Governance

     Many things are familiar when you are in a foreign county, even one as poor as Liberia.  People are friendly, they (generally) follow the rules of the road, restaurants can serve good food (at least in Monrovia).  These are things that you see which look pretty normal, but there are always structures, beliefs and asumptions that underlie what can see.  In the US, we pretty much know what to expect  of the underlying  assumptions when we see something, but that is something that you can't assume in the develping world.  Take for instance governance relationships.  

     Liberia is a country only a dozen years removed from a decade plus of civil war.  The warlords called the shots and had their ways of establishing relationships.  These were usually patronage systems of mutual obligation (you provide me with resources and I'll provide you protection etc).  Something also to remember is that as a warlord, you don't get your power because you have 'soldiers' and guns.  Causation often was the other way around.  You get 'soldiers' and guns because you have power.  The power base came first through money, tribal position, personal charisma and things like that.  The warlord then deploys that power (with or without guns and 'soldiers') to further his position or pay back obligations that he incurred.  This dynamic persists even after the end of the civil war.

     The civil war ended due to external pressure and the collapse of the country's economy.  No side really won or lost.  The leaders of the factions (except Charles Taylor) still wheedled power, just not through military means.  The elites came to the conclusion that they were better served by competing using other methods besides warfare.  Thus the frequent 'ballots not bullets' signs scattered throughout the country.  You still find warlords in key government positions, the same family power brokers are in place in Monrovia and you sometimes need to work with the warlords even during times of Ebola.  

     This can be a bit tricky as the relationships that they are used to are very much person centric and not rule centric.  That places us in interesting positions when we are and have to respond to rule centered structures.  A warlord may request financial 'consideration' and expect you to provide it because that is how people do business in Liberia.  If you don't provide 'consideration' (and we didn't) then you must be their enemy.  It also flows from a (Liberian) perception of zero sum games where if you aren't for someone, you must be against them.  This would leave us in the middle of a conflict between our morals standards, USAID rules and the need for cooperation from Liberians in positions of authority.  It gets even trickier with things like consulting fees, equipment distribution and inflated costs for resonable expendatures.  We didn't buy influence, but I can see how easy it is for some organizations to go down that path.

     Well, we have managed to provide our services and to take care of people despite these challenges.  These phenomina aren't unique to Liberia, they were just exacerbated and magnified by the recent civil wars.  From all the reports, things are getting better.  But it was still a learning experience for me.  

Germany

     This is a funny title for a blog from Liberia, but that is where I am.  I flew out of Monrovia last night and arrived at my brother's appartment in Berlin late this morning.  I left Tappita one week before that to work on a grant request for Heart to Heart.  There was a lot of work to do with a very short deadline.   After a lot of progress, we decided that we didn't have enough time to finish that part of the grant request so we concentrated on another funding line that was listed in the funding oportunity.  Once we called off my line, it was too close to my departure to go back to Tappita, so I flew directly out of Monrovia.

     Monrovia is a lot different than Tappita.  It is definately deep in the developing world but it also has lots of expats and non governmental organizations.  That lead the local economy to adapt and a bunch of resturants and hotels arose to meet the demand.  While there isn't much that would get an epicure excited, there is some variety and it is safe.  The hotel where I stayed was clean, had doorways that I didn't have to duck through and had toilets that flushed.  It may seem that my standards for hotels  aren't high, but it is so much better than we had in Tappita.  I was more isolated in Monrovia.  Yes, Julie or Brian was there, but not the people that I spent 5 months working with.  In Monrovia, much of the time was spent locked in my hotel room, away from distractions, writing or researching the grant request.  It felt a little like a golden prison.  But, it got the job done.  

     It will be interesting to see Berlin.  I haven't done anything here yet but take the subway with my brother's wife and put my bags down in their apartment.  We'll go out this evening when my brother finishes his classes.  Despite living in (West) Germany for over 4 years, I never visited Berlin.  I will spend a week here before flying to Dublin to meet Jo, Jan and Ric.  I still don't know how I will react emotionally.  I don't feel anything weird now but I did spend 5 months in a pretty weird place.  I remember when I flew out of Iraq in 2004.  The first place we landed was in Germany and I remember the contrast as pretty jarring.  We will see.

     There were so many other really odd things about Liberia.  With a little more free time now, I will continue to write and post.  Thanks for following along with me on this and keep all those in West Africa in prayer.     

Random Thoughts

     A few random thoughts from Liberia.  Tomorrow marks the 42nd day (as reckoned by the government of Liberia) since Ebola has been reported in Liberia.  The significance of this timeframe is that it is twice the maximum incubation period of Ebola Virus Disease. This is quite a landmark and marks an official definition of the absence of Ebola from Liberia.  It doesn't mean that the threat of Ebola is gone.  The virus persists in immune privileged tissues of the body in survivors for a prolonged period of time.  The last case of Ebola in Liberia resulted from sexual contact with a survivor whose semen contained virus 100 days after the virus had been cleared from his blood stream.  Indeed, an article in the New York Times reported the persistence of live virus inside of the eye of a US survivor, although in this case, he is not thought to be contagious.  There is also the risk of imported disease from Guinea or Sierra Leone but those countries seem to be getting the epidemic under much better control.  Of course, there is the risk from the natural reservoirs of the virus in the form of infected monkey and fruit bat meat.  That is what started the epidemic in the first place.  However, the procedures for recognizing and treating Ebola in Liberia are so much better than they were one year year ago.

     As we prepare to decommission the Ebola Treatment Unit, we work a lot with local medical providers and public health personnel.  It is a challenge to effect a seamless transition from a high tech solution like an ETU to a less revenue intense system.  You have to factor in how you are constrained by your contract, the preparations of the local health care system and pending (but not yet in place) facilities.  

     Liberia will retain several ETU's but the large majority will be decommissioned or repurposed.  We will close our ETU and it is a lot of work.  You have to decontaminate the equipment supplies, equipment and the structures at the site.  You have to figure out what to do with the supplies and equipment within the constraints of USAID and the Liberian Ministry of Health.  Factor in community engagement, local concerns about the loss of the economic stimulus that we provided and negotiating about a post Ebola role, it can get your head spinning trying to get it all straight.  So much is still undefined or awaiting other people's decisions that it becomes an exercise in patience (and sometimes frustration).  But we will get there.  I am reminded again of Henny Youngman's line that some people stay longer when they are leaving than they do when they are there.  I think it fits.

Nepal

     Today we began receiving reports about a devastating earthquake in Nepal.  It was very strong, 7.9 on the Richter scale and located in the vicinity of their capitol city.  I was immediately brought back a little over five years to when I went with Heart to Heart's initial medical team to Haitian earthquake.  The similarities are striking.  Both countries are poorly developed with an inadequate health care system.  In both countries the earthquake occurred by the capitol where the centralized apparatus of state resided.  Both earthquakes were massive.  I am scared.

     In Haiti, the initial, fragmentary reports hinted at something awful without giving concrete evidence of what really happened.  When Heart to Heart arrived in Haiti, we saw the full manifestation of the power of the earthquake.  We saw the widespread destruction and the massive loss of life.  We saw a society torn asunder.  We are seeing the same situation developing in Nepal.  I pray that I am wrong but I fear for the worst.  

