Echoes

On Thursday, March 26, I left Geneva and “went solo” for the first time since the beginning of our training. As I’ve said, I was feeling more and more like myself, and about ready to get back to normal life. The idea was to walk the first 90 km of the “Chemin de St. Jacques” (the French part of the Santiago de Campostela pilgrimage trail). I’d already done the middle section – from Aumont-Aubrac to Cahors (well – all except for one day missing in the middle), but I wanted to do the “official” start, from Le Puy en Velay to Aumont-Aubrac. I thought I was leaving all the Ebola work behind, but – apparently, not so fast.

I got to Le Puy 

in the evening, dropped off my stuff, and went for a walk – mostly to the cathedral, since that was the only place still open. Almost the first thing I saw was a Latin inscription in a courtyard 

that had something to do with medicine and doctoring (there is mention of Hippocrates over on the right, at the end); I found out later it was an inscription about the healing properties of the waters of the well. Then, once inside the church, I came across a large painting 

showing a procession of townspeople giving thanks to the local Madonna for delivering them from the plague in 1630. But, wait – something is different about this Madonna…. Ah, yes – she’s black, and so is the baby Jesus on her lap, as is apparently relatively common in this region. 

Then, over to the left of the choir is a chapel with an intriguing dark stone – 

the “fever stone,” as I learned, famed probably since pagan days for healing people of their diseases. Once outside, almost the first building I came across 

was the old Hopital General (general hospital). And then finally, as I was eating my (delicious – ah, France!) dinner, I pulled out my book on the cheery topic of the 1918-19 flu epidemic. When you look at descriptions of how this disease affected people, one of the first things you think is how much it sounds like Ebola: massive respiratory distress; unexplained bleeding; terrifying transmission from person to person; normal funerals prohibited; schools closed; doctors and nurses dying; patients disoriented; alarming death rate. If that were not enough, however, that evening I came across a passage detailing how Freetown – yes, Freetown, Sierra Leone – was, along with Boston, MA, and Brest, France, one of the original epicenters of the pandemic. Who knew?

Disease, healing, black mothers and children, epidemic in Freetown, fear, deliverance…. Seems Ebola and Sierra Leone weren’t QUITE ready to let me go (or I wasn't quite ready to let them go) just yet.

I don’t know if everyone has heard/noticed, but per the public reports (which is all I know), my colleague who contracted Ebola appears, after a really hard struggle, to be getting better. Please keep your fingers crossed! Our Sierra Leonean colleague who got sick at the same time does not want his/her case discussed in any detail, but let’s just say that the news I’ve heard about her/him hasn’t been bad. And my other, non-sick colleagues who had to quarantine in places like Nebraska and Emory are also starting to go home. So maybe, then, we are getting to the end of this particular chapter?

I’m back in the States on April 9.

Last post (at least for now)

March 24, 2015 – Well, I would say that yesterday afternoon, I more or less returned to being myself.

Since last I wrote, I had been continuing my sort of random peregrinations, trying to start “enjoying myself” while here in this incredibly beautiful place, in the middle of Europe, and surrounded by friends. You wouldn’t think it would be so hard. But I was still in a pretty dark mood.

As you can imagine, by this time I’ve concluded that coming back from a job like the one I was doing in Sierra Leone is just harder than I would have thought. Although, in fact, I had an intimation of it.

How do you think? Ever since at least the time I was in college, one of the ways I think is that images or ideas will arise unbidden into my mind, and – if I manage to pay attention to them, which is not always the case – I will later find that they were a kind of intelligent crystallization of something I somehow knew, without being conscious of it. In other words, they are a conclusion – a thought – that I haven’t actually “thought.” I first noticed it in connection with a couple of my major college girlfriends. Before I even realized I was attracted to them I had images in my head of doing things with them – and then, shortly thereafter, we were involved! I don’t know whether to be more irritated that my thought processes are often independent of my consciousness (why should I remain so “stupid,” consciously?), or more amazed and grateful at my whole being’s ability to see and integrate important information, even if I’m not conscious of it. (Mostly the latter.) Anyway, at some point while still in Sierra Leone I had an image of myself at my friend Gundula’s house, staying in and spending time mostly alone; resting. In fact, the recovery phase lasted longer than it did in this image – but, in it’s basic message of “you will need some time,” it was on the nose.

