contacts:  368, with 264 seen today (71.7%)  This is the heart of containment, having surveillance teams face to face daily with contacts to monitor any who become ill, and encourage them to come in for isolation and care.
• Admitted in Bundibugyo:  8 (!), with 5 discharges, 3 new admissions, and 1 death.
• Admitted in Kikyo: 9, with 0 new admissions, 0 discharges, and 1 death.  We learned today that two of these are women who are breast feeding babies (age 3-4 months), and since the virus is highly transmissible in breast milk we are providing formula tomorrow so that the babies can be watched in isolation for symptoms but separated from their mothers . . . Another sinister aspect of this disease and the way it insinuates into the very relationships that should bring comfort and support.
• Stories:  well, there were a couple of sad ones.  First, a pastor died, a man who had prayed for Ebola patients before we knew it was Ebola.  In my view it is just like the health workers dying.  This man laid down his life by caring for others.  He probably laid his hands on Jeremiah Muhindo as he prayed for him.  So did Scott.  That always sobers us, though each day we move further and further from the common incubation period, and closer to the 21 day safety zone.  The clinical officer Joshua Kule’s son is another problem story—it came out in the meeting that a surveillance team visited him and determined that the fever he had was improving on antimalarials so he did not have Ebola.  At that point our MSF nurse spoke with obvious conviction and care:  it is DANGEROUS, she said, for the surveillance team to think they can make that judgment.  Any contact with fever has to be evaluated by a medical person and tested!!!!  This man was the primary caretaker for his father, who died, and is exactly in the incubation period for symptoms. Cases like this make it clear that we are not yet out of the woods.  Because people fear the isolation ward, they will try to hide or minimize symptoms, and thereby put their families and communities at risk.  
• High of the day:  Scott was able to visit four of the five families of health workers who died, taking them some food and comfort and words of Scripture about God’s care for the orphan and widow.  I think it was a touch of kindness and contact in a disease that is otherwise frightening and isolating.  And a way to show extra respect for the lives of these men and women.  He also tracked down the children of a woman admitted now, who is not dead, but whose children have been reported to be fending for themselves.  
• Low of the day:  Well, several really.  One is that the voices of reason and wisdom and experience may be thinning out as we end our second week of crisis response.  We hear rumblings that the CDC team is narrowing down to one (a really nice guy, but still only one of him) and our trusted WHO doctors and epidemiologists are also hinting they won’t stay much longer.  An experienced person warned us today to expect things to temporarily deteriorate again between Christmas and New Year as people slack off .. . Which makes us feel like we should be here then.  I miss my kids a lot tonight, more than usual, maybe hearing about them first-hand from Pat.  It was a discouraging meeting tonight, focused on money, and while I respect the hard work and leadership of most people involved, I feel the cross-cultural tension of distaste for the fact that the biggest budget items are extra allowances for most of the politicians.  My American viewpoint is that they are doing their job, so why should UNICEF money go to their pocket?  But I know the African view would be that they are underpaid, and that they are putting in extra hours, and that it is only right that their work be valued in this way.  But I have to confess it still grates on me.
• Unlikely heroes:  MAF.  Mission Aviation Fellowship flies people in and out almost daily, ferries blood samples to the lab, brings supplies here.  They also have found our team a house to stay in in Kampala, and helped them with everything from a generator to groceries.  We are a small mission, and in many ways MAF functions as our support base.  The pilot today even took an extra hour on the ground just to visit us and pray for us.  We are so grateful.
  

I’m wearing a shirt tonight in honor of Pat returning, a shirt that she gave me after buying it right off the back of a man in the market who was wearing it, during the ADF years.  It says:  If you aren’t living on the edge, you’re taking up too much room.  Here we are on the edge, hanging on.

Ebola Survivors - 2 Bundibugyo Health Workers

Dr. Steven Sessanga, the Medical Superintendent of Bundibugyo Hospital, was formally discharged as an Ebola survivor yesterday. President of Uganda, Yoweri Museveni, called him on the phone yesterday to congratulate him on his recovery. His illness lasted for nearly two weeks. His exposure occurred during his care for Mr. Muhindo Jeremiah, the same patient from which Dr. Jonah contracted the Ebola virus.

Issac, a nursing assistant at the Kikyo Health Unit also recovered from a prolonged illness due to Ebola infection. His severe vomiting and diarrhea resulted in his need for 61 bottles of IV fluid. He's currently back on the job, effectively immunized and safe from any infection from the Ebola-Bundibugyo strain (the title of the strain has not yet been determined).

District officials would like to capitalize on the fact that some patients--even health workers--are surviving Ebola. There's a tremendous resistance to admission to either Isolation Ward, as it is perceived as a death sentence. The experience of these two heroes challenges that fear.

Ebola Bundibugyo--Wednesday Night Numbers

We flew home at dusk on Scott’s motorcycle, the sky pinking westward and mist shrouded mountains silhouetted eastward. I saw a young girl dancing with abandon as we passed, and many people greeting, talking, walking, carrying their burdens and cooking their food, smoke rising from fires, just like any other day. Yes, Ebola is here, but for the vast majority of people it is only a shadowy fear, and their real life continues. I lose sight of that sometimes. A week ago we were stumbling through our tears and anticipating illness, wondering if we would leave this place alive, and if we did could we ever come back? Now a week later hope surfaces again. Even Melen is smiling more readily, her shorn head a final sign of her mourning coming to completion. This place breaks my heart and demands my all. But in God’s economy, that draws out love. I have thought often this week that the pain which was introduced into childbirth by the Fall had a redemptive consequence: that for which we labor with such cost becomes dear to our hearts. In the paradox of the Kingdom, a difficult child becomes the one that we love. And a place so steeped in death becomes a place that we deeply care for. Today’s numbers also carry seeds of hope:

• Cumulative cases remain at 115. There was a story of a contact with fever who had not been reeled in quite yet, so it will likely increase tomorrow, but for tonight we’re stable.
• Cumulative deaths: 32. One more in the last 24 hours. (CFR 27.8%)
• Inpatients: Bundibugyo 11with 5 discharges, 0 deaths, no admissions. Kikyo 10 with 1 discharge, 1 death, no admissions.
• LABS: still in process, but there have been 31 confirmed positive samples, all from Bundibugyo district. All samples from suspected cases in other districts have proven negative to date.
• Spread: As above, all Bundibugyo so far, but Bundibugyo contacts have been dispersing themselves. They want to get away from Kikyo, away from the disease, and have been turning up in neighboring districts. So it is very possible that true cases will arise elsewhere.
• Contacts: 265 of 368 followed up today. Jonah’s family has six more days to make it to 21 and all are well. I have five more.
• Issues: there was a call for projections in order to plan the budget. Will this go on for a month? Two? More? The epidemiologists are supposed to bring us their best guess tomorrow. I did talk to the CDC and MSF about the impact on resuming Christ School. The official policy from the outsiders is that contacts should be able to continue their normal activities until they have a fever. They are not supposed to be very infectious the first day of illness, which gives time for isolation. I do wonder if the teachers or students will be willing to return even if we give the medical all clear. Anyway this should be more clear by early January when we’ll know the trend of cases better. Half the time I feel like life will go back to normal; half the time I feel like the stress of evaluating every fever or whiff of illness in everyone we know as a potentially fatal disease will be unbelievably stressful.
• Medical Care in General: Scott and Scott worked at NHC today. Scott W saw all the HIV positive people and even saved a child’s life by putting in a more complicated IV line for a blood transfusion. Every day that we don’t have Ebola cases at Nyahuka makes us more comfortable with expanding services there once again. We wish we had better mortality data for the district in general. I spoke with a family today whose baby had died the day after the Ebola announcement. I’m sure there are many dying at home, of malaria and anemia and sepsis and everything else, afraid to come for care.

Luke should have landed by now, we’re waiting for his call. Pat plans to drive back in tomorrow. See the posts below for a Christmas meditation, and the reminder of links for donating to help Jonah’s family and other needs. Scott will take food tomorrow to two widows (Joshua Kule’s , the clinical officer, and Anansio Maate’s, the eye assistant, as well as two children whose mother is in the isolation unit, and visiting to check on Melen, one of the ways we as a smaller organization can fill some gaps).

Christmas in the time of Ebola

A week before the news of Ebola broke, we sent our annual Christmas letter to WHM for mailing. It was written from our hearts, and looking back we can see that God was at work to draw us into the struggle with the whole theme of collateral damage in the story of His coming.

If you would like to read it, click on the "downloadable prayer letter" link on the right side bar to get the pdf file.

God in a box

Reading Job this morning, and that’s what the book is about.  Job’s friends try to put God in a box.  If you do A, God will reward you with B.  It is only in grief, tragedy, lament that real worship begins, not grasping God for His gifts but clinging to reality in the midst of confusion.  God does not answer with formulas but with poetry, not with explanations but with presence.  Today the churches will be praying and fasting for the end of the epidemic.  We ask for that.  But we don’t pretend that if there is enough outcry, then surely God will act the way we want.  No, we pray to say that we have not given up, that we still seek God’s presence in the face of loss.

Ebola Bundibugyo, Tuesday Night Numbers

First, let us thank our Minister of Defense Dr. Crispus Kiyonga, who wrote a tribute to Dr. Jonah in today’s New Vision.  Dr. Kiyonga was at one time the Minister of Health, and we met him when we were both “mature” students at Hopkins. In fact his picture was on our blog last month when he stopped by to greet us.  He has been concerned and calling many of us over the last few days, and today’s article is a very moving tribute to health workers here.  We very much appreciate it.  Here is the link:  http://www.newvision.co.ug/D/8/459/601388

Second, we continue to get calls from the erroneous radio report today that Scott is sick with Ebola.  It is a rare opportunity to experience Mark Twain’s famous quote:  rumors of my death have been greatly exaggerated.  Though we can take it with a dose of humor, we do feel terrible for our friends who live in fear and have lost so much already, to have to hear another report of bad news.

