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 D&G'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.