Dispatches from Displacement: Kampala at Christmas

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

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

Ebola Bundibugyo, Saturday Night Numbers

The Saturday night numbers…

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

Issues discussed in the Task Force Meeting…

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

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

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

Ebola Bundibugyo, Friday Night Numbers

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

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

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

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

A biblical reminder for sure...

Ebola Bundibugyo, Thursday numbers

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

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

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

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

Ebola Bundibugyo, Wednesday numbers

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

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

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

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

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

Tuesday Night Numbers-Still in Bundibugyo

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

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

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

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

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

In Kampala

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

21 Days! Ebola Bundibugyo on Monday Night

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

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

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

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

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

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

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

Ebola Bundibugyo: Sunday night report

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

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

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