     Pictures can show a terrible scene, but they don't come close to conveying the horror of the situation.  They don't convey the choking dust, the distraught faces or the smell of death.  They don't convey the cries of the children who are alone, the sobs of those who have lost their loved ones or the blank faces of those who have seen too much.  I can't go at this time since we are still in standby for Ebola and we close the ETU in two weeks.  However, Heart to Heart is assembling a team to go to Nepal.  Please support Heart to Heart as the team prepares to depart to help the Nepalese.  And keep the people of Nepal in prayer.

Closing the ETU

     At midnight, 15 April 2015, the Heart to Heart Ebola Treatment Unit in Tappita, Liberia was closed to new patients.  Over the last several months, the number of Ebola cases in Liberia has been falling.  As of today, Liberia is over 3 weeks free of Ebola.  There isn't a need for the many ETU's that are here although some will be maintained for cases that might enter the country from Guinea or Sierra Leone or that come from natural reservoirs.  Also, male Ebola survivors can harbor active virus in their semen for up to 6 months and maybe beyond.  The last Liberian case is thought to have come from unprotected sexual contact.  However, the large number of ETUs are unnecessary at this time and our ETU is included in that number.  We have been in standby status since the 15th and our last day in standby is 8 May.  

     After that, we will be decommissioning the ETU, decontaminating the area, disposing of equipment and supplies in accordance with USAID and Liberian Ministry of Health rules.  This will need to be completed by 31 May which is the end of our contract with USAID.  Wow, there is a lot of stuff here we need to distribute in three weeks.  Some of it is pretty straight forward, medical supplies are distributed according to need as agreed to by HHI and the county Health Officer.  Others are ones I wouldn't have suspected.  There is enough plywood and timber in the structure and shelving in our warehouse for two small houses.  People have approached us about selling the crushed rock with has significant value.  Even the PVC piping buried under the gravel has value here.  Then we have to factor in possible ongoing projects and we are left with a lot of moving parts.  There is so much to do that I am reminded of an old Henny Youngman line about people at a party 'they stay longer when they are leaving than they do when they are here'.  

     There are a lot of emotions about leaving.  A lot of them revolve around people.  Anticipation of seeing loved ones when we go home.  Sadness at leaving behind Liberian friends and watching expat friends depart.  I guess I will write more about those feelings later when I have processed everything.  I just know that we have been a small part in a noble effort to save lives for people in need.  And I thank God for the opportunity.

Road Warriors

I got in the vehicle with the new driver for the trip to the Sanniquellie County Health Partner's meeting.  The vehicle was an old one.  It registered 164,000 miles on the odometer, but looked like the speedometer cable had been disconnected a good portion of it's existence.  I thought it a little odd that the vehicle keep rolling a little down the hill whenever the driver concentrated on something else.  We picked up our Community Relations officer and two nurses who wanted to go to Ganta for the day and took off.  I tried to buckle up my seat belt but found that the belt had been cut off at the floor board.  The vehicle rattled and creaked and I noticed that the driver had to pump the brakes 2 or 3 times every time wanted to slow down.  That made me worry more and I realized the the vehicle was also too old to have airbags.  Well, I thought, this will be an adventure.  

     I kept flashing back to a talk I had heard a number of years ago that addressed motor vehicle accidents in sub-Saharan Africa.  If you analyzed MVAs like a disease, it would be the third greatest killer in Africa, behind malaria and diarrhea.  I also remembered an article that noted that the single greatest killer of missionaries in the developing world was the motor vehicle accident.  Well this will be interesting.

     There are a number of reasons why MVAs are such a problem over here.  One is the poor condition of the roads with the ruts, potholes, absence of shoulders and mud with occasional exposed areas of eroded pavement.  The stretch we were to cover was noted to be one of the worst in Liberia.  A second reason was the usual poor condition of the vehicles.  Our vehicle was no where near the worst on the road but it was much worse that we normally have.  A third reason were the crazy drivers.  Yep we got that one today in spades.  To be fair, drivers have a lot to put up with.  They have to negotiate the road, the people who use the roads to walk and other crazy drivers.  They have to comply with the informal 'rules' of the road.  Basically, they follow the old navy rule of right of way by gross tonnage.  If you are driving a car and you approach a motorcycle, the motorcycle has to get out of the way.  If you approach a truck, you have to get out of the way.  If you approach another car, you need to figure out who is chicken.  As a driver, you have to factor in non vehicular traffic on the road.  Adult pedestrians are pretty good about getting out of the way, older kids are too.  For that reason, the driver doesn't take any extra precautions knowing that the pedestrians will move.  They are a little more cautious around little kids, but not if there is someone older with them.  The driver will almost universally slow down for the sheep, pigs and goats that commonly occupy the road.  Chickens don't get as much respect.  I don't know what all this says about their priorities.  

     Back to our trip, our driver likes to drive very fast.  He will slow down for a few miles when you tell him to slow down, but then the speed creeps back up.  My arms ached from holding on to the interior handles and the poor folk in the back of the vehicle come out once we arrive in Ganta looking pretty green.  We spend the night in Ganta and took off the next day for the early morning meeting in Sanniquellie.  We survived that and then headed back to Tappita, again setting what for me is a speed record.  Two hours over a distance that usually takes three to 3 & 1/2 hours.     

     I did have the head of our transportation section get our vehicle into maintenance. I mentioned the driver to him as well, but nothing much will happen.  He isn't that much worse than the others.  Next time, though, I will make sure that I ride in a vehicle with seat belts.

Magic

     Magic is an interesting concept here.  That which is unexplained is often explained by magic.  Several times, there have been multiple deaths occurring in a village and the explanation from the inhabitants is magic.  We initially think Ebola or at least that we need to rule out ebola.  Often in resistant villages, they don't need any additional explanation.  It is magic and they don't even want to test for Ebola for fear of the repercussions.  This obviously is a potential problem.

     The belief in magic doesn't have to be due to ignorance.  It is part of the belief system here.  It doesn't matter that one is a Christian or if they are Muslim, they can still believe in magic.  In Senegal, I was offered a 'gigli' stick by a Muslim Senegalese physician.  He told me that it would make bullets veer away from me and make knives break when they were used to try and cut my skin.  While it would have been handy to have had, I declined.  It is also common in Haiti where it is said the the country is 90% Catholic, 10% Protestant and 100% voodoo.  Another physician was treating a native coworker for malaria.  He prescribed the medication but later in the day he say the coworker entering the hut of a native healer.  When the physician asked the coworker why he went to the native healer, the coworker replied:  'I went to you to be treated for malaria, I went to the healer to find out why I got malaria.  It is not always so straight forward.  I have seen gashes on the arms of children with fractured arms to release the evil spirits from the injury.  While many traditional healers do recognize their limits, many do not.

      One of our security guards was injured in an off the job moto accident suffering multiple fractures to his left leg and a basilar skull fracture.  We had offered his family some help to get him to Monrovia for treatment but instead his family was wanted to see how he would do with a native healer's potions.  One of our Liberian nursing assistants was helping the family.  When we asked the nursing assistant whether she tried to dissuade the family from taking their son to the healer, she wouldn't answer.  We suspect it is because she, at least at some level, supported that decision.  We all pray that it turns out well.  

