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Sunday, April 01, 2018

Dr. Jonah Kule Memorial Lecture --10th anniversary of his death from Ebola

Below is a transcript of the Dr. Jonah Kule Memorial Lecture, delivered by Scott to the Federation of Uganda Medical Students Association on 31 March 2018 at 10:30am at the Makerere University Main Campus.

(it was a 45 minute lecture so be warned, it's a long read...)


Good morning.  Thank you very much for the invitation to deliver the Dr. Jonah Kule Memorial Lecture to the Federation of Ugandan Medical Students Association. 

I would like to acknowledge the presence of Masika Constance, the firstborn daughter of Jonah Kule. She is a graduate of the Uganda Christian University, and was 15 years old when her father died from Ebola.  Her younger sister, Birra Phiona, who is studying Law at Uganda Christian University is also here.

It is fitting that I am delivering a lecture memorializing the life of Dr. Jonah Kule on the weekend of the Celebration of Easter.  Easter is the climax of the Christian calendar in which we remember the resurrection of Jesus Christ.  Easter weekend begins with the observance of Passover.  Christians call this Maundy Thursday.  Jews hold a traditional meal called the Seder during which there is a reading of the Haggadah, a Jewish text which means “the telling”. During the Passover Meal, the story of the Passover is recounted. It is a story of God’s deliverance of the Jewish people from slavery at the hands of the Egyptians.  I am here for a re-telling of the story of our friend, our colleague, Dr. Jonah Kule.  I have two objectives for this re-tellling.  The first is to honor the memory of our friend and colleague who gave his life serving the sick.  The second is to challenge you, a group of future doctors, to consider how you will live and work – and whether the life of Dr. Jonah Kule is one to which you might aspire.
Our part in the story began with our arrival in Bundibugyo District in 1993. We came as part of a Team, trying to bring life and redemption to a remote and forgotten district with efforts in health, education, church planting and Bible translation.  When we arrived, there were 49 Districts in Uganda.  In the education sector, the New Vision always published a list of the District Performance for senior secondary O-level results --which is a proxy I think of development – and Bundibugyo was always dead last.  My wife and I are physicians so our piece was in promoting health and healing the sick—preventive and curative health.  As we moved into needy communities with immunization campaigns and health messages we met a young energetic Clinical Officer named Jonah Kule.  Jonah was a Mukonjo, a person of the mountains.  We learned very quickly that this young man had a gift for shepherding communities. He could teach, persuade, correct, encourage, guide—and all the while lead community groups on a path of self-discovery and mobilization towards healthier lives--idn a way that we as outsiders could not…
We got to know Jonah and his family very well. He eventually had five daughters—Masika, Biira, Maga, Keren, and Serah—who were in the same age range as our own four children. We shared holiday meals together in each other’s homes. We traveled together. We were professional colleagues working for health in Bundibugyo. After a few years, Jonah shared his dream of going to medical school with us.  We decided this was a worthy investment of time and money, so we gave him the green light to pursue a medical admission. Jonah was over 30 years old so he took the Makerere University “Mature Age Entry” exam.  He scored in near the top of all who took the exam. He was called in and asked how he cheated.  He must have cheated—because it was not possible that a student from Bundibugyo District could have performed so well.  So, they deleted his result and sent him away.  He was determined, however, and came back the next year and again scored in the top three of all who sat.  This time they accepted his result and he was admitted to the Makerere University Medical School. 

Jonah was a smart guy, but biochemistry almost did him in.  I think he passed by 1%.   But he was very experienced seeing patients as a hardworking clinical officer.  So, he did well at MUMed during the clinical rotations.  But he was always singled out in class by the professors.  No matter which subject whether it was surgery or obstetrics—they would look at Jonah and say, “and if you are practicing way out in the bush with few resources—like, in Bundibugyo, this is how you need to think about this.”  It was a slight humiliation.  Calling out Bundibugyo as the least developed and most backward place in Uganda.  
Nevertheless, Jonah persevered and graduated in 2005 from Makerere—and was the first to graduate as a native born from Bundibugyo in 29 years.  The last previous Bundibugyo-born graduate was William Sikyewunda who went on to be a member of Parliament and the District Health Officer. The New Vision’s headline on 31 March 2005 said “Bundibugyo’s Reason to Smile”. He went on to do his Internship Year in 2006 at Rubaga Hospital where he was much loved and appreciated for his serious work ethic.

