Ebola Heroes

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

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

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

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

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

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

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

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

Ebola Bundibugyo: Saturday numbers

Encouraging statistics from today:

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

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

Ebola Bundibugyo: Friday Night Numbers

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

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

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

Ebola Bundibugyo: Thursday Night, Living on the Edge

The facts:

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

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

Ebola Survivors - 2 Bundibugyo Health Workers

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

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

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

Ebola Bundibugyo--Wednesday Night Numbers

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

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

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

Christmas in the time of Ebola

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

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

God in a box

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

Ebola Bundibugyo, Tuesday Night Numbers

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

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

Now the news:

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

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

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

Ebola Bundibugyo Tuesday Mid Day

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