Now the news:

• Total cases remain at 115, the first time we’ve had no new cases or admissions. Praise God for a respite.
• Deaths:  31.  CFR 26.9%.  One of the deaths today was the 20-something daughter of Jeremiah Muhindo.  She had been fairly stable, and we had hoped she would pull through.  It is an example of the power of this virus that even healthy young people who initially seem to have great hope sometimes succumb.
• Census:  16 Bundibugyo, with 1 discharge (Dr. Sessanga), 1 death, and no admissions.  `12 in Kikyo, with 1 death and 1 readmission.  
• LABS:  no new results.  
• Spread:  four highly suspicious cases in Fort Portal, all are contacts from Bundibugyo.  We agree with the advice that contacts should stay put for 21 days to help contain the spread of this disease, and we are doing so ourselves.  So far Jonah’s family is fine, again a tribute to his care.
• Contacts:  359 identified, 152 followed up today.
  

Can life become any more bizarre?  We ask that frequently. Our dear elderly neighbor has been struggling with congestive heart failure, hypertension, a hip fracture, and possibly cancer . . . So when his son came to call Scott to see him urgently today, I ran over to assess the situation.  Twice in the last year he has been near death but sustained by good management of his medications when Scott adjusts them . . .I found everyone on the porch and our neighbor in a closed room alone.  He had urinated blood colored urine.  The family was panicking.  He had no fever, no vomiting, no diarrhea, no contact with Ebola, so I reassured them that this was most likely a urinary tract infection, common in bedridden older people.  But what are the chances that such a sign would come up precisely in the middle of an Ebola epidemic???  

Last but not least, Luke is boarding an airplane in the next few hours, to return home.  His grandmother will miss him terribly; his siblings are going to be bolstered by his return.  I will see them as soon as my 21 days are up. Pray for safe travel.

Ebola Bundibugyo Tuesday Mid Day

The roller coaster continues to rise and plunge, from hour to hour. One day we wonder if the world as we know it is ending in an ever escalating toll of death, the next day we realize that some people are recovering and feel hopeful about putting this tragedy behind us. A BBC (Network Africa show) reporter interviewed Scott at 7 am this morning, and he was able to speak sincerely about our loss of our friend Jonah . . . We wanted to honor him. But then this afternoon Bamparana, Ndyezika, and Byarufu all rushed to our house, having just heard on VOT (Voice of Toro Fort Portal radio) that Scott had Ebola, a misinterpretation of comments regarding Scott's history of contact with Ebola patients made in the BBC interview. They were reassured to see him fine, and we were reassured to know that at least a few people are out there who would come and check on us . . . And so it goes, up and down. Today’s big event was the visit of the Minister of Health, the Honorable Dr. Stephen Mallinga, along with the Commissioner of Community Health Services, Sam Okware. We were steering clear of the hooplah by running a training for NHC staff but the RDC and the temporary medical superintendent from MOH stopped Scott on his way back from discharging Dr. Sessanga (cured!!) this morning and told him that they had assigned the training to one of their own doctors, instead he should come greet the minister. He turned back to Bundibugyo, and Scott Will and I went to Nyahuka to meet with about 40 staff, along with a doctor finishing his Masters in Epidemiology at Makerere and a senior nurse who survived the 2000 epidemic in Gulu. (We had just started when a helicopter hovered into sight and then landed at Christ School’s football field! It was the ministerial delegation, a bit lost. They eventually found their way to town while we continued our training.) The doctor lectured on the basic facts of Ebola, and both he and the nurse provided a lot of confidence, a boost in morale, an appeal to get back to work. She stood up in her navy blue uniform spattered on one side with purple bleach fades, and said proudly this was her badge of having worked in the isolation unit. I liked that. But of course NHC is not an isolation site, so the focus there needs to be on normal health care. One lesson I’ve learned is that the Ministry needs to clearly state the non-Ebola guidelines at the very beginning. Staff are confused about who needs to wear what protective gear, when, how to access more, how to call for help, whether there should be labs open, etc. It is getting worked out now, but it has taken more than a week. I like the doctor who came, he’s done a number of C-sections already and seemed fairly reasonable . . . But he did give out some misinformation, and he did imply that MSF was not running the isolation unit properly but now that the Gulu nurses were here that would all be sorted out. I spoke up on that, I feel that there should NOT be any even slight spirit of one-up-man-ship, of blame, but rather respect for each person’s work and contribution. Another lesson we’ve seen is that it is much easier to tell people what to do than to actually provide what they need to do it. The staff listened to the lectures, but now they have to organize a requisition and fight for their own gloves and boots and bleach. In this kind of crisis it seems that the supplies should be pushed down from above, not held until they are clamored for from below. Meanwhile Scott met the Minister, Dr. Mallinga. This was very confidence boosting, an upsurge on the roller coaster. Another lesson of this crisis is that there are some brilliant and dedicated doctors in this country. The Minister is one of them. Scott said he addressed the issues of witchcraft and discrimination that have arisen by saying that we are like full glasses of water, when trouble comes we are shaken and whatever is inside spills over, the trouble of life merely reveals the heart. It sounds a bit like what Jesus said to the Pharisees . . .For some that means the evil just below the surface comes out. For others that means the charity and self-sacrifice are called forth. He appealed for the latter. The government has now allocated 6 BILLION shillings to the response, which is 6 billion more than they had last week. . . . The crisis has also pointed out the problem of medical staffing. The Minister said Uganda has lost about 200 doctors to South Africa, 3 anesthesiologists to Rwanda, countless nurses to Kenya, more new grads to Sudan where NGO’s are paying huge salaries. Even here in Uganda some of the best minds and hearts we’ve seen responding to the crisis are Ugandan doctors who have left Ministry of Health to work for the WHO. This discourages me, how can the country be covered when the Ministry system is poorly paid, bureaucratic, frustrating, and easily circumvented for more lucrative jobs? Why isn’t medicine more like the military, you have to do your two years of service after school, you are posted all over the country and everyone has to put in their time? It used to be that way, and this is one instance where decentralization has probably hurt more than helped. I can already see that some of these hard working and helpful men are going to be gone in the next few weeks, and we’ll be left with the same hobbling health system we had before, minus Jonah. It is a week today since Jonah died. Though Melen and I had a little cry together this morning, I can see some signs that she is emerging, thinking a little bit into the future beyond the 21 day contact isolation period, she even smiled once this morning at her daughter Sarah’s antics. Thanks for praying for her.

Ebola Bundibugyo, Monday night

Just when I thought the tears had run dry, someone sent us a beautiful picture of Scott and Jonah together taken a few months ago. I still can’t believe he won’t come back from Kampala any day and sort things out. I do think sometimes about him meeting my Dad in Heaven. They had a good relationship of respect, and I like to think of them recognizing each other there.

OK here is today’s report. Scott was gone from morning to night. The day began with a clinical conference, with Scott, Dr. Jackson Amoni from Ministry of Health, our heros Dr. Yoti from WHO ( also a Ugandan and formerly with MOH) and chief nurse Rosa from MSF. The four of them were tasked to sort out protocols and procedures for caring for the sick in isolation. Our main contribution is to agree with Dr. Yoti and confidently endorse him to everyone else. Scott then went to Kikyo to try and install the Gray’s “village phone”, which includes an antennae we hoped would overcome the mountainous terrain and distance from the tower and allow that health center immediate phone access at all times. Sadly it did not work, but we are still grateful that the Grays let us try. Somewhere in there he managed to get the lawnmower back to complete the airstrip mowing for the daily flights, and to pick up mosquito nets for pregnant and HIV positive women, and to see some maternity patients too I think. The day ended with the two of us zipping back up to Bundibugyo on the motorcycle for the evening task force meeting, while Scott Will, who had been working at Nyahuka Health Center today, stayed back to cook us dinner. Very nice.

The meeting tonight was a bit calmer and more amicable, thanks for prayers for cooperation. Here are the facts:

• Cumulative cases: 115
• Cumulative deaths: 29 (CFR 25.2%)
• Contacts: 368. 298 were seen today! Amazing really if you think about the challenges.
• Bundibugyo Isolation Ward: 17 inpatients, 4 discharges today (!!), 2 admissions, 0 deaths, with 2 of 17 remaining in critical condition.
• Kikyo Isolation Ward: 12 inpatients, 1 discharge, 1 admission, 1 death (sadly a 17 year old boy), and 1 of 12 remaining in critical condition.
• LABS AT LAST!!: 17 patients had samples run today in Entebbe, some were specimens that had been collected days ago. 10 of 12 samples from Bundibugyo were positive for Ebola, either by antigen detection or production of antibody response. ZERO of 5 samples from other districts were positive. In other words all confirmed cases to date stem directly from Bundibugyo. There is still a large back-log of tests so we are not quite ready to breathe a sigh of relief, but at least the initial news is good, the spread may not be as fast and violent as feared.
• Jonah’s labs: his initial test done on Saturday (day 4 of illness, day 2 of admission) was positive for antigen (presence of the virus) but negative for IgM antibody (he was not yet mounting a detectable immune repsonse). The sample two days later was positive on both counts. It is no surprise that he truly died of Ebola, but provides some closure to have it confirmed.
• Tribalism: Sadly almost all the cases stem from the Bakonjo tribe (including Jonah). The Bakonjo are a minority in the district; most of them live in Kasese and Congo. The majority tribe here, the Babwisi, have been relatively spared. Since transmission is person to person, this makes sense, that the disease would stay within one primary ethnic group. However even in ADF days there was suspicion and accusation between the tribes. Now the Bakonjo are accusing the Babwisi of poisoning them, and we heard that today some refused to buy rice in market that was grown by the Babwisi women. Yet another way that fear and misunderstanding can be used to foment ethnic unrest.
• More unrest: on the Fort Portal side of the mountains, that district had decided to locate their isolation unit as close to the Bundibugyo district border as possible, in Kichwamba. But local people rioted last night, breaking windows in the ward, and forcing transfer of two suspect cases back to Fort Portal Town’s main hospital. These tensions are essentially the same that sparked Rwanda, the fear that one’s own family and tribe are at risk and therefore the justification to lash out violently against those perceived to be enemies. We are praying for peace. Thankfully no violence here where the real cases are, but the mistrust and bickering is a smaller symptom of the same issue.
• More discrimination: a local government official who has been conspicuously absent all week showed up today, complaining that in Kampala he was ostracized as “the walking dead” because he was from Bundibugyo. We all acknowledge that the country is in a quandary, most people are very upset about the possibility of catching Ebola, and anyone from Bundibugyo is suspected to be a carrier. The district’s ONLY bank closed today, in spite of pleas by the security officer that there was no danger in banking. Inability to access money will definitely put a damper on the response.
• Tomorrow’s tasks: The minister of health himself and three other top ministry officials will fly in for an official visit tomorrow. Before that Scott and Dr. Yoti will ceremoniously discharge Dr. Sessanga from his home isolation, declaring him cured. Then the Scotts (both) will be participating in training staff at NHC to help allay fears and provide adequate protection so patient care for non-Ebola cases can proceed.
  