More Animals

     I haven't written much about animals so I thought that today it would be appropriate to write on the most common type of animal that we find here, bugs.  It is flying ant (termite) season.  After a certain amount of rain, something triggers the migration of the termites and out they come.  They look like large ants but they sprout wings and emerge all together in large swarms.  They will head to the lights like many flying insects and you can see them swarming in the halo of the overhead lights.  You can see them collect in the .5% chlorine step buckets that we use to disinfect our boots.  There were so many there this morning that you had to depress the mass of them to get your boot soles wet.  Then they shed there wings which also litter the walking paths. In some areas, there are so many that you can't avoid stepping on a few as you walk.  Then, in another day or two they are gone, back underground.

     There are a lot of other notable insects as well.  Certainly there are a lot of mosquitos but not as many as I had feared.  This may change when during rainy season when water starts pooling everywhere.  Another insect that is prominent is the rhinoceros beetle.  This critter can be almost 2 inches long and an inch thick.  It does have a  large horn similar to a rhinosorus.  It doesn't bother anyone, but it does occasionally freak out one of the expat nurses.  Then there is the Nairobi bug.  It is a brightly colored half inch long bug that doesn't seem particularly impressive.  However, you do need to be careful of insects that don't need to camouflage themselves.   This one secretes, basically oozes, a toxin that causes a nice burn on the skin.  You don't even need to hit it, even brushing it off can get enough of the toxin on you to cause a nasty burn.  There have been several of the expat staff who have had a bad encounter with the Nairobi bug.

     Of course there are many other insects, spiders etc located here.  Some are familiar like ants, house flys etc.  Some are big and juicy but don't cause any problem except cleaning your boots when you accidentally step on them.  Also, these insect support a great many insectivores, but there always seems to be many more insects than there are of whatever might catch them.  I guess I could do with a few less of the bugs.  I'm rooting for the insectivores, except when they are in my room.

What we eat

     Liberian food is just different from ours.  I am not saying that it is worse, literally a matter of taste.  But it is different.  Our first cook in Tappita was a little more in tune with US tastes.  We certainly had a lot of Liberian food, but she would mix in meals with fried eggs and a type of chipate pancake, there was some degree of familiarity.  And once she learned to add sugar to the cinnamon rolls, you had something to look forward to.  Our new head cook hasn't learned these peculiarities yet.  Now breakfast is almost always a cream of wheat type porridge, occasionally with hard boiled eggs.  Cold cereal is usually available.  Once or twice a week we get a donut looking piece of fried bread dough which is a nice break.

     The staples of Liberian diet are chicken, fish, beans and rice.  We would have multiple variations on these possible combinations, usually with a lot of hot spices.  In the US, I will normally eat my meals a good bit more quickly than the others with whom I share the meal.  Here, I can't eat too quickly because my mouth would burn up.  It does help with conversation around the table, but even then it can take 15 minutes for my mouth to feel normal after a meal.  

     Spaghetti noodles have become popular and in Haiti were even a regular part of the breakfast meal.  Here they usually come with lunch or dinner.  You will notice that I didn't mention anything about vegetables.  The main one is a dark green leafy vegetable, often called Lagos spinach which is mixed with the stewed chicken or fish.  There is one type of food that both the Expat and Liberian staff enjoy;  french fries and barbecue chicken (not KC BBQ, but the chicken does taste better than it is prepared at other times (still really spicy)).  Sometimes, I think to satisfy the expats, there will be sliced cucumbers and in half the meals we do get fruit.  Usually it is pineapple and you hear no complaints from anyone about this.  The pineapple here is fresh off the tree and amazingly sweet.  I usually save it for dessert (which is a tradition that seems to be absent in this part of Liberia).  

     So, enough of my first world (barely concealed) complaints.  When we drive through the villages, there are still a lot of children with the pale brown hair and boney arms of chronic malnutrition.  You can also see the stunted adults and the drawn faces of the chronically hungry.  I am indeed thankful for the food I receive, but I do look forward to a nice piece of prime rib with a twice baked potato at Hereford House.  

Ceremonies

Sorry for the delay in posting.  We have started our sixth day without internet.  I am borrowing a sim card to let my iPad connect.

     Our daughter Sarah just announced her engagement to Joe.  It was difficult to perform some of the traditional engagement rituals with me over here.  However, it got me thinking about how engagement is done elsewhere.  I have observed a wedding ceremony in Uganda that included the giving away of the bride, exchange of gifts etc and it was really interesting. Our ETU is a pretty multinational group here and I started asking about how engagement is done in the different countries.  

     In a Liberian engagement, there is a ceremony where the groom to be approaches the parents (usually the father) of the bride with his father or someone else in authority (often a tribal chief).  The groom to be then asks the father for permission to marry the daughter and a dowry is exchanged.  It is a token dowry here, usually cola nuts or a ten cent piece.  That exchange of dowry also constitutes a legal obligation.  If the groom dies after the dowry is exchanged, then the care of the bride to be is the obligation of the groom to be's family.  After acceptance of the dowry, there is an exchange of gifts between the parents, usually involving a good wine that is consumed in the following celebration.  In the Congo, the minister has a huge role.  One of our physicians is from the Congo and was married just before coming to Liberia.  It is traditional in the Congo for the groom to be to approach his minister who questions him on his preparation for marriage.  If the minister is satisfied, he (almost always a he) goes with the groom to be to the bride to be's parents with the groom to be and there the groom to be asks the father of the bride for permission to marry.  A dowry is exchanged, usually symbolic but occasionally more substantive and then a large party ensues.  In the Congo, the minister will accompany the couple to the courthouse so that they can be legally married (usually to make sure that they are both at least 18 years old) before the ceremony of marriage.  In Nepal, there isn't as much ceremony, just the families getting together for a large party after the groom on his own, asks the parents (both) for permission to marry their daughter.  In the Philippines, it is much more westernized and the couples will announce their intent to marry to both sets of parents and a large joint party ensues.  Elopement is common.

     It looks like we won't get to observe an exchange of dowry with Sarah and Joe.  However, a good bottle of wine and a party sounds like a part of the tradition that we can do.  Congratulations Sarah and Joe!

Our fishbowl

    Sometimes it is hard to write the blog when nothing happens.  Sometimes it is hard when there is a lot happening.  I am afraid that both have applied over the last week.  Personnel issues are never fun and I have jokingly said that my job position title should be changed from Chief Medical Officer to Chief Personnel Issues Officer.  

     There was a good article in the New York Times recently on aid worker stress.  Thankfully, our stress here has revolved more around being ready and not having enough to do.  But that is also quite significant in it's own way.

     The expats here live in a strange social environment.  We are cut off from most of the social supports that we have at home.  Yes we have email, yes we have the US news, at least by internet.  But we don't have the interpersonal contacts from which we draw our comfort and reassurance.  Not in the same way that we have them at home.  We can develop some of those over here, but it usually is not the same.  Some people just don't do as well when isolated, especially when they aren't busy all the time.  These limited social interactions can also reduce the social inhibitions on behavior.  People can do things that they normally wouldn't.  That can make things interesting from a management point of view.  