So – I was kind of wandering around, feeling grumpy and down. I did go to some lovely places, like the vineyards over Lac Leman outside of Lausanne; 

or like Neuchatel, a small city built largely of this gorgeous yellow stone that smiles and stretches with warmth when touched by the sun;

or like Fribourg, an energetic French/German university town built above and inside a river gorge. 

I was very aware, without going into it here, that I do have some legitimate reasons for feeling down even in my “real” life – things I’ve done that I should have stopped doing years ago; lessons staring me in the face that I have kept failing to learn. So I was thinking that maybe I had just, to crib from Freud, begun to transform neurotic Sierra Leonean misery into ordinary New York unhappiness, and maybe that would be it.

But – on Sunday I made a decision (like pulling teeth, in that depressed-deciding way, but nevertheless I made it) to stop wandering around (I had been thinking of running up to Strasbourg for a couple of days) and instead just focus in and be in Geneva. I looked up what was going on in all the museums; I made plans to see a movie with some friends; I thought about stuff I’d wanted to do here in the past but never got around to doing; I arranged to meet a colleague’s wife who is here temporarily doing public health work; I made plans to do things like just washing my clothes. And, Monday morning, I dove in.

Aside from the laundry (remarkably satisfying just to do your laundry sometimes, isn’t it?), I went out to CERN for the very first time to see their visitor center. 

In a wonderfully Swiss way, this is housed in a space-age looking spherical building that is nevertheless “sustainably” built out of, of all things, wood. Inside there is a very well-done introduction to the main problems being investigated there, from the (now discovered) Higgs boson, to the problem of the superabundance of matter over antimatter, to the puzzle of dark matter and energy, to the (I gather even greater?) puzzle of the “missing void energy,” to the question of what the primordial soup of quarks in the first millionth of a second after the big bang might have looked like. It reminded me just of the pleasure of wondering, asking, looking.

And then, as I was leaving, I got a message from some people I’d emailed in the morning – the paragliding school on “Le Saleve.” This is a 3500-foot ridge just south of Geneva that is one of the most beautiful places I’ve ever been. It’s location and height mean that, when you are up there on a clear day (and up there, miraculously, there is nothing but pastures and a few little old towns), on one side you see the entire valley of Lac Leman with the Jura mountains in the distance, and on the other you see the enormous white teeth of the high Alps, all the way down to Annecy in France and Mt. Blanc over toward Italy. 

There is a paragliding center up there that I’ve known about since I lived here, and always told myself I would take advantage of (they offer tandem glides, so you don’t have to know what you’re doing), but had never made the time for. Yesterday (a gorgeous, clear one) they had availability at 4:30 in the afternoon, so I went on over.

What pleasure. What pure pleasure. In the movie “Wings of Desire,” we are listening to the thoughts of the woman who eventually falls in love with the angel, and she thinks a line (even more perfect in it’s clunky translation from German) that I’ve always loved: “Absence of pleasure – that’s what makes me so clumsy.” Isn’t it like that sometimes? And don’t you see it in other people, too? When your life is a sort of dry well, so that even if you have wheels that could move, you can’t lubricate them, and even they are stuck? Maybe that’s what I needed then – the lubrication of some delight.

It’s not even necessarily something I’m dying to do again. It was just – for that half hour – it was like having my senses reset to childhood. To see the cliffs from in front of them. To feel myself slowly, slowly, approaching a cliff, seeing it gradually pull itself into focus and detail. To just cruise through the air, with nothing particularly dramatic, just fields, below me, but with the wind passing smoothly by. It didn’t mean anything. It just felt wonderful to be there.

I went out to the movie afterwards, “Electroboy,” a documentary about a strangely charismatic Swiss model/internet pioneer/party organizer and his tragic family, highly recommended although I’m afraid it might not make it to the States - with a friend and two friends of his. And afterwards we just had a lovely time. Chatting, teasing, eating, laughing. Joy made a reappearance – first time in many weeks.

So maybe I’m back on the map I more commonly inhabit, whose coordinates I recognize. In any case, I’m looking forward to my days more, and the dread of each social contact has lifted. Tomorrow, I’m going to make a final dinner for my friends (roast chicken; root vegetables; salad; cake), and the day after I head off for a few days of walking in France. After that, some time in Sicily with my brother. Back in the States on April 9. I expect to enjoy the next two weeks, but I do think I’m ready to be back in the familiar and the normal.