We can’t thank you enough for your care. We’ve been particularly encouraged by several people contributing to the emergency response fund. We will be spending some immediate money on more gloves, and trust that the school fees for Jonah’s children will be provided by the time they need them in late January. It is good to sense how clearly we are only one small part of the larger community of Christ in this time.

Ebola Bundibugyo: Sunday numbers, no sabbath

As usual we headed to Bundibugyo town this evening, but this time we stopped first in Kirindi. Jonah’s brother had called me earlier in the day, and I had gathered there was something he wanted to tell me though the connection was terrible.  All I could ascertain was that everyone was OK . . . So we drove up there at 4, bringing mosquito nets and insect repellant in response to massive numbers of insect bites I’d seen on the girls, and more air time for Melen’s phone in case one of the family became ill.  We found Melen sitting outside for the first time, in a clean dress for the first time, and then it became clear that the message was about the Oluku, funeral rites, they had been inviting me to participate.  Oh well.  After four days of mourning there is a tradition of bathing, washing clothes, and bringing closure.  I’m glad they were able to achieve this, and make some slight progress in life.  Jonah’s mother and brother continue to remain symptom free.

The task force meeting occurred as usual outside, a circle of plastic chairs, in the shade of the RDC’s office building.  Tonight he went on the offensive immediately.  He wanted answers, and results, and now.  We like him, he’s an effective and persuasive man. But tonight he was looking for people to blame, and this was the tone of the meeting in general.  Everyone is under stress.  Some of that may be related to unfavorable press in the Sunday papers questioning government response, some may be due to the growing possibility that this epidemic spread by travelers to a handful of other districts before Ebola was identified as the cause.  It is not a simple or hopeful picture.  So here we go:

• Cumulative cases:  112
• Cumulative deaths:  28 (Case Fatality Rate 25%, which while horrific is certainly not as bad as the 90% sometimes seen)
• Contacts identified:  368
• Traced today:  189 (51% and building, they feel they are able each day to improve their outreach.  This is the key to containing spread!  I confirmed with Melen that their family had been checked on daily for the last three days).
• Social Mobilization:  many churches were visited, but no one outshone our own Scott Will for sheer volume of services rendered!
• Isolation Ward, Bundibugyo:  19 current census.  5 new admissions today, 2 deaths, 3 discharges .  . . And another 5 nearly recovered and ready for discharge.  3 however remain critical.
• Isolation Ward, Kikyo:  13 current census.  2 new admissions, 0 deaths, 3 discharges.  Of these  13, 2 are considered critically ill.
• Staffing:  complete staff of 16 nurses now in Bundibugyo but some still in training so only 7 functional, staff in Kikyo 8 of the desired 12.  There was some controversy about doctor staffing.  The RDC looked severely at Scott and asked why expatriate doctors weren’t working in the isolation ward.  Hmmm.  But MSF denies needing help.  We’re not sure where that leaves us.  If we could help build trust by being in the mix Scott would do it, but we don’t want to get in the way either.  It is difficult to get people to understand that a 25% CFR in Ebola is actually good news; they tend to feel that the announcement of any death represents a medical failure of care.
• Labs:  No results yet.  6 more samples collected.
• Controversies:  besides staffing, the main discussion points were spraying and herbs.  There is a public perception that spraying the house of an infected person with chlorine solution (bleach) will stop transmission.  MSF routinely instructs their ambulance teams to spray the home after picking up a patient to transport in to the ward.  However the district would like to see the homes of all 112 cumulative cases sprayed.  We talked a long time about the fact that the virus can’t live more than a few hours outside of a host, so going back to spray the homes of people sick weeks or months ago seems pointless, except for the psychological benefit, which may not be justifiable if it drains precious human resources from stemming the current spread.  On herbs, some of our district leadership truly believes that the local culture may have herbs that cure this disease.  It seems that patients don’t want to enter isolation because then they’ll be cut off from their local remedies.  The CDC voice of reason pointed out that we don’t know if any of these treatments might actually be harmful, and that if they are administered by cuts or enemas they could promote transmission of the disease.  The RDC voice of reason stated categorically that we will only use science to determine treatments.  But it was clear that most of the people present at the meeting who were actually from this district had their doubts, and were holding onto the hope that some herbal combination would provide a cure.
  

Please pray for our team in Kampala tonight.  Three members will leave in the morning, two for normally scheduled ends of their terms, and one for an earlier-than-scheduled month-long trip.  The rest of the team remains in the competent and caring hands of Dan and Gini Herron.  Tonight there was some panic because of a typical minor illness in one of the kids, the kind that happens on almost every trip to Kampala, different food and water leading to fever and a bit of diarrhea.  This is not Ebola.  But we realize now that as a team we’ll be living with that added stress, the impending doom feel that every head ache or loose stool could be the beginning of the end.  That’s pretty difficult for all of us.

Disclaimers....

We are just people who happened to be in the epicenter of the most recent Ebola outbreak, and this is just a blog. This is not an official news source, this is not a scientific record, this is not the policy voice of WHM. Today we’ve received numerous calls because the country’s paper the New Vision took quotes from this blog and printed them (even on the scale of our bizarre life this week, washing up dishes from breakfast and getting a call from the President is a bit unexpected) . . . Leaving us with a dilemma. If we screen every word to make sure it is politically and theologically correct, then we are safer, but we’ll hold back. If we don’t, we are more genuine, but we may say the wrong thing. For now I would like to continue as we have been. We are here to serve the sick, to step into whatever gaps we can to assist the national and international responders, and to be a voice of witness to our friends and family to the suffering of Bundibugyo. Those three roles seem to be the path God has called us to. For instance, we try to interpret culture to the foreigners, and we are available to Ugandans who want to use us to connect with NGO’s. Right now Scott is working on dismantling one of the mission phone antennas to see if he can improve the signal for Kikyo Health Center. Later we’ll go check on Jonah’s family, then to the briefings. Tomorrow he and Scott Will are planning to make a concerted effort to get patients back to Nyahuka Health Center for treatment of all the other myriad of non-Ebola life-threatening conditions that have always been abundant here. So we are stretched. If you read things that give you pause, then please give us grace. If we are told by our mission that we are overstepping our bounds, we’ll listen. This is not about us, it is about people whom we love and care for, and we only want to communicate what we are truly experiencing in a way that enables their story to be heard and your prayers to be informed. Sundays have been shown in previous outbreaks to be key times for social mobilization . . . Scott Will visited a handful of local churches this morning, while we focused on the crowd at Bundimulinga Presbyterian Church, trying to give facts and answer questions, inform prayers. There will continue to be interdenominational days of prayer and fasting on Wednesdays. After church we debriefed with the CDC representative who had also visited one of the largest congregations around, the Catholic church in Kanyanpunu. We all got similar questions. People are convinced that there is a combination of 17 herbs which local practitioners are selling, to use as enemas or as poultices rubbed into shallow razor-blade-cuts made in the skin, which will cure the disease. We are concerned that such a hope might encourage risky behaviour, and an herbalist using these methods could actually transmit the disease. So we try to answer respectfully and calmly but also to protect the fearful public from those that would use this crisis to enrich themselves. Thanks for listening, and for walking through this valley with the people here.

Article Honoring Dr. Jonah

John Spangler’s article is now up on the web:  http://abcnews.go.com/Health/Germs/Story?id=3970795&page=1
We are thankful for those who join with us in recognizing his sacrifice.

Ebola Bundibugyo: The Saturday Numbers and other things

Scott’s report from tonight’s task force meeting:

• Cumulative cases: 106 (note that he discussed with the CDC the fact that most of the early cases had been excluded.  This is understandable, they are retrospective diagnoses, but it is good to remember that this number is at best a guess.  It does not include the first dozen (?20 ?30) cases from the Kikyo area, before a real epidemic had been recognized.  On the other hand it probably includes a number of non-Ebola cases that have similar non-specific symptoms.)
• Deaths:  26.  There were two more in Bundibugyo, and one in Kikyo.  One of the Bundi deaths was a lady who had been admitted on a general female ward and then developed a rash . . .the rash is usually a late sign and this lady died soon after transfer to the isolation ward.  It points out again the difficulty in distinguishing cases because of the different not-so-hemorrhagic nature of this strain.
• Hospital Census:  19 Bundibugyo (2 died, 1 was discharged, no new ones . . . 3 of the patients are critical).  Kikyo 14 (1 died, 2 new, 3 were discharged, including 1 health worker, also have 3 critical cases.)
• Health Care Workers:  16 nurses are now in play, only about 4 from Bundi working on the isolation ward but a good number from MSF in other parts of Uganda or Europe.  We’ve met two young female doctors (Belgian and Nordic).  The MSF team is now huge with their WatSan (water and sanitation), logistic, anthropologic experts, etc.  We met the airplane today with the CDC health communications man, whom we then hooked up with Hannington Bahemuka as a good source of cultural information and language appropriateness.
• Contacts: 340.  Today 158 received check-in visits from mobile teams (46%).
• Lab: was supposed to do a practice run with non-Ebola blood today to ascertain safety precautions were intact, first run of potential Ebola samples tomorrow.  We’re all on the edge of our seats for this news.
• Fear:  definitely there.  It is hard to really overestimate the impact Jonah’s death has had on the public perception of the epidemic.  He was such a loved and public figure, his death has very much intensified the feeling of vulnerability that people carry.  Sadly the families of patients who have died, especially Jonah’s and Joshua Kule’s, have experienced isolation, neighbors running away from them, merchants refusing to accept/touch the money they are offering to buy food.  Even we have heard that people are afraid of us, and avoiding us.
  