     Once it is over, you look back and say, 'wow, that was crazy'.  But if I think that things get weird inside our fishbowl, it is important for me to remember that I am in that same fishbowl like everyone else.  You just have to be careful.

Working together

One of the things that you notice in Liberia is the wide variety of organizations and nationalities that are represented.  There is a literal alphabet soup of acronyms on people's ID badges and shirts.  Many are the usual culprits like WHO (World Health Organization), UNMIL (UN Military Liaison), USAID (United States Agency for International Development) etc and, of course, the many NGO (Non Governmental Organizations) such as Direct Relief, MSF (Medisin San Frontier -  Doctors without Borders), and IMC (International Medical Corps).  Heart to Heart is also an abbreviation, usually listed on rosters as HHI.  However, many people still have their national uniforms even when they are working for other organizations.  There is a UN police presence in Tappita that includes police from Jordan, Nigeria and Zimbabwe, all wearing their national uniforms.  Many Other African countries are represented with people from Zambia, Congo, Kenya and Uganda.  Conversations between the different nationalities is usually conducted in accented English.  Some countries are over represented on the military side such as Bangladesh and Sri Lanka, the governments of which earn significant money renting out their soldiers to the UN.  There are some combinations that make you wonder.  While waiting on a UN flight back to Tappita, one organization loaded ahead of us onto a different aircraft.  Two of the members wore their countries military uniforms, Russia and the Ukraine.  I wonder how that works with them having to work together.  Although, maybe that is what is what they have needed, working  together to help someone else in need.   Hopefully a little good can come, one way or another, from this epidemic.  

Rustling up some grub

     Some of the more interesting things that you see in the developing world are on the side of the road.  In the US, we drive along and don't really see what is on the side of the road unless it is something pretty unusual.  If there is an accident, a particularly garish sign or something that effects the flow of our traffic, we might pick it out.  But usually, we drive right past whatever is on the side of the road without giving it a second thought.  However, it can be different in the developing world, especially on your first or second trip to the developing world.

     Here, everything that you see is different from what you would expect in the US.  The buildings, often right on the road, are of an entirely different style.  Security is usually at a premium and there may be many abandoned or poorly repaired buildings.  The people will be carrying unusual loads, often on their heads.  You will pass wildly overloaded vehicles, often with people hanging on to the cargo area.  Yesterday, I even saw a small group of goats, tied up in sacks with their heads sticking out on the roof of a car, bleating as the car drove down the road.  Probably on the way to the market or dinner.

     In the cities, there are many areas of slow traffic and these usually turn into the developing world equivalent of a convienience market.  Anything that someone might need can usually be purchased while you wait at a traffic slowdown.  Recharge cards for your phone, cold drinks, grooming articles and street food are some of the more common items for sale.  The food can be interesting from a developing world perspective.  You can buy raw sugar cane cut up into foot long sticks that you can suck on and chew for the sugar.  There are various baked breads, fruits and meat pastries.  Yesterday we were approached by a person with bags of succulent grubs suspended in a clear liquid.  When I asked about them, I was told that they were harvested from the bark of palm trees and the liquid is some sort of sauce.  Usually they are served fried.  I know insects can be part of the diet in Uganda and I have had fried grasshoppers there.  However today, I didn't feel up to trying these grubs.  Maybe next time, or maybe not. 

Where the wild ones are

I receved a request to discuss what animals that we find in the jungles of Tappita.  I will take you on a photographic tour.  Many of the animals that you can find near the hospital are ones that you might guess.  

There are lions.

 

and elephants, 

and tigers.

We even have panda bears

and dalmations!

These are just some of the offerings at a whimsical 'petting zoo' that was created by a refugee two years ago.  He was a regionally famous artist and he was allowed to remain on the hospital grounds.  To show his gratitude, he created these sculptures for the children.  They are made of a heavily plastered paper mache and are really fun.  I am surprised that they have lasted so long given the conditions.  But there is a 'park ranger' who helps maintain the area and protect the statues.  It really demonstrates that the animals that we think of as 'African' are mostly confined to game reserves in an attempt to stop the poaching.  There really aren't that many exotic animals that we have run into around the hospital, that is except the green mambas.  That is another story.

The countryside

     When you spend most of your time in the ETU, the neighboring hospital and the housing, you can forget what the rest of the countryside looks like.  Of course you see what is along side of the road when you go to meetings.  But those are areas that have been influenced by the presence of the road.  These roads are conduits of the vehicles, pedestrian traffic and commerce of the region.  Farther away from the roads, you find a more baseline culture.  Small villages of maybe 100 people that often have only footpaths connecting them to anyplace else.  The consist of a group of small buildings of clay with either corrugated metal or thatch roofs.  Often, the livestock is kept in the compounds.  That is how the majority of the 750,000 people of Nimba county live.

     And the countryside is jungle.  Maybe not jungle is the way that we learned when we were children, but jungle nonetheless.  Certainly there are many clearings, both man made and natural, but the large majority of the land is green and densely vegetated.  Some of the land, but not as much as I was used to in Haiti where every potentially arable piece of land, was cultivated.  The land is held in common by the villages.  If you want to farm some land, you can get permission from the village leadership to farm there.  You can keep the crops but there is an expectation that the food is to be shared.  Since the land is held in common, that only makes sense.  Even if you have worked the land for years, you are still not the owner.  The land belongs to the village.  However, working the land helps you to maintain your claim for usage.  

     The countryside is a lush green wherever you look.  From the top of the hill where we sleep, the land is covered with large leafed trees and shrubs.  There is almost always a haze or fog that covers the low lying land which is much denser in the morning.  Sometimes there is so much haze that the helicopters can't  fly.  There must be a meteorologic factor involved, but there is also a lot of moisture coming up from the foliage which contributes.  I am not sure how much this haze varies throughout the year, but it has certainly been a constant the last two months.  I guess that I will have a few more months to find out.

Waiting for rain

     One of the things that we worry about in Tappita is the weather.  The temperature doesn't vary much, it is hot and muggy year round.  The main variable is the rain.  Rainy season usually arrives in late March or early April.  It has all the usual hassles of getting wet wherever you walk, the mud and the increase in mosquitos.   Those problems may seem obvious but the rainy season has one important additional consideration, the roads.  The road from Monrovia has a 3+ hour stretch from Ganta to Tappita that is not paved and is often impassible during significant parts of the rainy season.  Since the large majority of our supplies come in from Monrovia or Ganta, that can be a problem.  

     This year, the signs point to an early rainy season, possibly starting by the end of February.  That changes a lot of our plans.  It means that we need to push our district health survey forward so that it can be completed before the rains come.  It also means that we need to modify our cooking area to provide more drainage and cover.  Using some long ago learned civil engineering, we have submitted to our logistic support organization a plan to run a diverting drainage ditch to run the water coming down the hill away from the flat ETU area.  In the one big rainstorm that we had since I have been here, the ground water flooded back into the ETU latrines and caused to overflow.  We also need to increase our stockage levels of food, fuel and potable water to be able to withstand stretches of time when the roads are impassible.  Just a few more things to do that should pay dividends when the rains do come.

