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.