Pray for the churches tomorrow to bring messages of hope, consolation, and be channels of information that will help people cope with the stress of this disease.  Pray for us to know if we should shift from supporting medical care to mobilizing public health efforts in the community.

I visited Melen today, actually walked half of the way there and back because Scott is so busy with other efforts . . . I found her sitting on the floor of the house with Jonah’s mother and sister, all looking drained and blank.  As before, and as with Job’s friends, it seemed the best thing to do was just to silently sit.  Eventually I tried to get Melen to talk a bit, but she was unable, saying her thoughts were “disorganized”.  I assured her that was OK, and that we were making every effort to provide for the children, so that at least that worry would not weigh upon her.  I was thankful to see that Jonah’s mother was well.  What a strong woman, to have buried now 3 of her 9 children and her husband, to have been exposed to Ebola but so far not succumbing . . The girls are distracting themselves with the books I brought, and there were a handful of relatives around the house, though still nowhere near the number of consoling visitors one would otherwise expect.  The district has sent food, and they seemed to be provided for, just overwhelmed with grief.

The most surreal moment of the day was a visit from a very kind and sincere American endocrinologist researcher, whom we met a few months ago in conjunction with his study of iodine deficiency in the Rwenzori region.  He decided to drive 10 hours from the southwest tip of Uganda where he is now working, just to check with his own eyes that Scott was OK and Dr. Sessanga was really recovering, and bring them both thoughtful and costly gifts.  That kind of generous concern from someone we have known only briefly humbles us, just like the many kind comments and sincere prayers from people around the world.

On Lament

In the midst of chaos I am longing for a small spot of order . . . So have taken to organizing bookshelves whenever I have a couple of hours at home (I’m sure there are decent and deep psychiatric reasons, but it is a pretty useful coping mechanism, and probably a good sign to have the energy to begin to do so).  Hardly anyone dares to come to our house anymore.  As contacts we are supposed to practice “social distancing” . . . A bizarre and unexpected opportunity to pull hundreds of books and years of dust and pen caps and random scraps of paper and broken flash lights and all the other detritus of life that accumulates on any horizontal surface from the bookshelves (we have many).  In the process this morning I came across a book by Michael Card called “A Sacred Sorrow:  Reaching out to God in the Lost Language of Lament.”  Ruth Ann Batstone gave it to me a few months ago but I had not opened it yet.  He opens the first chapter:  “Before there were drops of rain, human tears fell in the garden, and that was when lament began.”  His premise is that the Bible is full of the songs of complaint, frustration, sorrow, even anger; because the path to God is a “tearful trail.”

When I step back from the science, the advocacy, the planning, the medicine . . . I am left with the hollow-hearted shock that Jonah has died, and that more will follow.  And I am not here to justify or explain that, rather to acknowledge and experience it.  So I want to copy here a paragraph from this book’s forward by Eugene Peterson:
    It is also necessary as a witness, a Jesus-witness to the men and women who are trying to live a life that avoids suffering at all costs, including the cost of their own souls.  For at least one reason why people are uncomfortable with tears and the sight of suffering is that it is a blasphemous assault on their precariously maintained  . . spirituality of the pursuit of happiness.  They want to avoid evidence that things are not right with the world as it is—without Jesus (and Job, David, and Jeremiah), without love, without faith, without sacrifice.  It is a lot easier to keep the American faith if they don’t have to look into the face of suffering, if they don’t have to listen to our laments, if they don’t have to deal with our tears.  
    So learning the language of lament is not only necessary to restore Christian dignity to suffering and repentance and death, it is necessary to provide a Christian witness to a world that has no language for and is therefore oblivious to the glories of wilderness and cross.

I hope that many have the grace to weep and pray with Bundibugyo, and so discover the wilderness where God’s presence flames.

Ebola in the News; and responding financially

In the news: New Vision ran a previous interview they did with Dr. Jonah: http://www.newvision.co.ug/D/9/183/600944 An AP correspondent called Scott last night and filed this story: http://ap.google.com/article/ALeqM5h8nLHUlhDiLlgAafCb9-w_9Nki5QD8TCPQK80 And our dear friend Dr. John Spangler wrote a tribute to Jonah for ABC Online that should be available now http://abcnews.go.com/Health/Germs/story?id=3970795&page=1 . . John was part of our original “Africa Team” from college, committed to coming together. He had packed his belongings onto a container in 1997 when the ADF attacked, and due to the ensuing insecurity and chaos never moved here with his family. But his medical text books did! Jonah used those books all through medical school, and the two doctors developed a friendship and connection over the ocean. When John heard of Jonah’s death he wanted to honor him by writing his story. We are grateful for that. It is Saturday morning here, and after a week of hot dry winds blowing in the anticipated December change in seasons, storm clouds broke over us in the predawn hours, and now a dreary steady rain has settled in. This will hamper the MAF efforts to fly blood samples out mid day for delivery to the laboratory just being established in Entebbe, and also make it difficult for access to Kikyo where the road is steep, rutted, and narrow. Our day started with a call from the in-charge medical assistant there requesting that we help him contact MSF to send the burial team because one of the patients died during the night. Sometimes we are a little link between the Ugandans and the foreigners . . . Lastly, many have asked what they can do to help. World Harvest has set up an “Africa Response Fund” to help in this crisis. Right now money for medicine and supplies is pouring into Bundibugyo from huge organizations like UNICEF, and we don’t want to get into that confusion . . . But we do want to take care of Jonah’s family. Scott and I would like to guarantee that each of Jonah’s children is able to be fully educated. School fees were his main concern while alive; caring for his girls and paying for their education was the main reason he found the low government salary a problem. He had chosen to put them in private schools, so we would like to honor that. It costs about $10,000 to fully educate a child from primary up through Senior Six. He has five girls and one child on the way, so that is about $60K. We would also like to build a decent house for his wife who will no longer be eligible for hospital housing. And the third priority, if the response is tremendous, would be to sponsor another student from Bundibugyo to follow in Jonah’s footsteps to medical school, if there are any brave enough to walk his path. Our team will also have extra expenses over the next couple of months as this crisis settles down, for housing for the kids and non-medical people outside the district, for Dan and Gini Herron’s travel to come and take care of us all. So we thank anyone who wishes to give. Follow the link on the sidebar to go to the World Harvest Mission web site’s giving link.

Ebola Bundibugyo: The Friday Numbers

From today’s briefing:

• Cummulative cases: 104.
• Deaths: 23.
• Contacts (people with significant exposure to the virus by caring for someone sick): 328
• Contacts checked today to make sure they are not sick: 155 (65%, pretty amazing considering the topography)
• Medical Staff: ever increasing. 4 MOH nurses and 1 doctor with experience from the Gulu epidemic in 2000, and 3 MSF nurses, expected imminently
• Admissions: 3 at Bundibugyo hospital, one of which died right away. 0 in Kikyo
• Census on the Isolation wards: 24 in Bundibugyo, 16 in Kikyo
• Healing, or nearly ready for discharge: 4 in Bundibugyo, 2 in Kikyo, plus Dr. Sessanga who has essentially discharged himself from his self-imposed isolation. Scott saw him today and took a lab tech to get his blood sample for the CDC. This is hopeful. People do recover. One of the epidemiologists said she counts only 4 deaths among 18 admissions, which is less than a quarter, similar to the deaths among the confirmed positive lab samples in the original batch that led to the identification of the epidemic (2 of 8).
• AWOL: still 5. One of those went to their other home in Kasese district. Four are at home in Bundibugyo. Because this strain may be a bit less severe people may try to manage without admission, which can lead to more contacts and further spread. The surveillance team finds the lack of contact stability very challenging. They are trying to document and follow EVERY contact, which is tricky if people move around. Imagine a place with no addresses, no mail, no phones, no Social Security numbers, no credit cards, no drivers’ licenses, no ID’s, few taxes . . . And then you’ll realize how hard it is to keep track of people. They can easily disappear.
• People sitting in the meeting when these numbers were announced and debated: 54. The RDC continues to provide strong leadership, marshalling the troops, holding the meetings together.
• Classic Bundibugyo: WFP cautioned against giving food to all contacts. . . . Lest everyone begin to complain of being a contact and so overwhelm the surveillance teams.
• More classic Bundibugyo: a religious group who meets on Friday mornings slaughtered two sheep in Nyahuka today, and told their members that everyone who ate a piece of the sacrificed goat would be protected from the virus. The DDHS himself brought up the claims of herbal medicine specialists entering the district with Ebola cures, not to refute them, but to ask the group what they thought. Given the fear surrounding this disease, and the fairly high recovery rate, there will no doubt be many claiming to have a cure for the right price.
• Controversies: should local eating establishments be closed? The group debated this a lot. Consensus: no. Maybe a few placed that had poor hygiene . . .but most should stay open. There is an odd tension. They want to scare people enough that they change behaviours regarding contact with sick patients, and burials. Yet they don’t want to scare people to the extent that society grinds to a halt. After all, all these experts have to eat somewhere too. These meetings spend a lot of time on things like money and food . . .
• Non-Ebola patients in Nyahuka: 0. No admissions. No outpatients. The stigma and fear factor skyrocketed after Jonah died. We have all sensed the quietness, the eeriness of the town. Today a church leader reprimanded children around Scott Will’s house telling them they could get sick from him and die, so go home. We are beginning to realize that the three of us (Scott, Scott Will, and me) are considered unclean. And not without reason. I think that we have to live with that. It is logically inconsistent to send our kids away and then feel disgruntled that others avoid us. It is hard for people to realize that as long as we have no symptoms we are not dangerous. At least the MSF and CDC people aren’t afraid of us!
  

