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.

Ebola Bundibugyo: The Saturday Numbers and other things

Scott’s report from tonight’s task force meeting:

• Cumulative cases: 106 (note that he discussed with the CDC the fact that most of the early cases had been excluded.  This is understandable, they are retrospective diagnoses, but it is good to remember that this number is at best a guess.  It does not include the first dozen (?20 ?30) cases from the Kikyo area, before a real epidemic had been recognized.  On the other hand it probably includes a number of non-Ebola cases that have similar non-specific symptoms.)
• Deaths:  26.  There were two more in Bundibugyo, and one in Kikyo.  One of the Bundi deaths was a lady who had been admitted on a general female ward and then developed a rash . . .the rash is usually a late sign and this lady died soon after transfer to the isolation ward.  It points out again the difficulty in distinguishing cases because of the different not-so-hemorrhagic nature of this strain.
• Hospital Census:  19 Bundibugyo (2 died, 1 was discharged, no new ones . . . 3 of the patients are critical).  Kikyo 14 (1 died, 2 new, 3 were discharged, including 1 health worker, also have 3 critical cases.)
• Health Care Workers:  16 nurses are now in play, only about 4 from Bundi working on the isolation ward but a good number from MSF in other parts of Uganda or Europe.  We’ve met two young female doctors (Belgian and Nordic).  The MSF team is now huge with their WatSan (water and sanitation), logistic, anthropologic experts, etc.  We met the airplane today with the CDC health communications man, whom we then hooked up with Hannington Bahemuka as a good source of cultural information and language appropriateness.
• Contacts: 340.  Today 158 received check-in visits from mobile teams (46%).
• Lab: was supposed to do a practice run with non-Ebola blood today to ascertain safety precautions were intact, first run of potential Ebola samples tomorrow.  We’re all on the edge of our seats for this news.
• Fear:  definitely there.  It is hard to really overestimate the impact Jonah’s death has had on the public perception of the epidemic.  He was such a loved and public figure, his death has very much intensified the feeling of vulnerability that people carry.  Sadly the families of patients who have died, especially Jonah’s and Joshua Kule’s, have experienced isolation, neighbors running away from them, merchants refusing to accept/touch the money they are offering to buy food.  Even we have heard that people are afraid of us, and avoiding us.
  

Pray for the churches tomorrow to bring messages of hope, consolation, and be channels of information that will help people cope with the stress of this disease.  Pray for us to know if we should shift from supporting medical care to mobilizing public health efforts in the community.

I visited Melen today, actually walked half of the way there and back because Scott is so busy with other efforts . . . I found her sitting on the floor of the house with Jonah’s mother and sister, all looking drained and blank.  As before, and as with Job’s friends, it seemed the best thing to do was just to silently sit.  Eventually I tried to get Melen to talk a bit, but she was unable, saying her thoughts were “disorganized”.  I assured her that was OK, and that we were making every effort to provide for the children, so that at least that worry would not weigh upon her.  I was thankful to see that Jonah’s mother was well.  What a strong woman, to have buried now 3 of her 9 children and her husband, to have been exposed to Ebola but so far not succumbing . . The girls are distracting themselves with the books I brought, and there were a handful of relatives around the house, though still nowhere near the number of consoling visitors one would otherwise expect.  The district has sent food, and they seemed to be provided for, just overwhelmed with grief.

The most surreal moment of the day was a visit from a very kind and sincere American endocrinologist researcher, whom we met a few months ago in conjunction with his study of iodine deficiency in the Rwenzori region.  He decided to drive 10 hours from the southwest tip of Uganda where he is now working, just to check with his own eyes that Scott was OK and Dr. Sessanga was really recovering, and bring them both thoughtful and costly gifts.  That kind of generous concern from someone we have known only briefly humbles us, just like the many kind comments and sincere prayers from people around the world.

On Lament

In the midst of chaos I am longing for a small spot of order . . . So have taken to organizing bookshelves whenever I have a couple of hours at home (I’m sure there are decent and deep psychiatric reasons, but it is a pretty useful coping mechanism, and probably a good sign to have the energy to begin to do so).  Hardly anyone dares to come to our house anymore.  As contacts we are supposed to practice “social distancing” . . . A bizarre and unexpected opportunity to pull hundreds of books and years of dust and pen caps and random scraps of paper and broken flash lights and all the other detritus of life that accumulates on any horizontal surface from the bookshelves (we have many).  In the process this morning I came across a book by Michael Card called “A Sacred Sorrow:  Reaching out to God in the Lost Language of Lament.”  Ruth Ann Batstone gave it to me a few months ago but I had not opened it yet.  He opens the first chapter:  “Before there were drops of rain, human tears fell in the garden, and that was when lament began.”  His premise is that the Bible is full of the songs of complaint, frustration, sorrow, even anger; because the path to God is a “tearful trail.”

When I step back from the science, the advocacy, the planning, the medicine . . . I am left with the hollow-hearted shock that Jonah has died, and that more will follow.  And I am not here to justify or explain that, rather to acknowledge and experience it.  So I want to copy here a paragraph from this book’s forward by Eugene Peterson:
    It is also necessary as a witness, a Jesus-witness to the men and women who are trying to live a life that avoids suffering at all costs, including the cost of their own souls.  For at least one reason why people are uncomfortable with tears and the sight of suffering is that it is a blasphemous assault on their precariously maintained  . . spirituality of the pursuit of happiness.  They want to avoid evidence that things are not right with the world as it is—without Jesus (and Job, David, and Jeremiah), without love, without faith, without sacrifice.  It is a lot easier to keep the American faith if they don’t have to look into the face of suffering, if they don’t have to listen to our laments, if they don’t have to deal with our tears.  
    So learning the language of lament is not only necessary to restore Christian dignity to suffering and repentance and death, it is necessary to provide a Christian witness to a world that has no language for and is therefore oblivious to the glories of wilderness and cross.

I hope that many have the grace to weep and pray with Bundibugyo, and so discover the wilderness where God’s presence flames.

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.