This will be my last post for now. If either a) my last few “in country” posts from Sierra Leone are ever approved, or b) things worth talking about happen in connection with my sick colleague, my friends still in isolation, and/or the Ebola situation in Sierra Leone, I will write again. If so, I’ll make sure to alert you to it on Facebook.

Thanks for reading, everyone!

Feeling better

And, you know - when you spend your day doing this, you really can't complain.

Chateau de Chillon on the left, Alps across the lake

Slow climb

March 16, 2015 – Today was a more normal day. Not entirely normal, but getting there. Well, until the late afternoon, when I went to see the crushingly sad movie "Still Alice," and then came out to see the news that my colleague who is battling Ebola in Bethesda has now been moved to “critical” condition. There is no detail about what this means – did he go onto dialysis? Did they have to start breathing for him? - so it is impossible for me to make any sort of judgment about his course. But it is just dispiritingly sad.

What made it a more normal day was that I didn’t have a recurrence of the problem I’ve had for the last four days running, a bizarre little “storm” that would really have worried me if it weren’t that none of it in any way resembled Ebola. Between around noon and around 3:00 every day, I would get extremely anxious. Nervous, a little trembly, a sense of being close to tears, a sense of it all being too much, and some difficulty being around other people. Now, I am someone in whom any derangement of my physiology – going quickly to high altitude; not getting enough sleep; but also, getting sick – tends to produce hopeless, depressive thoughts – so you can bet that each time this happened, I took my temperature. Nothing! And my appetite was excellent (note that these bouts were happening right around lunchtime), my digestion fine, my energy level good. I just felt like an anxious wreck.

I still have no idea what was going on. Sure, all the sadness and stress I’ve spoken about, clearly, but why the periodicity? Malaria can give you periodic fevers, but – I didn’t have a fever. About all I can imagine is that I’ve been drinking too much coffee (the coffee here is much stronger than in Sierra Leone, too), that 12:00-3:00 is the “caffeine crash” time, and that that, combined with the sadness, combined with the worry, combined with the antimalarials, just pushed me over the edge. I did have a cup of coffee this morning, too – but not till 11:30, and that probably means I was already in the movie, feeling sad for other reasons, by the time the crash came.

Up until the movie, though, I had a nice day, taking the time to do something I almost always forget to take the time for. I saw off my colleague (who has finished his 21 days and is heading back to the States), then went to the Bains de Paquis and spent the day reading. The Bains is one of those things you just can’t not love about Geneva. Essentially it is a wide jetty extending about halfway across the lake (and right in the middle of town), where you can swim in summer, where they have saunas and Turkish baths in the winter, and where there is this wonderful, inexpensive bistro all year round. (This time of year, the evening meal, served around roaring wood stoves, is fondue – I’ll be going for that in the next couple of days!) This is the sort of place that can, I think, only exist in a SMALL city (or maybe a small part of a large city). That is to say – the glory and the curse of New York is its anonymity. When you go out to eat, you can be pretty sure no one is going to recognize you. On the other hand, you probably won’t feel much community with the people around you, either. The Bains de Paquis, like so many places in Geneva – I think of the theater bars, in particular – give you the sense of being run by your friends, even if you don’t know them. They pick out food the way you probably would (high-quality, organic); they cook it the way you probably would (delicious and zestful, but not fancy), and you feel somehow like everyone knows everyone else and you’re all in it together. It’s public but cozy, homey without being at home. I ate my pork tenderloin with mushroom sauce and fresh baguette, buckwheat, butternut squash, and cardamom-flavored spinach; I drank my (many glasses) of their “ginger drink” (basically hot ginger and lemon); and I read through many of the magazines I’ve been lugging around and not getting to for the better part of two months. Then I took one of the little yellow boats (“mouettes” - “seagulls” - part of the public-transportation system) across the lake. All very nice, until I spent two hours imagining losing my mind along with Julianne Moore, and then came out to hear about my colleague.

But I will say that I do feel more like myself today. And the sense that something dangerous that I don’t understand might be happening (or, more simply, that I might be in danger of getting sick) – that is not so strong.