     Sometimes, though, the rain seems farther away.   Usually the sky is either hazy or overcast.  It looks just grey or dark and almost muddy.  Last night though, the sky was unusually clear.  The stars were just popping out from a deep navy blue sky.  They seemed both infinitely far away and close enough to touch.  They looked a little unfamiliar from my vantage point near the equator, usually recognizable but with a twist.  I just stood there a while and watched them.  The stars were gone this morning when I went out to jog but the sky was still clear.  It will probably mean that we will have a scorcher today, but maybe worth it with the beautiful sky last night.  I will continue to enjoy those nights until the rains do come.

R&R

     I need to apologize for the lapse in posting.  I have been pretty busy since getting back from R&R but that was expected.  I guess, though, that I should explain R&R.  When you work 7 days a week in this environment, it is important to take occasional breaks to be able to maintain focus and emotional energy.  Sometimes the stress is from the work, sometimes it is from the waiting.  But it is there.  Burn out is a significant risk here and it can be hard to replace trained people.  For that reason, USAID built into the contract respite breaks every 6-8 weeks.  It improves the sustainability of the effort and helps keep good people.  

     R&R gives people something to look forward to.  People plan what they are going to do and where they will go for their next break.  Sometimes people want to go someplace warm (we are pretty acclimatized to the heat and Europe can be cold this time of year).  Sometimes they want to get away from the heat and Europe at this time of the year is a draw.  Europe does have the advantage that they don't care if you have been in an Ebola zone as long as you are not sick and don't have a fever.  Some people just stay in Monrovia at a hotel where they can just relax and get away from the ETU.   Wherever you choose to go, it can give you a chance to control your own schedule.

     R&R also gives you an appreciation of the passage of time in an environment where each day can look like the next.  In a place where the day of the week, indeed the month, doesn't effect your activities, you can loose a sense of the passage of time.  You may not appreciate how long you have been the or it may feel like the end of your tenure is forever in the future.  The R&R gives you a marker for past and future.  

     All that said, Brussels was great!  Jo flew out to join me and we had a wonderful time in a city with a lot to recommend it.  I don't know what I will do for my next R&R, but I will start planning for it in the not too distant future.

Brussels?

It has been a couple of days since I have blogged.  The reason is that I am on a respite break from the ETU.  These are scheduled every 6 weeks or so and are standard among organizations the run ETUs.  Most of us take the break in Europe.  Two reasons, one is that you only have a limited amount of time and two, the European Union doesn't care about a person's Ebola exposure as long as they have had no known exposure and aren't having symptoms.  Some people, though, have gone to Tunisia which is desperate enough for tourist dollars that they don't mind potential Ebola exposure.  A few have stayed in Liberia where you can stay at a local resort and not lose the travel time at either end of the trip.  The important thing is that no matter where you go, you get away from the ETU and relax.

    I chose to go to Brussels.  One of the main reasons was that neither Jo nor I had had been to Brussels before.  A second was that all of our flights (all of two per week out of Monrovia) are routed through Brussels.  One of the nice things was that Jo was able to join me in Brussels.  It has been six weeks since we had seen each other and it was good to talk to her and to relax.  I must admit that I didn't travel over to Liberia with any thought of cold weather and I brought no cold weather clothes.  I have also lost a bit of weight while in Liberia and that didn't make the cold weather any easier to handle.  Jo was my angel and brought me my coat, hat, gloves and some long underwear so things have been manageable.  Since arriving, we have have relaxed and have done the usual tourist things and it has been a wonderful time.  I can't say that Brussels has totally taken me away from Liberia, I do have email.  But it has been quite relaxing.

     I will fly back to Liberia (and Jo to the U.S.) on Friday.  It will have been a good break, but there is more to do back in Liberia.  Much of it involving what needs to be done in running an ETU and mundane.  But we have to be prepared because the number of cases of Ebola have increased in Liberia for the second week in a row. 

Human behavior

     At the weekly Partners meeting in Monrovia this week, the CDC reported that Ebola cases had started increasing again in Liberia.  They also started increasing again in Sierra Leone and Guinea for the first time in a month and a half.   The reason is not yet known (or at least not reported to us) for the resurgence.  It could be a little statistical 'noise' which is the scattering nature of data as it occurs in the world.  It could be due to the Ebola deniers.  However, there are no more deniers now than there were 3 weeks ago.  This leaves us with the most likely answer, human behavior.  

     People here want to live what for them are normal lives.  They really don't want to worry about Ebola.  They have had enough of that.  They want to be able to hug friends, take care of sick family and go to parties to dance.  All of that was suspended when Ebola struck and it was a hard lesson.  If there was Ebola in your neighborhood and you ignored the rules, you stood a fair chance of contracting Ebola and dieing.  Losing friends and family changed a lot of behavior.  But it didn't change the desire for a normal life.  

     As the epidemic waned, people started relaxing.  They congregated with friends for New Years Parties and they could again be seen hugging and shaking hands.  Schools were scheduled to be reopened.  In that setting, Ebola can spread, if it is present and unfortunately it is present.  Hopefully, spike in cases is a little bit of statistical noise or just a minor letdown in protective behavior that can be rapidly corrected.  It is hard to say right now because the spike in cases is so new.  I guess we will just wait another week or two to see what happens.

Rick

PS.  The baby whose mother had died has herself died.  No one knows why and we will never know why.  That is how it is in the developing world.  There aren't enough resources here to keep people alive, much less to find out why people die.  We will just gather all the baby things that we had purchased for her and save them for the next opportunity.

How to write a report.

     I am a little brain dead right now as I wait for my Granddaughter Charlotte's fifth birthday party which starts at 11:30 tonight.  Normally this is not a problem and I love that I can stay up for the party.  We are going to try to Skype.  Usually, the Internet can't come close to handling a video stream, but late at night is when it seems to be at its best.  Fewer users, less sun interference with the signal, maybe some space time continuum thing that brings Liberia a little closer to the U.S.  I don't know the real reason, I just learn to appreciate the mystery.  Since the Internet was spiffed up last week (to where is is merely slow and unreliable rather than positively atrocious), I felt it was worth a try.   But I am still brain dead despite my excitement and let me explain why.

     Heart to Heart International helps support it's operations in Liberia with a generous grant from USAID, Humanitarian  Response.   They do require extensive reporting on the grant and rightfully so, it is the US taxpayer money.  Reports are due quarterly.  We had reasoned that since the ETU had only been open for a month, that the quarterly report would be due after three months of operation, so we submitted a request for extension.  Somehow, that request got lost and we were notified of that the extension request had been turned down and that the report was due in two days. Never having submitted a USAID report, I started gathering what I thought was required and we developed the report.  Hoo Boy was I wrong.  So much more was required but no one here had submitted one before.  Thus began a 9 hour thrash in trying to simultaneously develop the additional data and to get the data entered into a persnickety program that was best described (with substantial understatement) as not intuitively clear.  

     Well, we made it through by 7:00 PM but I will admit to being butt sore and brain tired at the end of it.  In a way, it was fun.  It certainly is a challenge when you have to figure out something when the instructions are very little help.  And we did get it done.  But next time, we will know to start a little earlier.  And no, they didn't teach us about this in Medical School.