Our mission, World Harvest Mission, sponsored Jonah with a Bond Agreement that he would return to serve in Bundibugyo District for at least 5 years.  For Jonah that was not a burden – he desired to return to Bundibugyo.  Immediately upon finishing his internship at the end of 2006, he did return to Bundibugyo.  He was immediately posted to the District Hospital.  It was a place he knew like the back of his hand since he had worked there for many years as a Clinical Officer prior to attending medical school. But there was still a requirement that he have an Official Tour at the time of his posting. On that tour, he was shown the Operating Theatre where he found a pregnant woman lying on the operating table. He asked why she was lying there and was told that she was waiting for the family to come up with the money for the surgeon before he was willing to do the surgery.  Jonah was annoyed and immediately terminated the tour.  He said, “Get me theatre scrubs and boots…I will operate on this mother—for no money.”  That story spread like wildfire in the ensuing days.  “Dr. Jonah is here… and he is not charging money to do surgery!!”
Jonah came back not just to be a doctor but to stand up to the rampant corruption.  That action shook up the District.  But life became hard for him.  Not everyone was happy that he came back to serve.  There were those who feared him and were jealous.  Everybody knew that Dr. Sikyewunda came from Makerere Medical School and became a member of Parliament.  People began to talk already that Dr. Jonah would be the first Mukonjo Parliament Member from Bundibugyo.  That was a radical idea.  I don’t think Jonah was entirely opposed to the talk.  He knew that corruption was rampant and might need to be cleaned out from within.  But I think he thought that would be some years down the road. 

So, he began to serve his people…

So, when there were a rash of deaths in Kikyo Sub-County (a mountainous area on the slopes of the Rwenzoris) in August of 2007 (six months after he began his posting), he took an interest.  He went up and treated people and investigated.  There were a cluster of deaths in one family – about five.  The father and all of the sons of one family—and then soon many more from that clan.  So, the pattern seemed to be infectious.  In retrospect, it is thought that these men were involved in butchering monkeys hunted in the mountains and then many more died who were involved with the burials. But that was covered up because it was an illegal practice.  Jonah brought in the District Surveillance Officer who sent off samples for testing for Hemorrhagic Fevers to UVRI.  The tests were negative.  There were no hemorrhagic features clinically.   Malaria tests were also negative.  It was mostly a picture of fever, vomiting and diarrhea.  At the time -we thought it might be typhoid.
Jonah passed by our house one day on his way up to the Kikyo Health Center.  Jennifer went into our stores and gave Jonah all of the Ciprofloxacin, gloves and alcohol hand sanitizer that we had.  He was in a hurry, but we insisted that he wait until we get these supplies together.  He did wait but as he pulled out on his dilapidated motorcycle he laughed and said, “I must serve my people.  If I die, then I die.”

And so it went.  Things smoldered and flared through September, October and into November.  Finally, on Thursday 29 November 2007, we got a call informing us that the CDC figured out that this disease was due to a new strain, the fifth identified, of the Ebola virus.  Much later in 2008, it was given the name Ebola bundibugyo.  Nobody in Bundibugyo or Uganda was happy about the fact that it was named for a place in Uganda.
So, this was the 17th documented outbreak of Ebola since 1976.  All of the significant clinical outbreaks had occurred in Africa except for some of laboratory contaminations in other parts of the world.  The last previous Ugandan outbreak prior to this was in Gulu in 2000.  Uganda lost another hero due to that outbreak, Dr. Matthew Lukwiya, who died while caring for Ebola patients at the St. Mary’s Hospital in Lacor on 5 December 2000 – almost exactly 7 years prior to Dr. Jonah’s death.

As soon as the diagnosis was announced, Uganda MOH epidemiologists visited Bundibugyo and reviewed the records of many of the cases as they could find and decided that officially speaking (during that early period of the epidemic) there were 79 cases with a 43% death rate.  My own opinion is that it is a significant underestimate.  They used extremely strict case definitions and had no medical records for many patient deaths which made it impossible for them to be categorized as Ebola-related deaths.

So, we received the news from the USA CDC and immediately changed our approach to the way we handled patients, but by that time it was too late….