Fearing contagion

In the previous post, I alluded to anxiety about the possibility of actually having contracted Ebola. But I haven’t given you a sense of how, exactly, that’s played out over my first couple of days here.

It starts pretty much as soon as I wake up. Does my head hurt? Do my eyes hurt? Does my stomach hurt? Was that poop (sorry) maybe kind of suspiciously loose? Luckily, there is the thermometer, my objective friend. I pop it into my mouth many times a day, and so far, it has continued to tell me to calm down. A good thing, because both of the past afternoons around 1:30-3:00, I have felt REALLY WEIRD. Anxious – irritable – almost tearful – tired – barely able to tolerate anyone else. Both times, it passed – once after a nap, once just over the course of a meal with friends. I still have no idea what it was (is this the antimalarials?).

When I look at the bigger picture, however, everything seems more or less okay. First of all, “feeling weird” is one of the few things that ISN’T a symptom of Ebola. Beyond that – I have an excellent appetite – my poop, in fact, really isn’t that loose – I’ve had enough energy to go out two nights running – and the thermometer continues to tell me I’m okay.

I don’t know if I’m lying to myself, but what I’m most worried about doesn’t actually feel like it’s my personal health. I’m sure that would quickly become my focus were I in fact to test positive – but in the meantime, I’m much more concerned about what it would mean to my friends and to the city of Geneva. Both the friends (actively, personally) and the city (more passively) have been generous enough to take me in, and the idea that I might reward this by causing my friend to have to deal with a decontamination team in her apartment doing god knows what with all of her lovely stuff, or by setting off a panic in this usually very cool city, kind of torments me. If anyone else were then actually to become infected because of me (which I truly believe is impossible, but, hey – when has that ever stopped someone from worrying?), I can’t imagine what I’d feel.

Happily – let me just underline this one more time – there is in fact no suggestion whatsoever that I have Ebola!!! Just reading this post, you can kind of see the rabbit hole one can go down when one starts to think about it too much. But, for the moment, everything is going according to plan, and neither my friends nor the city have anything to reproach me with. And, in fact, tonight it felt a bit like something “clicked.” Can’t say what it was (maybe writing this helped?), but some time this evening I started to feel a bit more like – myself. We’ll see how it feels tomorrow morning, but maybe – just maybe – it means I’ve taken one more step back toward “home.”

Sadness

Boston is going to be tied up for some time in managing recent events (which sound crazier and crazier – unfortunately, I don’t know much more about them than you will if you read the NYTimes), so I don’t have much hope of having my last posts from “in country” approved any time soon. I’ll continue with non-(directly)-work-related posts until then.

I have been puzzling over how I feel being away from Sierra Leone. From time to time, I’ve tried to describe it to my friends, but – for one, it seems like it requires a somewhat longer description than is conversationally polite, and also – doing so in French would wear me out. For some reason it hadn’t occurred to me to write about it here until today.

I don’t know how many of you read Craig Spencer’s article from the New England Journal of Medicine that I posted here (it’s really worth a look: http://www.nejm.org/doi/full/10.1056/NEJMp1501355), but he said something that made a moderate impression on me when I first read it a couple of weeks ago and which now really stands out: That when he got back, he felt very sad. In particular, he said that he has never been a depressive person (which I can well believe from the two weeks I once spent with him on a course), but that, in his first few days back, he felt like he became depressed. It seems that something similar has happened to me (er – except for the fact that I AM a depressive person!). I feel anxious, doomy, and close to tearful frequently over the course of a day.

Perhaps it seems obvious what this must be about – all that death; all that inability to stop it; all that awareness that trying our best wasn’t really helping that much (and that at times it may even have done some harm). I’m sure that’s the main thing. (Although I, personally, have never had an experience where pain was so clearly and neatly deferred, like a task or a conversation – can’t feel it while I’m working; start to feel it as soon as I’m not. Is emotional pain really that fungible? Maybe it is.)