Tappita Fashion

     Heart to Heart's Website recently featured our ambulance section practicing operations in their Personal Protective Equipment (PPE).  PPE is a subject near and dear to everyone that works in the hot zone of an Ebola Treatment Unit (ETU).  There are very specific sequences and methods which are used to put on (or don) and take off (or doff) PPE.  These methods are taught initially in 'cold training' and reinforced in 'hot training' and shift work in ETUs.  This training is conducted by different organizations in different locations and there are often slight differences in the way it is taught.  Some organizations may teach 3 pairs of gloves, some will teach 2 pairs.  Some will place the straps of the goggles inside the first hood (of the Tyvek suit) and some will place the straps over the first hood and under the outer hood.  Some will seal the cuffs of the outer gloves to the suit with tape, others won't.  These may sound like trivial differences, but they aren't, or maybe they are.  The problem is that nobody knows for sure.  You can always add a little more 'just to be safe', but sometimes that addition may make doffing of the PPE more cumbersome increasing the chance for error.  The majority of identified healthcare worker Ebola exposures have occurred during doffing.  

     You are also much more comfortable with the method in which you were trained.  Standardization of methods helps reduce errors, but how do you accommodate differences in training when the feelings about the styles are passionate.  It isn't surprising that people are passionate when potential problems could mean yours or others survival.  Or maybe not, and you can't know for sure.

     We faced that dilemma in our ETU with two groups that trained under different systems.  Each side felt passionately about their method and there wasn't much inclination to compromise, which was a problem if we were to maintain some degree of standardization for doffing.  We eventually decided, by majority vote, for the less stringent methods, but that left many of our members, including the Liberian staff, very unhappy.  

     The next morning, a team from the CDC arrived at the ETU unannounced.  They had come to investigate reports about the village with multiple unexplained deaths.  That village was in our area so they stopped by our ETU before going to the village.  Providentially, their team included an expert in PPE!  We had a wonderful question and answer period and were able to resolve our disputes.  It felt like a pretty contrived happy ending, but that is what happened.  It was good to resolve this question before we had our next patient, who arrived the next day from the village that the CDC was investigating.  

Do what you can

     Patients are often admitted to an ETU when they are sick with something other than Ebola.  Among the general population in West Africa, a myriad of conditions can cause fever, body aches, stomach pain and headache.  However in the setting of an Ebola outbreak, those symptoms meet the criteria for a diagnosis of 'Ebola suspect'.    First, you have to rule out Ebola and then you can get the patient to somewhere where they can be more thoroughly evaluated and treated.  You just hope that they don't get worse while you are evaluating them in the ETU.  

     We had a patient admitted to the ETU after having a cesarean section in the neighboring hospital.  Initially, she had been doing well then she suddenly turned worse.  The hospital staff became concerned about a possible Ebola infection and unfortunately, she meet the case definition and we had to admit her.  We quickly tested her, found her to be negative and we returned her to the hospital.  Over the next day, she did better, but then she suddenly turned worse and died.  To make sure, we tested her again for Ebola which was again negative.  She had probably died of a pulmonary embolus, but she left a 6 day old baby girl.

     This is a problem.  The baby's father isn't married to the mother and there is no tradition of wet nursing in Liberia.  A baby's chance for survival in Tappita is somewhat compromised anyway with the poverty and disease prevalence, even with an intact family.  The situation is so much worse with a baby is so young and without support.  We have no technical obligation to help the baby.  She wasn't our patient and there was no diagnosis of Ebola.  There was even some question about what we could officially do for her.  But we couldn't just not do anything.  We passed the hat and collected enough money for formula and will continue to provide that for as long as we are here. The sister of the baby's father agreed to watch her since she has no girls.  We arraigned for multiple 'community outreach' visits to the home to weigh and check on her every week or two.  Yes, we will only be able to help for the next three or four months.  Yes, we are well aware that even this effort is Quixotic and that the child still faces long odds of making it to her first birthday.  But despite the odds, we are called to care and we are called to at least try.

What Ebola does

     Ebola has so many effects outside of the damage that it does on the human body.  It can injure people psychologically, economically and socially.  We evaluated an Ebola suspect in our ETU whose test came back negative.  We returned him to his community, but they wouldn't accept him because they were afraid that he still had Ebola.  We had told his family about his negative diagnosis and provided him with an official certificate, but his neighbors still wouldn't allow him near.  Our psychosocial team had to go to the community and work with the patient's neighbors to finally get them to accept him back into the community.  

     That fear of being quarantined by neighbors can work against measures used to control the disease.  Last night we were notified that a nearby village had had eight deaths in the last 3 weeks due to 'magic' and that two bodies were still on the ground.  We notified the Nimba County Ministry of Health and they dispatched a burial and contact tracing team the next morning.  We also sent our laboratory technician to collect tissue samples to test for Ebola.  When the team arrived in the village, the Headman told them that there were no bodies and that they had already been buried.  He further said that all the people who died were old (in their 50's and older-ouch) and that they had simply died, without any symptoms of Ebola.  Unfortunately, villagers will often lie about Ebola.  If Ebola is believed to be in a village, the surrounding villages will blockade all the inhabitants until they are convinced that the village is Ebola free.  That creates terrible hardships for a village, sometimes leaving them without access to food or even water.  I understand the village Headman's dilemma, I just hope that he was telling the truth.  In this case, eventually, time will tell.

Tappita

Tappita is a city of around 90,000 people but with a interesting way of doing things.  Here you see a typical gas station.

No this isn't unusual and yes that is gasoline in the glass jars on the shelf.  You may consider this a bit inconvenient, but where else can you get a service station that actually pumps gas?

And if you get impatient, you can always visit Starbucks, or the local equivalent which is the Tea shop in the center of this picture.

     I tried to inject a bit of levity but from the pictures, you might begin to appreciate the material destruction of infrastructure that occured through 15 years of civil war.  However, you can only begin to appreciate the loss of human infrastructure that the war has caused after talking with the people who survived the war.  That was even worse and that was before Ebola.  While the situations in the pictures look pretty primative, the people are recovering better than one might expect.  They are hopeful, bright and industrious.  They still have a very long way to go and our hope is that we can help them get at least a little farther along on that road.

An observation

     A random observation while I have decent internet and am waiting for the meeting this afternoon.

     Driving down the road, we passed a Liberian carrying a stalk of bananas over his shoulder to market.  He was of interminable age and could have been anywhere from his early 20's into his 40's.  From the route, we knew that he still had several miles to go to get to the market and we had no idea of how long he had been walking.  Bananas are a commodity, but banana trees are widespread and that stalk of bananas couldn't have too much value.  

     It makes one reflect on the monstrous inefficiencies in the developing world.  The man that we passed will have invested a whole day in carrying a heavy stalk of bananas to the market, selling it for a small amount of money (or bartering for something of similar value) and then walking home.  While this may produce enough money to meet his needs, it also results in higher prices for commodities when the only way that you can obtain them is through an inefficient manner.  Eggs in Tappita cost around $1 US per egg.  