• Time between Dr. Matthew Lukwiya, the doctor who was in charge of one of the main hospitals in Gulu affected by Ebola in 2000, and Dr. Jonah Kule’s death: 6 hours short of an exact 7 years. Dr. Jonah died at 7:30 pm Dec 4, 2007; Dr. Matthew died at 1:20 am Dec 5, 2000. That is one of the most distressing aspects of this disease, to take out the two men who laid down their lives to save others.

Reflections at the end of Response Week 1

Yesterday marked one week since the diagnosis of Ebola was announced.  In that week we moved from thoughtful concern to alarm to grief to acceptance of the daily reality of work.  As soon as we heard the news last Thursday Scott was setting up chlorine and gloves at the health center and communicating with MSF and Ministry of Health, and holding meetings with our team to inform and calm.  A week ago today the advance team flew in and out.  In the first few days help seemed to come in slowly, this is a remote place, not easy to access with tons of supplies.  It took time for the experts to set up barriers and isolate people, to train staff on protective techniques.  In those first days we felt the crunch of panicked patients, fearful and sometimes absent staff.  But now a week into the response the sheer volume of people who have arrived is astonishing. We find ourselves moving more and more to the periphery as agencies much bigger than ours, and people with more power and experience take over.  And the non-Ebola medical needs are becoming more difficult to quantify as people stay home, afraid.

Three comments on the big picture:

1. I have come to appreciate more deeply our relationships with local government and leadership in Bundibugyo, by seeing the contrast with the current moderate tension and jockeying between agencies.  I think I took it for granted, but now I don’t.  Local people may just want to take advantage of us . . .but for the most part they have always acted like they liked us, and we like them.  When we interact with our health and government leaders, the exchange is amicable and respectful.  We don’t trust everything that goes on, but we do cooperate.  Now our district leadership has been overwhelmed by Ugandans from other parts of the country; and the foreign presence has ballooned.  I can feel the undercurrents, I’m sure much of it based on good reason, as the Ministry of Health tries to hold onto control of the situation, as people from Kampala and elsewhere make their pronouncements.  They need the outside expertise, but they resent the outsiders a bit too, flying in with their resources, their computers and cell phones, their rules.  It was more like that in Kenya, and the absence of that mild tension of race is one of the things I have forgotten to love about Bundibugyo and its relative lack of exposure to the western world.  We find ourselves lumped with the foreigners in the eyes of the MOH people.  Sigh.
2. The mis-information in the press is a daily astonishment.  The wrong names, the wrong titles, the wrong numbers, the wrong science.  Much of that comes from local papers and then gets multiplied when picked up by bigger news agencies.  So today when I found an article in the Monitor (one of Uganda’s two national dailies) that was articulate and wise I was very impressed.  The author turns out to be a member of parliament from Kanungu (remember the people who locked themselves in the church and burned it, one of Uganda’s sad moments in the last decade) who is also a physician.  I hope this man gets appointed to greater and greater responsibility as his career progresses, because he is a voice of reason and clear thinking (like Dr. Yoti) in the midst of a lot of bluster and blame.  Pray for more young people to rise up like him, and like Jonah.  Here is the link to his article:  http://www.monitor.co.ug/artman/publish/opinions/Tracing_the_origin_and_nature_of_Ebola.shtml, and to the tribute to Dr. Jonah (which has a few errors but is still quite good and positive):  http://www.monitor.co.ug/artman/publish/news/Fallen_Hero_A_tribute_to_Dr_Kule.shtml.  The Monitor is doing a better job than most at this moment.
3. The calls for martial law, for quarantine, for force are being voiced in the papers, mostly from people far from the problem, sitting in Kampala and worrying that it could spread.  Yesterday one of the MSF people told us that after a few weeks in another epidemic in another country, the local people turned on them, began to blame them for actually BRINGING the disease, and began to throw stones and DEAD MONKEYS at them!  They left abruptly, but thankfully had trained their local counterparts to handle the isolation techniques, so the epidemic was contained (it was not Ebola).  I think I felt the medical care and epidemiology were so important the first week,  but now in week two I think the “social mobilization”, the education, is probably the most important work being done.  Walking the fine line of warning, to keep people from doing dangerous things, and yet to not paralyze the entire economy and community with fear, is not easy.

Ebola-Bundibugyo, Thursday Night Numbers

First, Scott posted pictures of the burials today (first link called “Ebola Burial Pictures” on the sidebar to the right) which probably do more than the proverbial thousand words to explain why this situation is so intimidating. There is also a picture of Jonah’s mother and wife, and his three oldest daughters Masika (15), Biira (12), and Magga (10). The other two, Karen (5) and Sara (2 1/2), stayed back home with their aunt. I missed the briefing due to the burial, but here is what I can glean:

• Cummulative Cases: 101
• Deaths: 22
• New admissions: 1 in Kikyo and 0 in Bundibugyo

Hmm . . . How can new cases increase more than admissions? Well, there were five patients evaluated today by triage who were told to go into the isolation ward but somehow disappeared. Not encouraging for control of the spread . . . But consider this dilemma. Someone comes to triage. She has a low grade fever and mild diarrhea. 10 days ago she stood in a known patient’s presence and prayed for them. She claims to have not touched the patient. Is she a contact? Is she a suspect case? If she is lying and she really did touch the patient she’d be a definite contact, and a contact with a fever and symptoms should be admitted. But she says she didn’t touch, so then she’s not a contact, just a person with diarrhea who happened to be in the room of an Ebola patient once. Yet if you are making the decisions and you take this lady’s denial of contact at face value ( in a culture where truth is very fluid and relative) then you might be condemning others to die as she gets sicker and spreads the virus. On the other hand, if she really didn’t touch the patient and she has some mild crud that is not in any way related to Ebola, yet you admit her to the isolation ward, she’ll probably get Ebola from the patients already there, and she might die. That is very very tough. And the above case scenario was actually presented to Scott today, who turfed the decision to those with more experience. No easy answers.

• Inpatients seen by Scott W in Nyahuka: 1
• Maternity cases Scott M was on call for in Bundibugyo: 1

Another Hmmmm. . . . Where are all the sick people? Hiding at home. Lastly, the CDC epidemiologists are searching now for the earliest cases. Fascinatingly, the in-charge from Kikyo, Julius (the man who has cared for the most patients of all!) told Scott that in the first family to be affected, four brothers all died. There must have been someone who survived, because the story later came out that they had eaten a monkey together. It is not clear whether they found a dead monkey or shot one (men do hunt up in the forests that border the Rwenzori National Park, I see them sometimes on the road or an obscure bike path, suddenly emerging from the bush with their mangy little brown dogs and their bows and arrows). It is also not clear if the “monkey” was a primate, since we do have chimps in the district and we know that Ebola can infect chimps and gorillas. I hope the CDC team or one of the other epidemiology groups can shed light on how the virus suddenly appears.

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.

Last Words of Dr. Jonah

Scott was speaking today to one of the World Health Organization visitors who related information from the MSF doctors who cared for Jonah at the end. It was spine-tingling to hear Jonah speak from beyond the veil.... Tuesday afternoon, he was still walking and talking, and said to them “I have seen these patients die, and I know that I am dying”. I don’t think they believed him, and I wonder now if that is why he was determined to call us though his efforts were not successful. Moments before he died he said “I am going to die now. And I pray that no one should ever have to die of this disease again.” Right to his last moment he was thinking like the compassionate doctor he was, looking beyond himself to others. Tomorrow his body will arrive, having been carefully decontaminated (as far as possible) and enclosed. His family was still en route when I last talked to them a couple of hours ago. Whenever we speak of him again to someone who cared about him, the tears come freely. We have seen some men here cry like we never saw men cry before. I think Jonah was perceived as a resource, a gift, to the whole district, everyone feels bereaved and robbed of their man, their doctor, the one they could trust and count on. When we see his family, we will have the complication that they are now contacts too like we are, and we should not be touching each other. So we have to go to the burial of our dear friend without any hugging, comfort his wife and children without touch. That feels harsh. My mind keeps reaching back to some words of the Psalms which I can’t place, though a thousand have fallen at my side, yet I will trust. We feel the falling of Jonah so acutely, we were both on the same front line of the same battle fighting side by side, yet he went down and we have not. I know I can’t trust in anything other than God . . . Certainly not in not dying, which is not guaranteed, as Jonah shows. If we make it through this then what about the next tragedy? Safety is not the basis of trust. Instead our trust needs to be in God, inexplicable God, dangerous God, other-than-us God, who does not order this world according to our will, but knows more than we do and loves more deeply.