So, let me try to walk through the timeline of the final ten days of Jonah…

Friday 23 November  is the day Jonah believed himself to have been infected. That was the day he and I examined Jeremiah Muhindo.  Ebola experts call this type of patient a “super-infector”.  Very sick patients with high viral loads and lots of caregiver exposures.  He was an important man in the community – many people were involved in his care.  There were five health care workers who died at Bundibugyo Hospital and they all had contact with this patient:
--Rose Bulinpikya, nurse matron
--Johnson Kiza nurse
--Joshua Kule,  senior clinical officer
-- Asanasio Matte, ophthalmic assistant. (few of the patients in this epidemic had bleeding manifestations, but many did have conjunctivitis, so the ophthalmic assistant got involved – again, before we knew it was Ebola).

In between two of the times we 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 25 November Jonah traveled to Kampala to pick up Masika from school as they were breaking off later in the week.

Wednesday 28 November 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 29 Nov the EBOLA epidemic was announced by the Ministry of Health. 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. We talked to him on the phone about this time – our first time to talk since the announcement of the Ebola epidemic.  I asked “How are you doing?”  With a sort of nervous laugh, he said “well, I’m not feeling so well.”

Friday 30 Nov  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 boda-bodas and both rode to Mulago Hospital. There he was put in an isolation tent.

Saturday 1 Dec  a blood sample was taken to test for the Ebola 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 Hospital doctor assigned to his care had 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 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. 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. 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 Jennifer did inform the family due to direct information from MSF, for which his wife and sister were very grateful.

The picture of Jonah in this situation 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.

After Jonah’s death, we spoke with doctors from MSF who had cared for him.  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 his doctors really believed him.  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 that he was, looking beyond himself to others.

The final numbers of the Bundibugyo Ebola epidemic are not huge:
Cases: 143
Deaths: 36
Case Fatality Rate (CFR): 25.2%

The CDC Team in Atlanta published a summary in the journal, Emerging Infectious Diseases, and they only officially recognized those Ebola patients who had laboratory confirmation of their infections:

Total infections: 56
Total deaths: 17
CFR: 40%
This is almost identical to the overall death rate of the massive Ebola epidemic in West Africa of 2015-16.

Ironically Jonah’s death was not included in the official tally of deaths of the Bundibugyo Ebola epidemic because he died in Kampala.

These numbers are super tiny compared to the 2015-16 recent epidemic in West Africa where
Cases: 28,616 (200x bigger)
Deaths: 11,310 (300x more)
CFR: 39.5%

Bundibugyo was not the largest epidemic in history.  But we did learn more about the disease as a result.

It was a tremendously organized effort.  Large organizations came and invested enormous amounts of manpower and money:  the Uganda MOH, Uganda Red Cross, Medicins sans Frontiers, the USA CDC, and the WHO.  There was one member of the WHO team who had been present at ALL of the previous Ebola epidemics.  He was primarily interested in trying to understand where the Ebola virus was coming from.
The Ebola Task Force included all of these organizations and was headed by the RDC and the Uganda MOH.
It was composed of a number of sub-committees:
1.    Clinical Care (MSF)– organizing the care of the sick
2.    Social Mobilization (MOH/Red Cross)—the community educators putting out messages of prevention
3.    Contact Tracing (WHO)– following up on those potentially exposed
4.    Lab (CDC)
5.    Logistics/Finance – Ug MOH
We learned this about Ebola:
Incubation: 2-21 days (the larger the viral exposure, the shorter the incubation)
Transmission: contact (no evidence of airborne transmission – except perhaps droplet transmission when health care providers have been sprayed down and blood has been aerosolized).  One brief anecdote here…The Sunday after Jonah died, Jennifer and I were home alone, having breakfast.  It was eerily quiet.  No kids (we sent them to Kampala so they wouldn't be at risk if we got sick).  No visitors because people thought we might be infected…and then I cell phone rang.  The guy on the other end of the line said, “Please hold for the President…”  President Museveni then came on the line.  We had a 10 minute conversation in which he asked lots of specific and intelligent questions about Ebola.  Specifically he wanted to know if Ebola could penetrate intact skin (my best answer: NO)  because he was trying to make public health recommendations for his country. At the end of the conversation he asked, “Is there anything I can do for you?"
I always regretted that I didn’t ask him for Ugandan citizenship for me and Jennifer :(

Reservoir: to the best of my knowledge it was during this epidemic that they made progress in understanding that the long-term reservoir of the Ebola virus was Fruit bats.
Intermediate host: primates (it is believed that the first cases in Kikyo on the mountainside occurred in a family who were hunting and butchering monkeys)

Those at risk: Health care workers and family care givers and especially those that bury the dead.