     But what would efficiency add?  If someone set up a Walmart in Tappita, what would that do?  Immediately, people would buy their bananas from the Walmart at a much cheaper price and not buy from the man walking down the road.  People in the market would no longer have 'jobs'.  Then, how would resources be distributed so that the man earns enough money to feed his family?  The efficiency of a Walmart could mean starvation for the people on the margins.  

     I am certainly not advocating continuing the inefficiencies in the developing world. But I do think that we need to be very careful with 'top down' solutions.  Programs such as education, improved communication, improved infrastructure and access to capitol could produce more lasting progress with much less disruption.  They would be tools by which that man could produce more bananas and more efficiently bring them to market.  He could then sell a greater number of them at a lower price and make enough money to improve his familiy's situation.  We need to have a more organic program of development that facilitates the people in the developing world in finding their own better paths forward, rather than top down solutions that can hurt as much as they help.  At least most of the time, in most situations.  Nothing is universal.

     Thanks for your prayers.  After I return to Tappita, I may have a harder time posting due to the bandwidth of our internet connection.  However, improving that is one of the projects that we are working on.

   

Our first patient.

     Sorry for the delay in posting.  We have been busy and this is the first time in several days that I have found enough bandwidth to load Facebook.  

     We had our first patient.  He was a sick older man who had a fever and three of the constellation of symptoms that gave him a diagnosis of Ebola suspect.  We dispatched our ambulance, picked him up and transferred him to the ETU.  After our triage we tucked him in overnight with antimalarials, antibiotics  and fluids pending the blood draw the next morning.  By noon, we got his blood test back and he was negative for Ebola.  Given his constellation of symptoms, I wonder about Dengue fever or pneumonia but we don't have X-rays or any blood tests besides Ebola and Malaria in the ETU.  He certainly was too sick to send home so we transferred him to the neighboring community hospital in Tappita.  

     Overall, it was an excellent opportunity to work out kinks and minor coordination issues.  Trying to learn little things like who calls the drivers, how we get the sprayers who clean the ambulance in full PPE back into the ETU to doff their PPE, etc.  I learned that, when I wear them for extended periods, the triple gloves that we wear in PPE are a little too small for my hands.  After one half hour in PPE, the fingers of my right hand were going numb from lack of circulation.  And of course you are not in a situation where you can just take off the gloves.  Many if not most of the health care workers who become infected with Ebola, for whom you can document a route, became infected during the removal of the PPE.  You just finish the rounds and make a note to get supply to get bigger gloves.  

     I am off to Monrovia today to attend one of the WHO meetings.  Not the most fun part of the job, but it is very important to 'show the flag' and to meet the main players.  Who knows, maybe I'll find better internet!

Serving With Others

One of the more interesting things about this assignments is the diversity of the people who are here.  The Liberians are dedicated, intelligent and they pick up the system very quickly.  The expats though, are a really heterogeneous group of people who are united in a desire to help people at the edge of what most will tolerate.  After that, not so much unites them.  We have physicians who run clinics in other developing world countries, administrators who have worked in a series of positions and organization scatted across Africa or in South and Central America, nurses who have served in a wide variety of developing world countries for shorter or longer periods, people who hitch hiked across Europe for 6 months and many, many more.  Relaxing over a beer at a restaurant (that popped up across the street after the opening of the ETU), talk goes on about adventures covering 6 continents.  The discussions of what we have eaten or things we have done are not the sort of thing you would hear at a bar in Johnson County Kansas.  Of course, strong people often come with strong personalities and that can make things interesting as well.  Thus the 90/10 rule.  The bulk of the people working here are on 6 month or duration contracts and they have all given up their jobs to come here and fight Ebola.  They are a great group of wonderful people and we are grateful for their service.  Even if they are a bit challenging at times.

Waiting patiently

  I have started running over here.  I am not in as good of shape as I usually am and I won't embarrass myself by saying how slow or short the runs have been but at least the weather is great for running.  Low 50's I would guess by the coats, hats and mufflers on the Liberians.  Part of my speed issue may be the gerbil wheel aspect of running the 1/4 mile loop around the hospital.  Once I build back my speed and endurance, I will reward myself with longer  runs out of the compound.  

     Still working on setting up programs and procedures and double checking little things (how loud is the ringer for the ambulance phone and where does it ring?).  Things that seem nit picking but can mean a lot to how well everything works. Also working a lot on personnel issues.  That is one thing that I remember well from the military.  The 90/10 rule applies here as well.  

     Thankfully, the situation here is quiet on the disease front.  Cases have been north of us, but none have made it to our ETU.  This has given me a chance to structure things in the ETU as I like them.  If it remains quiet (God willing), we will further expand our outreach activities.  We cannot perform medicine outside of the ETU, but we can teach and mentor.  Our Public Relations crew is sounding out the community for opportunities for teaching and outreach.  Even if we don't treat much Ebola, we will leave Tapeta a better place for our coming.

A new role in Tapeta

     I haven't posted for a few days because the situation here has been a bit unclarified since I arrived in Tapeta.  I came over here with the intent of just 'filling a stethoscope" and simply being a doc in the ETU (isn't that enough?).  Sadly, I had to put on my Heart to Heart Board of Directors hat and assume the responsibilities as the Chief Medical Officer in the ETU in Tapeta.  Sometimes you plan the situation and sometimes you have to react to it.  Things being as they are here, I have extended my deployment through early April which is the end of Heart to Heart's contract with USAID.  Jo, College Park and HCA have graciously (but maybe not excitedly) accepted this extension.  I wasn't exactly packed for 3+ months but that is ok, I can work with it.  I just ask for your support and prayers.

     My duties are much different.  Basically, I am responsible for the smooth functioning of a very complex clinical operation.  I have to approve, modify or establish procedures to ensure that all potential Ebola cases are evaluated and treated in a safe and efficient manner (with much more emphasis on safe).  I am stepping into and operation that has just started and am learning the personalities and evaluating procedures for effectiveness.  I also have supervisory responsibility of all the administrative and logistical aspects which impact our clinical operations (basically everything).  I hate to quote Donald Rumsfeld on anything but he did have a point about there being known unknowns and unknown unknowns.  I am still discovering what I don't know.  But I am getting there.

     I haven't said much about the location.  Tapeta is a city of 90,000 people but no restaurants that an expat could trust.  They do seem to have an adequate supply of Liberian beer.  It can be a bit hazy and cool early in the morning but quite hot and muggy during the day with temperatures in the mid 90's.  We are currently in dry season and it is dusty.  Rainey season starts sometime in April.  

     Our cooking staff provides food for about 150 people each meal and the food is quite good compared to what is available in other ETU's.  I won't say that there is currently much variety, but it is plentiful, safe and satisfying.  Sleeping accommodations are about what you would expect for a higher grade of housing in a poor country.  It works (mostly), but certainly with no frills.  It is very safe and the local population is quite happy that we are here.  Everyone waves at you as you walk around.  

     Liberian English is pretty difficult.  One thing that I have noticed is that it is more difficult the farther that one travels from Monrovia.  I find myself repeating back what a Liberian says as a method to make sure that I comprehend what they have said.  Still sometimes I only pick up half of what they say.  People have discussed how English is becoming a world wide universal language.  Well, I am experiencing the opposite effect, how English is evolving into another distinct language.  