Ebola Bundibugyo Wednesday Numbers

Back from the daily Task Force meeting. The group is getting larger every day, as planes fly in, and is both numerically and culturally more complex. I can easily count 8 different countries represented; there are probably more. The Africans and the MSF advance team showed up first, but the bajungu (whites) are increasing in force. It is oddly reassuring to hear those good old American accents from the CDC, and heartening to see four fresh young doctors on the ground. The epidemiologists outnumber the clinicians I’m afraid. There must be a dozen people there with high graduate degrees working on the numbers, the transmission, the pattern . .. . But only three seeing patients. I have such great respect for all of them, but particularly those who are donning the head to toe PPE “Personal Protective Equipment” and caring for patients. OK the numbers:

• Cumulative cases 93 (controversial actually. Now that we have MSF, WHO, something like African Epidemiology Network, Ministry of Health, and CDC all wanting a say in who is a case and who isn’t, they don’t totally agree on this . . .also as wise Dr. Yoti pointed out, if numbers shoot up this week it can be a reflection of good surveillance, of contact tracing, not of a spike in the epidemic.)
• New admissions to isolation units today: 4. Two were in Bundi and two in Kikyo.
• Deaths: 21. But they decided not to include Jonah’s death in that number because he died in Kampala not Bundibugyo. Clearly he got his disease in Bundibugyo, so in my opinion 22 more accurately reflects the toll of the disease to date. Again one must bear in mind that there may have been others that were missed in the community.
• Deaths in the last 24 hours: 3, all medical workers, Dr. Jonah Kule, clinical officer Joshua Kule, and nurse matron Rose.
• Money the task force budget wishes for: 400 millions shillings . . . (about 250,000 dollars, for a major epidemic. Luke told me today that the Virginia DOT has budgeted 80 MILLION dollars to for snow removal this year).
• The government agencies involved don’t seem to have much in the way of funds . . . But UNICEF has already given clearance for the money allocated for this district be reassigned for use to combat this problem, and clearly MSF and CDC are bringing in lots of resources. There were calls for transparency from people whom I personally know to be opaque and slippery. Maybe a bit of scrutiny of spending patterns would be one of the good things to come out of this tragedy.
• Main discussion points: should public gatherings be banned, even weddings? Is it a mixed message to ban public gatherings and then travel in a film van to show an educational film about Ebola, if that attracts hundreds of people? The decision was: yes. Bag the film for now and educate in small groups. Should community educators be paid for their mobilization efforts? I bit my tongue when it was mentioned that would be too expensive, yet the lab plan is to fly samples every other day from Bundibugyo to Entebbe (at $600/flight??).
• Specimens collected for testing and sent today on MAF: 28: the CDC has set up a lab in Entebbe at the Uganda Viral Research Institute. They have a few people in Bundi, not sure what all they do, but the main lab will be off site. They will try to leave behind a sophisticated lab that Uganda can then use to find answers on outbreaks like this much faster. They said that the PCR (test for presence of virus by detecting the genetic material of the virus) has not been fully developed for this new strain, so we’ll have to rely on antigen detection (looking for various proteins the virus makes) which has “very good” sensitivity (read: we think it should work for this strain like it has for others to find all the cases but we don’t know the real numbers yet, so it is hard to feel too secure about a negative test) and 99% specificity (read, if you get a positive test, it really means you have the disease). They will tests all samples for the antigens (presence of the virus) plus antibodies (evidence of a person’s immune response, therefore indirect evidence of the virus). Unfortunately not all the lab equipment arrived, so the first batch won’t be run until Friday.
• Data I wish we had: non-Ebola district death and suffering, as a result of fear, of lack of health center staff, of patients running away. The usually bursting-full maternity unit was EMPTY. Maybe that’s fine, maybe that’s not fine and there will be dozens of dead babies or mothers or both in the wake of this.

Ebola Bundibugyo: Mid Wednesday

Since every day seems like a week, multiple posts seem appropriate.  Joshua Kule, the senior clinical officer, and the head nurse of the hospital (?Peluce) also died this morning, so with Jonah that brings 3 of 6 health care workers admitted dying within 12 hours of each other.  So it is not surprising that both Scotts found the hospitals rather empty of patients and short on staff.  Many are afraid, but a few brave and hard working souls persist.  Scott said it was very disturbing and poignant to be given the key to Dr. Sessanga’s office and told to use it . . . And to find the top paper on his administrative stack was a request by Joshua Kule for his month of annual leave to begin today.  I know that Dr. Jonah was also planning an annual leave beginning this week.  . . . A Uganda Police Surgeon assisted Scott in seeing all the non-Ebola hospital inpatients, and then he worked with the administrator to designate a cemetery area. It seems the district feels it would be a fitting honor to health care workers who die to offer burial on site, and to create some sort of memorial for them.  We’re OK with that as long as they aren’t coerced out of fear of transporting the bodies home.  Meanwhile our airstrip might need an air traffic controller.  I met a mid-morning flight bringing in the director general of the Ministry of Health as well as an assortment of WHO officials and someone with MSF too I think, it gets confusing.  We don’t shake hands here anymore, so that puts an odd crimp in introductions.  I hear another flight landing now, and I know there’s a third one this afternoon, with CDC officials and I hope an MSF doctor.  There are actually a significant number of doctors here now . . . But only three (as far as I can tell) are actually seeing patients (Scott, Dr. Yoti, and the Police Surgeon).  The others are one step removed, tracing contacts and managing data and handling logistics and reports.  By the end of the day we hope that will have changed as a new medical superintendent is promised, and the MSF team expands.  

Our mission sent a prayer guide based on Psalm 91 that was very appropriate and encouraging, pleading with God to save people from this disease, asking Him to use it for good in some way that we can not yet see, confessing our bewilderment over the death of Jonah.  In the church meeting here this morning people took turns standing up and giving testimonies, comments, etc., it is very African for everyone to get a chance to speak.  I noticed that some chose John 9 as a text, the story where the Jesus rebuts the idea that sickness is a punishment for someone’s specific sin.  I’m glad to see people wrestling with the “why”, looking for meaning in a bleak and frightening situation.  Even in the task force the idea of blame sort of swirls below the surface, if that patient died then maybe it was someone’s fault . . . But the truth is that Ebola is a powerful virulent organism, and there is not much one can do to stop a patient from dying once infected.  

Concern is mounting all around us too.  Two districts within Uganda announced that they would close off access to anyone from Bundibugyo, and the DRC announced closure of the Congo border (though I doubt their ability to enforce that).  If the CDC lab can become operational today and the samples from scattered patients (Fort Portal, Mbarara) be confirmed negative that might help the general sense of this thing spiraling out of control.

More from the front lines when Scott gets back, he’s been gone all day again.  Since so many are reading and praying, please pray for SLEEP.  We are in a situation where the difference between life and death might be the overall resilience of our bodies to resist or pull through this infection; yet we’re also in a situation where the work is tremendous and the stress keeps us on edge, making it hard to get healthy rest.  So when one of us feels particularly tired, we have that sickening knot of wondering deep in the gut, is this because we laid awake for hours last night, or is this the beginning of a fever?  Thankfully so far it is the former.  Pray that for the MSF nurse Rosa too, who is the primary Ebola care-giver.  And Dr. Yoti.  Thanks.

Grief and Fear

Those two emotions wave over us hourly.  The church had previously called for a multi-denominational day of prayer and fasting so we started the morning with people there.  I’m going back in a few minutes, to be with people who are also grieving and praying.  I don’t know of any other death that could so severely affect this district.  Everyone is crying.

Jonah first went to investigate this epidemic weeks ago, it was probably still October then.  Rumors had reached him of a mystery illness.  I remember well the day he came into the Paediatric Ward and told us about it.  I gave him gloves and my bottle of alcohol hand gel, pitifully inadequate measures now.  We had not heard of any bleeding, just vomiting and diarrhea and unusual deaths.  We wondered if it was a cholera outbreak.  I remember him slinging his backpack on, and getting on his motorcycle, saying “If I die, I die.”  When he came back he guessed typhoid fever, due to the prominent abdominal pain and even what seemed to be two cases with intestinal perforation.  He noted the family grouping of the cases and held some community meetings to sensitize on hygiene, the basics of handwashing and latrines.  He dispelled rumors of witchcraft and poisons.  He wrote up a report.  Then over the next week or two there was a task force set up, some Ministry of Health epidemiologists came and took blood samples.  We got the good news that it was not Marburg or any Viral Hemorrhagic Fever based on samples sent . . . Not sure where.  Then there was the message that more samples had been sent to South Africa.  Days went on.  Uganda’s attention was on CHOGM.  Jonah continued to attend to patients as they came into Bundibugyo Hospital, as did Scott.  Jonah was the primary doctor for Muhindo Jeremiah, an older gentleman who had been active in visiting the sick in Kikyo then fell ill in Bundibugyo.  A week and a half ago Muhindo died.  A few days later Jonah went to Kampala on personal business; he has a house there still from medical school days with rooms he rents out, and three of his daughters are in school in Kampala, and his mother and brother stay with them there.  We went to Kikyo the day Jonah went to Kampala, all of us still wondering what this disease could be, still being told the samples had been sent from South Africa now on to the CDC in Atlanta.  Then last Thursday the bombshell announcement came, that it was Ebola, a new strain.  That day we talked to Jonah on the phone, he had a headache he said, maybe early malaria, he’d watch.  By Friday morning he found it prudent to admit himself to Mulago hospital.  That was his last act of bravery and wisdom.  We talked on the phone that day, he sounded so normal, so himself.  I went to find his wife Melen who was still here.  We prayed and wept and embraced and called him again.  Saturday morning I drove her early to town to get on transport to go to Kampala, even though she knew she would not be allowed to see him. She’s six months pregnant with their sixth child.  From Friday until 4 pm yesterday every report we got from the doctors was hopeful.  He was walking and talking, drinking.  His doctor even said he was wanting to call and talk to us but they were looking for a way to charge his phone which he had with him in the isolation.  He did have a couple of days of reduced urine output indicating an effect on his kidneys, and he did continue to have fever.  With each new symptom and passing day the hope that it was all just malaria became less and less.  Still Jonah is a strong man, healthy, smart.  He was in the country’s main hospital, not out here in Bundibugyo.  He was getting lab tests.  He had a team of doctors, including MSF Spain.  We had hope.  Then suddenly last night they called back.  He had died.  Maybe there was bleeding, involving his kidneys and lungs, I don’t have the real story yet.