This is the insidious and seemingly evil part of this virus.

Let me just say a little bit about Jonahs burial…
We lived in Bundibugyo for 17 years and we attended dozens if not hundreds of burials.  Jonah’s was unlike any other we ever attended. 
Since Jonah died in Kampala, his body had to be transported back to Bundibuygo.  That was done by the Doctors Without Borders – Spain team.  The district leadership planned bury it with no ceremony, no attendants, not even his wife. We strongly objected. We knew there was no danger to standing a few feet away and watching the MSF team put the coffin into the ground. We drove Melen, the three oldest girls, his sister Sophia, and his mother, to Bundibugyo Hospital. When we arrived the other two staff were just being buried.  I 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. We 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.  And they stood at a distance.  Quietly.  While the MSF Burial team lowered the coffin into the ground. 
By our estimates only his youngest brother and his mother had any potential exposure, touching him or cleaning up from his sickness. But the entire family was ostracized as dangerous and put into quarantine for 21 days.  It was harsh.

Jonah’s wife did receive a small worker’s compensation lump sum from the government since he died while doing government work, but inexplicably they published that fact and the sum in the New Vision.  This was a horrible decision as every distant relative descended on Melen, trying to vie for a piece of the pie.  And Melen was pregnant with their sixth child at the time of Jonah’s death.  A child he would never meet.  And it turned out to be their first boy, now named for his father.
At the graveside, as they lowered Jonah’s coffin into the ground I read

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 and 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. 

I would like to pause here for a moment before I move to my final points—to address the issue of how we deal with such a tragedy.  How do we make sense of the death of a good man, one who we have poured so much into, who has just finished six years of medical training who has come back to serve his people, who is the father to five children.  It makes no sense, humanly speaking.  I will say two things:

First, We cannot see the ways of God.  God is all-knowing and all-loving and all-powerful. We know these things from the ways he has revealed Himself in history. But sometimes we cannot understand His ways.  We must accept that God is Mystery –with a capital “M”.  It will never make sense to us – but we cannot see all of history in the same way that God can.  Look at it this way. If you wanted to understand the ocean, but you only had a cup of water from the ocean.  You could say that it is salty, that it might have some sand, and some microorganisms in it. But that cup of ocean water could never reveal the depths of the ocean and the undersea world of creatures and vegetation and beauty.  In the same way, we only see dimly now through a veil.  God is beyond our understanding…

Second, there is some good that has risen from the death of Jonah…we established the Dr. Jonah Kule Memorial Leadership Scholarship Fund to sponsor students in medicine and other health-related education.  We have seen 6 doctors sponsored at Mbarara and KIU; in nursing at UCU; in lab medicine at Mulago and Mengo; in anesthesia at Mulago.
Those sponsored in medicine included Baluku Morris, Monday Julius, Katuramu Tadeo, Peter Kisembo, Isaiah Kule, Birungi Fred.  And they are all bonded to 5 years of service in Bundibugyo (though it seems unlikely at this time that the District will have the finances to hire them all).

So, what does this mean for us today?
How should we then live?

We are here today remembering and re-telling the story of the final days of Dr. Jonah Kule.  Is his life a model for us? 

As medical students, I used to presume that you were motivated by a sense of service and calling.  That there was some desire to heal the sick, to comfort the dying, to help your fellow humans.  These last few years though I’ve run into more and more young doctors who are motivated only by money.  I have a Kenyan colleague who seems to be willing to do a Cesarean delivery on every woman possible to make as much money as possible.  There is a doctor in Bundibugyo recently who has been doing unnecessary hysterectomies in order to make as much money as possible.