     Again, thanks for your support and prayers.

Arriving in Tapeta

     One of the ETU physicians told me yesterday that they hadn't had a positive Ebola test in Monrovia for over one week.  This is a great sign and a testament to the hard work and sacrifice going on in Monrovia, but people are getting a little complacent.  There have been large crowds at the beach and people were dancing and partying for New Years eve.  While a certain amount of release is expected after getting through such a period, it is a problem when that release also increases the risk of Ebola transmission.  There are no reported cases yet from New Years eve, but we aren't yet near the end of the up to 21 day incubation period.  

     It is a different case outside of Monrovia and in the neighboring country of Guinea.  The main road from eastern Guinea into Liberia traverses the city of Ganta which is 3.5 hours north of Tapeta.  10 days ago, a man sick with Ebola crossed into Liberia in Ganta and died en route to Tapeta.  He had 40 known contacts including 7 health care workers (without protective gear) with 4 confirmed positive tests for Ebola (so far).   On my ride to Tapeta today, I passed the body of a young man, lying on the side of the road 30 minutes south of Ganta.  There was no sign of trauma and there was no one else there with the body.  I did not leave the car to investigate further.  In an Ebola outbreak, an unexplained death meets the case definition of 'suspect case' for Ebola.  While there is no current case of Ebola in Tapeta, we will need to keep a high level of suspicion.  

     Another thing to remember about this country is that it is not far removed from a horrendous civil war.  My driver today survived the civil war by laying low.  The rebels took his wife and left him with two children to raise.  He has never learned the fate of his wife. The forces were tribal based and there is still a lot of animosity between the groups.  After the peace treaty, some of the rebels returned to their villages and were killed for what the did during the war.  You can still see signs on the roadside advocating 'ballots not bullets'.  But even with all of that, people here are making significant progress.

     Tomorrow, I will start working in the ETU in Tapeta.  Please keep all of us in your prayers.

     

Pictures from Liberia

I thought that I would post some pictures as I will be leaving tomorrow for Tapeta (the change is changed).  In disaster response, it is always good to be flexible in your planning.  I am getting to practice my flexibility today.  Since the internet in Tapeta is much slower and less robust than it is in our offices in Monrovia, I thought I would take this opportunity to post some pictures. This is a picture of the MoD1 ETU.  It is fairly typical with lots of tents and a fairly standardized pattern of organization.

This is the classroom in the ETU during a break.  It was pretty warm but the instructors said that it was good practice for being in PPE.  

This is a picture of me donning PPE during the training.

This is the handbook we use as a clinical referance.

This is the 'memory tree' from MoD1.  On it, there are colored ribbons for each survivor and a black ribbon for those that didn't survive.

This is the survivors board from the MMU ETU in Monrovia.  This is the ETU set up by the US Public Health Service exclusively for health care providers (of any nationality) who become infected.

More on Monday after my 10 hour drive to Tapeta tomorrow.

More training - I meant to publish this yesterday.

    One item that I don't think that I have commented on is the the ubiquitous smell of chlorine.  Chlorine is the disinfectant of choice here.  It is inexpensive, easy to handle and effective against the Ebola virus.  Most of the time, it is used for hand washing.  You will see it in front of restaurants, grocery stores and public buildings.  There is a hand washing station at the entrance to our guest house.  Usually you use a 0.05% strength for hand washing and a 0.5% strength for cleaning equipment.  However apparently under the theory if a little is good, more must be better, you occasionally run into more highly concentrated solutions.  You can tell pretty rapidly by the feel and smell.  Hopefully you have some normal water to rinse off with afterwards.    But at least in the ETU, it is the smell of security. 

     Today, we had mock 'patients' in triage.  These were 'patients' who would have just come to the ETU to be evaluated.  The first case was pretty straight forward and we were able to question him and see that he needed to be admitted.  The second case did not speak English and I was without a translator.  After an initial huh?, I basically started playing Charades with the patient to try to obtain the history.  Not my strongest suit but made even more interesting by needing to coach the use of a thermometer and to pantomime diarrhea.  I think the rest of the team was amused but also thankful that this wasn't their patient.  The hardest part was when the 'patient' sat down, the plastic chair collapsed and unconsciously, I reached out to catch him.  Of course, you shouldn't do that since you will only be in light PPE (gloves, apron, mask and goggles) and not fully protected agains Ebola.  But it is just hard to suppress something that happens so quickly that you don't have time to consciously consider.  Structurally, most triage areas are set up with a barrier between the triage officer and the patient.  Originally, I thought that this was to keep the patient away from the triage provider, but I see how that can work the other way as well.   

     The ETU here has a motto:  "We protect ourselves so that we can save lives."  It is interesting that the emphasis is on the protection of the provider first and then on the patient.  This was followed later with the statement that 'A life lost is bad, but a lost health care worker is much worse'.  It is an interesting inversion of many concepts of service in the US.  'Service above self' for Rotary and Jesus' admonition to love your neighbor as yourself.    I certainly see the reason for this from a utilitarian point of view.  The early loss of health care providers has proven disastrous over the course of this epidemic and has cost many more lives.  I have no problem adopting the motto, however it still feels a little funny.

     More training on Friday then a ten hour drive to Tapeta on Saturday.  Thanks for your prayers.

When Healthcare providers get sick

    It is an interesting drill when a health care provider gets sick.  For most of us, most of the time, we can recognize what is going on and make a decision whether to treat ourselves (if minor) or get with a colleague.  It is a little different here.  Certainly, there are a lot of illnesses as one would expect in a developing world country.  But the specter of Ebola distorts the normal way you approach a set of symptoms.

     First you have to start with the WHO case definitions of Ebola.  A probable case of Ebola consists of a known contact with the virus, and usually a fever sometimes with a constellation of symptoms that can include diarrhea, vomiting, fatigue, sore throat, unexplained bleeding, headache, abdominal pain and hiccups.  A suspect case of Ebola will have the fever with the symptoms without a known contact.  A confirmed case requires a confirmatory blood test.

     The problem is that many of the common illnesses that occur here can have those same symptoms with a fever.  Food borne illnesses, malaria and many others can cause some or all of the symptoms, with bacterial gastroenteritis being a particularly common offender.  Particularly for people whose GI tracts are not used to the local bacteria.

     As a health care provider in an Ebola zone, you can easily recognize these symptoms when they occur in you.  The risk is that you could minimize their significance.  Clinically you know that when these symptoms are due to Ebola, they are usually severe, but you also know that all severe symptoms start out as not so severe.  So, you fall back on the algorithm that says;  fever plus 3 typical symptoms without known contact equals Ebola suspect.

     There is the formal algorithm that states that the patient will be admitted to the suspect ward of the ETU until there are two negative blood tests separated by 48-72 hours.  There is also an informal algorithm for healthcare providers that, if the symptoms are not severe, you can have your blood drawn and go into self isolation pending worsening or improvement of symptoms.  Dependent upon how you do, you may need a second test.  Sometimes it is good to be the doctor.  But it is even better to have a negative Ebola test.  To my friends and family:  I have not been ill.