I think that at the moment, though, all of this is compounded by anxiety over the possibility of actually catching Ebola. As I’ve said before, it wasn’t something I consciously worried about that often, but seeing that a colleague really can get the disease makes you think about all the run-of-the-mill mistakes, all the things that happened that weren’t completely kosher, and you start to wonder – was that enough that I caught it, too? And the thing is, there simply is nothing to do but wait and see. I’d say I still have something like 5-10 days before I will feel completely internally confident that I am clear, and in the meantime any strange occurrence or sensation starts you worrying again. All in all, stressful/fearful, which I think compounds the sadness. (Also, right at this moment – many of my friends still over there are caught up in various possible exposures, various possible evacuations, and I’m worried about them, too.)

Then, as one of my friends pointed out, we were all probably running on an unusually high dose of adrenaline, just due to the daily stress of the work. So it may be that no longer having that hormone burst means that, on a simple, physical level, we are more prone to a kind of inner collapse.

Finally, there are the antimalarials. Here are some of the side effects that are listed for Malarone, the one I am taking (which isn’t even the scary one): “sleeplessness,” “trouble sleeping,” “unable to sleep,” “discouragement,” “fear,” “feeling sad or empty,” “irritability,” “loss of interest or pleasure,” “nervousness,” “trouble concentrating.” My guess is that they play a part, too. (I can’t stop taking them, however, until the full course is finished in four more days. If I got malaria (very, very unlikely, but still), the hospital here would have no choice but to treat it as possible Ebola, and that is a road we just don’t want to go down.)

So, many possible sources – but whatever the reasons, I’m feeling more sadness, and more anxiety and doubt (and grief?), than I would have predicted.

In Switzerland

March 12, 2015 – I have a number of posts awaiting approval in Boston but here’s a non-work-related one just to tell you what’s up with me.

I am in Geneva, having come in on the overnight flight (Freetown-Brussels; Brussels-Geneva). Let me tell you, when you hit a major international airport after 5+ weeks in Sierra Leone, it’s like you’ve been roped into some a sick joke. I’m sure an economist could explain to me why I’m wrong about this, but it’s impossible not to feel like the fact that we live at this level of wealth is somehow connected to and dependent on the fact that they live at that level of poverty. It seems completely unsustainable, and I think it is completely unsustainable if we care about living with a modicum of justice or fairness. “…[H]eavens, deal so still!/Let the superfluous and lust-dieted man,/That slaves your ordinance, that will not see/Because he doth not feel, feel your power quickly;/So distribution should undo excess,/And each man have enough.” When will that be, do you think? Will there be a reckoning in our lifetime, or will we manage to lurch along for a while, or a long while, or a very long while longer?

That said, it is unquestionably nice to be in a place where everything works (and where it is cool). The weather is gorgeous; my generous friends are putting me up; the health officials here are friendly, accessible, and utterly reasonable. Even though I slept well on both flights last night, the first thing I did when I got here was sleep four hours more. And then get up and write to friends still in Sierra Leone for a couple of hours, and then go out and have a glass of wine with another friend who left the country a couple of weeks before I did. Yes, I think it will be a little hard to leave it all behind….

I can’t say anything about the latest developments yet – when/if I can, I will.

A couple more pictures while we wait

A picture of the nice river valley we cross on the way to the ETU, taken when I walked to work with a colleague on my last day shift. It's so nice to be in a tropical country where there is plenty of water! We're almost at the end of the dry season, and the rivers are still pretty full (driving to Freetown, you cross one as plump and flush as, say, the Connecticut). This valley is a place where you see many people bathing, washing clothes, swimming, on any given day. The Chinese are building a small hydroelectric dam just upstream - they stopped during the height of the epidemic, but are back now - so it all may change soon. Ah, progress.... (Sorry about the grayish tones - it was morning, but also, the Harmattan wind bringing dust off the Sahara, and the incredible, constant humidity, make the air kind of grey-brown and hazy pretty much all the time.)

And here I am in my PIH-style PPE, on my second-to-last shift!

More soon....

Get out of the kitchen?

March 5, 2015 – 99 degrees today. I went in in the afternoon and after about 45 minutes began to feel anxious – a kind of panicky feeling, like I won’t be able to handle…something. I and a colleague were working on a particular project: Cleaning up and ordering all the medical supplies in all the rooms. You can perhaps imagine how they become a complete mess: People going in can’t check what is already in a given room (after all, you can’t go into the room unless you’re in full PPE). So we bring things we think we might need – IV tubing, “flush” syringes, IV fluid, needles, oral rehydration solution. When we get into the room, we put what we’ve brought down on a bed, but usually – since we are always being better-safe-than-sorry – we don’t use it all. Most of the time, we’re working pretty hard in there, so we don’t take the time to consolidate whatever we’re not using with whatever is already in the room. So, over the course of many shifts, little piles of miscellaneous, mixed equipment collect all over unused beds. It’s a complete mess – and beyond making things hard to find, it’s just depressing – makes it feel like things are out of control, which you’re already close enough to feeling during those busy, limited sessions in the unit anyway.