I would like to leave you today with one more verse from the Bible, Micah 6:8

He has told you, O man, what is good:
And what does the LORD require of you
But to do justice
And to love kindness,
And to walk humbly with your God.
I would implore you as medical students to reexamine the reasons why you entered medicine. Of course, medicine is a sure meal ticket and potentially a lucrative career.  I’ve heard so many intellectual justifications about why you DESERVE to be living comfortable and convenient lives.  You’ve worked hard.  You’ve suffered.  You’ve put yourself in harm’s way.  You deserve to drive a nice car, own a big house, wear the best clothes, and to send your kids to the best schools.

But let’s look at this verse from the Book of the prophet Micah…


1      DO JUSTICE…God does not call us to lives of convenience but to lives of justice. 

The Bible is full of evidence of God’s concern for justice:

Isaiah 58
Cry loudly…raise your voice…declare to My people their transgression...on the day of your fast you find your desire, and drive hard all your workers…Is this not the fast which I choose? To loosen the bonds of wickedness, to undo the bands of the yoke, and to let the oppressed go free? Is it not to divide your bread with the hungry and bring the homeless poor into the house?
If you remove the yoke from your midst, the pointing of the finger and speaking wickedness, if you give yourself to the hungry and satisfy the desire of the afflicted then your light will rise in darkness…You will be like a spring of water whose waters do not fail.

And I would like to make a distinction here between charity and justice.  Charity is giving something to someone in need.  Caring for the poor.  This is a good thing.  But justice is doing something in which there is a structural change in the system that oppresses the poor and those in need.

You see corruption and deceit in your communities, in your hospital. People taking money from patients for dressing changes and placement of IVs.  For services that are declared free by the government. I daresay that if we see it and don’t speak up then we are complicit in promoting injustice.  Injustice is an oppression of the poor –who have no other resources to access private care. 

Jonah stood up to injustice when he rolled up his sleeves and did the CS for the woman on the table who had no money.  He stood up to the corruption, called it out, and did the just and right thing.  He challenged the system of corruption and publically condemned in it word and deed.

Doing justice is doing the right thing.

What is that for you today? 
What does that mean for you in your life? 
How can you be working for justice in an unjust world? 
Does that require some sacrifice in your life – of course, it does.

2.  LOVE KINDNESS…This is about who we are as people.  How we treat each other. 
Aristotle defines it as being "helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped.

Kindness is a comfort to those it touches.  It makes their life easier, more pleasant.
Another way we can think about Kindness is generosity.  Giving.  Some say it’s more blessed to give that receive.  To live generously is to live with a spirit of kindness.  Always looking for opportunities to bless other people.
Philippians 2:3  - count others more significant that yourself…

There are so many organizations and movements in our culture and in social media extolling the virtue of kindness…
The Kindness Boomerang, the LifeVestInside, Random Acts of Kindness, Pay it Forward…
The common thread here is doing something for someone else expecting nothing in return.
Usually these are small acts. 

Jonah was a kind man – one who thought always of others first.  Of how he could serve, of how he could help…

What opportunities for showing kindness do you have in your life?
 Are you touching others with unexpected, unmerited kindnesses? 

3.  Walk Humbly with your God.

What does that mean to walk Humbly with God?

To be humble in the Bible means literally to ‘submit yourself to the humbling process of God’

It means you submit control to God.  You have faith that He is in control.  That he is great and we are not.

I remember one time Jonah and I were traveling together.  It was early in our friendship.  He was still a Clinical Officer.  We were staying in a guest house together.  We had a small room with two beds.  I think we arrived late.  We ate dinner and I came back and collapsed into bed.  Jonah took a shower.  By the time he got back I was almost asleep.  He said, “Scott did you pray? We need to pray before we sleep.”  I smiled and nodded.  He prayed, giving thanks for the day, for our safe travel, for our accommodation and our meal.  And asked that God would protect us through the night and give us rest.”

Jonah was a man who pursued justice, who practiced kindness, and who walked humbly with his God. 

He gave his life serving others.

He is an example and a hero to his family, his friends, to Uganda, and to the world.

Masika, little Jonah, Mbusa, Melen, and Biira


Pamela said...

Beautiful tribute. Extraordinary man. What a privilege it was to know Jonah for several short years... and what grace that our God, in all his mystery, is a God who brings new life out of the terror of death.

Charles Woernle said...

A wonderful tribute in honor of a special man.