Jonah was a man of integrity.  He refused to charge patients extra fees for his services, even though that is widely practiced in government hospitals.  He was completely trustworthy with his responsibilities and resources.  He was a leader who knew how to motivate, listen, draw consensus.  He was not afraid.  He worked hard, entering medical school in his mid-30’s after an initial career as a medical assistant.  We sponsored him all the way because we saw in him both the clinical prowess to save lives and the character to change the system.  He was the first person from Bundibugyo to graduate from Makerere University School of Medicine in 29 years.  He knew that God was the one who provided his opportunities, and he had a strong sense of his duty to serve.  His father was killed by ADF rebels in about 1997.  When the initial attacks came Jonah and Melen fled to our house.  We supported each other through war, school, families, children.  I was present for the birth of one of their girls (Biira) in their home.  Biira and Caleb were baptized together.  We’ve spent holidays together, traveled together, been present for each other’s significant events.  Since graduating from medical school Jonah has not found it easy to be back in Bundibugyo.  A person who stands against corruption meets obstacles here.  He has struggled.  But we always thought he would eventually prevail.  

I think I know now how Jesus’ disciples felt Friday night after the crucifixion.  What is God doing?  Will evil win?  Our hearts cry out.  Before all of this happened we sent out a December prayer letter, and now I can see that the Spirit was preparing our hearts.  I’ll try to post it some time.  But the message was:  the Kingdom coming is a dangerous business, real people get hurt and die.  I never dreamed it would be Jonah.  

Of course our grief is mixed with fear, with wondering what that means for our own exposures, though less than Jonah’s.  Scott and the WHM leadership made a decision last night that I will no longer be allowed to see patients, even non-Ebola ones, so I can wait out my incubation period and hopefully be cleared to reunite with our kids.  Scott Will is taking over my NHC duties.  I just got a message from him that there are only 12 patients admitted and no staff yet visible, but he said “God is still here”.  Scott Myhre is taking responsibility for Bundibugyo Hospital.  He said he’d like to mourn today, but it is like a battle, when your comrade falls that is not the time to quit.  We have moments of clarity and peace, and lots more moments of shivering dread.  The outpouring of prayer and posts has strengthened us.  I think we are too weak and numb to pray well, but in the body that’s OK, all over the world people are doing that work for us.

Dr. Jonah Kule...killed by Ebola

Dr. Jonah Kule died this evening, Tuesday 4 December, at Mulago Hospital.

We have lost one of our best friends.

To say nothing of the devastating impact on his family, on the district, on the country.

Ebola is horrific. There are no words to express our grief. And this makes the whole epidemic even more frightening, if that were possible.

Pray fiercely for an end to this, soon.

Ebola in Bundibugyo: Tues night Report

The District Task Force responding to the Ebola crisis meets every evening for several hours, and today I went with Scott.  Mostly because I felt so wiped out by the day in general and wanted to stick with him, as well as experience the politics and planning side of the epidemic.  About two dozen people, mostly men, mostly Ugandans except us, MSF, and two Kenyan epidemiologists, gathered in a circle of chairs outside the RDC’s office. Bottom line:  there are a slew of competent and motivated people at work.  The RDC himself serves as chair, and he’s an impressively large and voluminous presence, practical and authoritative, the kind of person you want in charge.  
THE FACTS:

• cumulative cases as of 5 pm on Tuesday:  90
• cumulative deaths:  19
• New admissions: 7; that includes 3 in Kikyo and 4 in Bundibugyo
• Current admissions:  23 in Bundi, and I think 14 or 15 in Kikyo
• Positive lab samples:  9, but that will change tomorrow, since there are about 15 samples waiting to be sent on the flight, and the CDC has landed and will be operational with their biohazard level 4 virology lab in Entebbe tomorrow.
• Identified contacts being followed:  327 (which does not include Scott or me, though the epidemiologist told us to follow ourselves because we should be considered contacts)
• Subcounties from which suspected cases have originated:  5 (Kasitu 50, Bubukwanga 18, Bundibugyo Town Council 10, Busaru 4, Harugale 3, others unknown).  Note that the case may be counted as arising from a subcounty because the patient’s home is there even if the contact was made elsewhere . . .
  

THE HEROS:
We chatted prior to the meeting with some of the doctors and others involved.  Dr. Yoti was (as he put it) a young fresh-from-school doctor in the 2000 Gulu Ebola epidemic, and when he survived that he decided to study Infectious Disease as a specialty in South Africa, and now works tirelessly all over Uganda under the auspices of the WHO tracing epidemics and disasters and trying to save lives.  I found him clinically solid, thoughtful, and humane, and the kind of guy I’d hope to have in charge of any patient I cared about.  Rosa, the MSF Medical Coordinator, a nurse with the experience of the 2007 Congo epidemic and the down-to-tacks hard work and confidence to pull off the isolation and care of patients.  She’s spent several days now setting up the isolation wards, arranging for food, water, triage, training teams to man an ambulance to pull in suspected cases safely and another team to safely bury those that die, teaching attendants to protect themselves, as well as managing the patients.  Dr. Ann (MSF) and Dr. Thomas (WHO) are carefully tracking the numbers.  There are umpteen other people pitching in in every way they can.

Ebola in Bundibugyo-Tues-Day 6

I hit the wall, perhaps because now my kids are out of the danger zone (I hope), perhaps because we’re finding it hard to sleep, perhaps because we now have lots more information on Jonah who is holding his own but definitely continuing to have symptoms, perhaps because the adrenaline has limits.  I’m very weary, and back to borderline weepy.  

Jonah:  still with fever, not terribly high, still with diarrhea, no bleeding, up and talking and walking and drinking in Mulago Isolation unit.  Day 5 of illness.
Sessanga:  Refused to unlock door for Scott to enter his house this morning, but answered the phone.  Diarrha and vomiting better, but complaining of headache.
BGO Isolation ward:  one death this morning 5 am, another contact of Jeremiah Muhindo, who seems to have been very infectious.  2 new admissions, so total caseload 22.  Scott says they are finally getting up the mesh fence and controlling the access a bit better.  
Kikyo:  no news yet today.
The rest of Uganda:  Panic mode.  Lots of people are coming to have their symptoms evaluated at other hospitals, worried.  We have word from the CDC that their lab in Entebbe should be functional on Wednesday, so that will help SO MUCH with the sense of impending spin-out-of-control spread, if the suspect cases from Fort Portal and Mbarara are not confirmed (though I don’t even want to think what it will be like if they are).
The REST of the patients in BGO:  Scott got called for another obstetric emergency at 7:30, was up to BGO by 8 but the mother had died, perhaps a ruptured uterus.  She had delivered one twin in a distant health center, but by the time they got her to Bundibugyo and called it was too late.  He and Scott Will saw all the maternity ward inpatients this morning, trying to discharge those not critical for their own protection.  He ultrasounded about 15 women.  Staff are present and functioning.  There is a police surgeon who came in, and we anticipate any moment the arrival of another doctor sent by Ministry of Health, to be medical superintendent.  
The REST of the patients in Nyahuka:  Meanwhile I went down to Nyahuka where we still do not have any confirmed cases, nor is there anyone admitted for isolation.  The staff is somber but present, willing to work, even a couple of nurses who are not usually there showed up to volunteer during their school break!  That surprised me.  Since I don’t have any kids I made “hot ice cream”, milk from our cow cooked with eggs and sugar, and took the whole lot down to the ward to feed warm to the inpatients.  I was able to discharge 8 kids, one I hesitated on since he had hepatosplenomegaly and diarrhea and a prolonged fever, though he was improving, I considered whether he qualified as an alert case . . . .  Then I was called to see a new admission, who is almost certainly going to die.  A two-year-old, malnourished-looking, with a week and a half history of fever at home, mucus stools.  Not classic Ebola symptoms by any means, but when I saw him gasping and hot and dehydrated . . . I put on gloves at least.  Then the knot of panic began to build—is this kid infected?  What should I do?  Called Scott who called MSF who said that they never saw a child as the first case in any community, so since this kid was from a village with no cases and the only one sick, not considered a suspect.  OK.  We are giving IV fluids, antimalarials, and antibiotics, but I think they came a day or so too late.  When all the inpatients were seen and I had moved around the hospital checking in with all the staff, I came back up to the community center where we had shifted our normal first-Tuesday-of-the-month distribution of food to families with motherless infants (we provide a month of milk when a mother dies, then a ration of beans to increase the caloric intake of a surrogate breast feeder).  I should have counted, we must have had 40 families or more.  We used the opportunity to do some community education about Ebola, they asked good questions, like WHERE DOES THIS DISEASE COME FROM???  And another lady wanted to know what she should do if her husband gets sick, should she care for him or keep away with the baby??

In a single day we can go back and forth twenty times from “we are OK, we are protected, people are praying for us, we will get through this” to “what if one of us or even worse both gets sick?”  Is it wrong to feel anxious when you’re living in the middle of an Ebola epidemic?  I don’t think God will judge us.  I miss my kids, oddly when I read about myself in my team’s emails I cry.  

Ebola in Bundibugyo: Monday night, still escalating

The official case count has gone up from 51 to 79 since the initial numbers were released four days ago.  We now have 21 admitted in Bundibugyo (up from 16 yesterday) while only one more patient came to Kikyo (10 total).  Dr. Sessanga continues to struggle on with his case; Dr. Jonah needed IV fluids today but was reported to be stable.  It was another dawn to post-dusk day for Scott, which included two three-hour-long meetings as well as final assembly and initial use of a brand new lawnmower we just imported in the nick of time to keep the airstrip open for the sudden increase in flights.  Three MSF personnel hitched a ride in on the plane that took our team out; more CDC and WHO folks are expected on Wednesday, so keeping the airstrip open is an important part of the logistics of this operation.  Pray for Scott to have wisdom to know his role, to respond with leadership and compassion and wisdom and courage. We are used to being a bit more on the sidelines politically, focusing on patient care.  This crisis throws him into the middle of everything, and the lines of authority are not always clear.  Added to that is the fact that this is a new strain, so if one person makes a statement about transmission and another challenges it, we really can’t be sure who is right, because this epidemic may not progress in the same way that others have done.  The MSF team is impressive and fascinating, they are tracking numbers and plotting maps and have already concluded from interviews that besides patient care in the hospital, the greatest risk factor is the handling of dead bodies at burial.

We do sense the incredible outpouring of concern and prayer from our friends.  It is a bit edgy to go hour to hour with the background thought of . . .do I feel a twinge of nausea, could that be a fever coming on . . . But mostly we remain confident that our measures to protect ourselves even before we knew the gravity of the situation were adequate.  The kids made it to Kampala safe and sound, and compared to the agony of deciding to send them away, the reality of missing them is not nearly as painful.  Scott was remembering the days of war, when the team dwindled down to two or three adults only, it feels like that again now, with all the separation and uncertainty.  

Explaining Ebola

This afternoon seven of the eight boys who are my kids’ close friends hung out playing cards.  I tried to explain ebola, most of these boys are CSB students whom we sponsor.  They asked good questions, but one got me thinking:  Is this disease only in Africa, or is it in other parts of the world?  I felt disloyal, or sad, to admit that all the major outbreaks had occurred relatively close (on a global scale) to where we now sit, in eastern Congo, southern Sudan, northern Uganda.  Almost the only time the filovirus has been found elsewhere was when it was inadvertently transported out in monkeys from Uganda.  I could see the world-wide image of Africa, the continent of disease, being reinforced once again.  And it is not just a matter of how uninformed or prejudiced westerners view Africa, the assumptions are so powerful they trickle down into the minds of these boys.  It seems unfair that Bundibugyo only gets the five minutes of world attention because of yet another disease.

They're Off

The Caravan lifted off a few minutes ago with its precious cargo . . . I have never been in Bundibugyo without our kids before, it is very very quiet all of the sudden.  There are still people laughing and chatting on the road, still kids coming into our yard, still bright red tomatoes piled on the counter to be cooked, which lend an air of unreality to the fact that we are in the midst of a major public health crisis, temporarily scattered as a family and team.  Julia and Caleb were efficient and helpful all day, they have matured even faster in the last three days.  Jack spent most of the day with his friends, especially his closest one Ivan.  Ironically now all my kids are gone, but my students who were released from school today are all sitting on my porch waiting for the “plan” since they normally spend most of their days here when on break.  If I sent my team and kids away to protect them from risking contact with us, how can I allow these boys to be here?  What about my houseworkers?  Other friends?  Always these evacuations bring painfully to the surface the options we have that others do not.  Someone wrote that it reminded her of kids being shipped out of London in WW2, which gave me a new empathy for those parents.

Scott is gone from sunrise to sunset and past every day it seems.  As soon as the plane took off he was back up to yet another meeting.  I think this is probably the hardest point of the whole crisis, the fourth day, when things should be falling together but there is still considerable confusion and jostling for who is responsible for what, how do MSF and WHO and CDC and Red Cross and Ministry of Health all cooperate, and what is our role in all that?  All intensified by the absence due to disease of the two men who would be most able to hold it all together.  

Feeling a bit numb.  More later.

Ebola Bundibugyo Monday Morning

The good news:  Jonah is improving.  Dr. Sessanga is still critically ill (down 10kg, 8 days of fever, barely talking) but the MSF doctor said the fact that he can still sit and even walk a little on day 8 is a good sign.  The cavalry is still a bit slow in arriving, only two came yesterday but more expected today.  Scott spent the entire day with them again.  16 admissions at BGO hospital, still 8 in Kikyo.  We now have the “Ebola Bible” manual for the epidemic and need to work today to shut down non-essential medical services that could spread the disease (like immunizations) and clarify which services are essential (the guidelines take a pretty hard core view of that, such as C section to save the mother only not the baby, due to the volumes of blood involved).  Had a good mini-advent time with team focusing on HOPE, on Mary’s song of God’s power in the weak and poor, of God turning impossible situations around.  We feel that.  This will be short, Scott is already at the airstrip at dawn with the new lawn mower which finally arrived, because in the midst of everything else we realize the airstrip is an essential part of logistics for help.  MAF comes at 3 pm to evacuate our non-medical team, and our kids, primarily to prevent the danger of them being infected by us should we fall ill.  I am dreading the moment and have great sympathy for mothers who give their babies up for adoption because they think it is best for their child.  But before that happens I need to pack for them, assuming at least three to four weeks away from home, possibly longer.  Thanks to all who are leaving encouraging messages, we see them and are grateful.

Ebola Bundibugyo, the Emotions

I am making this two separate posts, to separate the facts from the emotions.  And since my mother and my son both read this from America I probably won’t be fully honest.  But I will say that the emotional toll of the last 72 hours has been tremendous.  There is first of all the wrenching anxiety about the patients that we know.  Since about a third right now are hospital staff, they are not mere numbers in a list.  Jonah of course top of the list of people we love who are in danger.  A virus that selectively attacks the people who care for the sick seems positively diabolical.  Then second there is the small but real possibility that one of us, mostly Scott, would fall ill.  Since the only other two doctors who have seen these patients are down, we can not ignore that risk.  We have been careful and pray that we’ve been careful enough.  The full protective MSF biohazard garb is arriving today, before that we’ve worn masks and gloves only.  And related to that sobering hypothetical scenario is the responsibility we feel to protect and care for and make good decisions about our children and our team, a third area of gut-twisting thoughts.  It is unbelievably painful to consider that we (Scott, Scott Will, and me) might be dangerous to them.  So over the last day we’ve been growing in our conviction that we need to get the non-medical team members out of here, away from us.  It is an impossible dilemma, to look at my beautiful three children who are here with me, and think that for their own good I need to send them away from me.  To look at our bewildered team scrambling to make plans and feel that we can’t go with them.  So far we are all well, but if our medical exposure stopped this minute it would still be at least two weeks, maybe three, until we were sure we were safe.  Over the last three days since we knew it was Ebola, I have only been with one patient who may have been a case (she died), while Scott has continued to care for the ill until MSF arrives (hopefully soon).  Clearly it would be good to keep one parent healthy, but where does that leave the support we need to give each other?  And if those three areas of stress are not enough, there is the parallel crisis of the collapsing medical system.  Scott has been gone all day again, third day in a row of juggling the medical and surgical emergencies that would have fallen to Dr. Sessanga and Jonah.  How do we weigh ethically protecting ourselves and our children and our responsibility to the community here where we’ve spent  a large portion of our lives, in their time of greatest need?  

So those are the thoughts that wake me up in the middle of the night and make it hard to sleep, that catch me unawares in the middle of hot afternoon sunshine and make me cry.  The hymn that keeps surfacing in my head is the one about protecting soldiers and sailors . . .Eternal Father, strong to save . . . Oh Trinity of Love and Power . .. We are clinging to that love, and that power, as our only surety.  Please pray.

Ebola Bundibugyo Sunday Facts

Admitted at Bundibugyo:  15, including Dr. Sessanga whose sister just came to our house looking for Scott because he’s no longer responsive; the matron (head nurse); the nurse who was working in the isolation unit Fred; a clinical officer named Joshua Kule; and an ophthalmic assistant.  Among the other patients are six direct contacts (mother, brother, wife, daughter and two friends) of Muhindo Jeremiah who died just over a week ago.

Admitted at Kikyo:  8 as of yesterday, haven’t heard today.

Died:  official number is 18.  Likely higher, hard to say.

Calvary:  Still en route, but expected any minute.  They slept in Fort Portal last night.  There is a 17 person team from combined MSF branches (Belgium, France, Spain, etc.) including the doctor who was in charge of the recent outbreak in Congo.  They have two doctors, four nurses, and a wide variety of other staff who won’t see patients but do logistics, education, investigation.  Even an anthropologist.  The CDC lab team arrives in the country Tuesday night.  They say they’ll be up and running for labs in Entebbe (Uganda Viral Research Institute) by Thursday, possibly even Wednesday evening.

Jonah:  I just talked to his sister, she says there is definite improvement since yesterday.  We heard he had a positive malaria smear, so it is possibly not Ebola.  But then he developed more symptoms, so we are waiting for a confirmation.  His blood sample is with the CDC in Uganda, not yet reached America.

Team:  OK.  We had a prayer and discussion time this morning.  As team leaders we are leaning towards sending out non-medical staff and children, to be cautious.  Scott and Scott zipped up to Bundibugyo again mid-meeting to do an emergency C section, but by the time they got the mother into the OR the baby had died, and she then delivered the still-born vaginally.  So you could, in a public health sense, count that as another Ebola casualty.  As soon as they got out of that they were called to see a motorcycle accident victim, a lady with severe facial trauma and fractures they need to refer to Fort Portal, but probably can’t because she’s a family member contact of an Ebola survivor (one of the cases Scott has been following the last two weeks).  He was actually driving the motorcycle when it crashed.  It is incredibly complicated.

Community:  the churches have called for an all day prayer meeting in our Community Center on Wednesday, which is a really encouraging sign, I hope many people come and pray. There were educational videos shown outdoors in the market last evening.  Anxiety is mainly high among the health center staff, with good reason.  One of our staff just came and brought me a chicken and said goodbye—she’s from Arua, and she wants to escape with her children while she can . . . Schools are closing a week early, and CSB is sending kids home tomorrow.  Ndyezika’s wedding has been postponed, and likely others will too, a real blow to marriage since after years and years there are more wedding planned for December (six that I’ve been invited to) than the last several years combined.