We had gotten all the “suspect” rooms organized in the morning, but my colleague was handling a torn plastic pill package that cut through both her gloves, so we had to leave before we’d done much with “confirmed.” So, in the afternoon, we started there – only to realize the rooms were such a mess that each was going to take maybe 30 minutes to organize.

Anyway, I breathed through the anxious feeling – a little difficult since the only masks we have available are the ones affectionately referred to as the “waterboarding” masks. They are soft paper/fabric, and as you sweat they gradually get saturated and collapse, till you’re trying to breath through what amounts to a wet towel millimeters from your face. Periodically the anxiety would rise, periodically I would breathe it down – I really, really wanted to get the rooms cleaned! Over the next half hour, I noticed my heart rate rising, my breathing rate rising, my head beginning to pound, my concentration beginning to unravel, and always the anxiety…. In the last room, I got the medication box organized and most of the supplies consolidated, and then my colleague (who is probably 25 years younger, but was also hurting) and I kind of shoved it all into a more-or-less rational pattern and got out.

Definitely the worst PPE session to date. I took my temperature (100.3 on a thermometer which usually clocks me around 97.9), downed a couple of liters of water and ORS, and, interestingly, gobbled down some cold French fries – maybe craving the salt? Now, two and a half hours later, I feel more or less okay – sleepy – tired – but okay.

Meanwhile – remember that time I told you that no one had died in the confirmed ward for a week? Well, I’m pretty sure that, over this past week, no one there has survived. I remember a fellow student in medical school who lamented – “Whether I study or don’t study, I still get the same grade on every test!” It’s beginning to feel that way here – we do what we do, fine-tuning it, “improving” it week to week, but whatever we do, half the patients die. It’s the same dispiriting picture as when I first got here….

I actually think we are delivering GOOD care. That is, given the limits of what we can do here (and of what we know – it’s incredible how much about the basics of just what happens to your body when you have Ebola no one knows), I think we are doing what we can. We’re giving each patient personal attention; we are treating every problem of theirs we find that we can treat; we are giving them medications to suppress other infections that might add insupportably to the strain on their bodies. There is nothing obvious we could be doing that we’re not. And yet we’re still nowhere near the survival rates achieved in the West. Maybe you just simply need more and more sensitive monitors, a wider range of life-support techniques, and more continuous (i.e., not just 15 or 20 minutes six times a day) care to dependably survive.

A break

March 4, 2015 – The silence ends! I don’t really know why I haven’t written lately; perhaps because I had 4 evening or night shifts in a row, which upsets one’s sleep schedule and makes one less productive. Perhaps because I just worked 7 days in a row (which, I hadn’t really realized till now, is pretty uncommon in our usual work lives, isn’t it?) and am just tired. Perhaps because – despite some dramas and concerns re: treatment that I won’t go into here – the work has become more routine – not in the sense of boring (it is VERY engaging), but in the sense of familiar and thus less in need of being described, from my point of view. In any case, I have felt less like coming home and sitting down at the computer to dash off my thoughts.

Right now, I am on the tail end of a blessed two days off (the first was the day after a midnight-to-8am shift, though, so it doesn’t REALLY count!), during which I came down to Freetown to spend some time with one of my favorite cohort-mates, who was assigned to a different facility and whom I thus haven’t seen in almost four weeks. Such a nice visit; so nice just to get a change of scene; wonderful how refreshed I feel! I think it is two things:

First – the work is, I believe, more stressful than I actually realize when I’m doing it. I’ve touched on all the reasons why this is so at one time or another in this blog – the ever-worrying knowledge that our care is not all it could be, due to resource and time constraints; the consciousness of the imperfections of being a clinician; the concern to “hit our marks” (give enough fluid to those who need it; give scheduled medications to everyone on our list while also treating any fevers or other symptoms we happen to come across; clean any patient up who is lying in their own diarrhea; etc.) every time we go in; the tension between fluid, on the one hand, and difficulty breathing, on the other (the disease seems to get to a place with most very sick people where their lungs are “wet” but their blood vessels are “dry,” as I explained in an earlier post, leaving us uncertain what to do). Etc. Also – and I tend to discount this, but I think it is real and ever-present – the background worry about actually catching the disease. I do NOT think about this, let alone obsess about it, very often, but I think it is always there. Did everyone read Craig Spencer’s article in the New England Journal (or the description of it in the Times)? Here it is:

http://www.nejm.org/doi/full/10.1056/NEJMp1501355

Reading it is a reminder that having the disease is no picnic, even if you do get better (and that is by no means guaranteed, despite the success with expat patients up till now). Also – I don’t know if you’ve heard about this or not – there is a lot of evidence suggesting that, even when you have recovered, there is the possibility of a “post-Ebola” syndrome – inflamed eyes, weakness, tiredness, aches, confusion – that may affect some or many people, for literally no-one-knows how long. You don’t want to go there, if you can possibly avoid it! So, when you look at that sleeve smeared with diarrhea after you’ve moved an incapacitated patient to a clean mattress, or that glove running with blood after you’ve bandaged the site of a former IV that the patient, thrashing around, has pulled out, you do kind of wonder – am I sure that none of this is penetrating the protection? I have no reason to think it is – but you do ask the question.

Second – and this I hadn’t really registered till I came to Freetown – it is, in fact, stressful living in my temporary, provisional digs. There is the long hike to the toilets; the (very good but) institutional food eaten on their schedule, not yours; the always vaguely icky, humid shower tent. Most importantly, I NEVER sleep well at the camp, probably because, for some reason I do not understand, the Danish insist that all public lighting – in the corridors of the tents and outside – stay on ALL THE TIME! Also, the cots are maybe 2.5 feet wide, the mattresses are thin, and I have arthritis in both hips, making finding a comfortable position difficult at the best of times. In any case, I wake up again and again all night long, and almost never feel rested. This despite my two recent improvements: Playing the arthritis card to get a SECOND thin mattress from the camp staff (the same sweet, vaguely humorless young Dane who checked us in told me that they didn’t have many of the mattresses, but, “in your case, it is a medical reason. We need to have you fresh to care for your patients!”). And – TMI coming up – peeing in a bottle instead of hiking out of the tent every time I have to urinate in the middle of the night (something which inevitably left me completely awake by the time I got back to bed). Mornings I can be seen sporting my backpack to the toilet block in order to furtively pour the night’s production down the can.

So – stressed at work, stressed at “home.” I am NOT complaining (more reporting), and I feel, all the time, so glad to have the chance to do this really important work. But, you know – I have been counting the days till my departure since I first got here, and I’m counting them still. Six more shifts. I will happily come back again in a few months, if the need continues (wouldn’t it be nice if it didn’t?). But I’m happy that this stint will be over in a week.

Tomorrow (if I can make it back to Maforki, ha, ha – there seems to be some uncertainty re: the transportation), I get to present my game-changing idea for preventing IVs from coming out so easily. I jest, but, on the other hand, if it works, it would in fact be a great relief to us all. It’s based on something I saw them do in Switzerland, and I could kick myself because I should have thought of it weeks ago. I’ll let you know how it turns out….

A really cool feature in the New York Times

In case you haven't seen it. 

http://www.nytimes.com/interactive/2014/10/31/world/africa/photos-of-workers-and-survivors-braving-ebola-at-a-clinic-in-liberia.html

The white guy looking soaked, with the fogged glasses - that's what we look like when we take off our PPE.

Tourism in a poor country

February 27, 2015 - Today’s class in first-world problems consists of one multiple choice question (BTW, this is a 100% serious question, my tone notwithstanding):

You have a morning off and you bike into town to have a look around. When you are surrounded by children asking to ride your bike and saying “apato!” (“white person”) and, not infrequently, “apato, give me money!”, you should (circle all that apply):

a) Smile, redirect them, and play. They’re just kids, after all

b) Give them money – you have a lot more of it than they do

c) Don’t give them money – no one really likes being a beggar, and it’s best not to encourage it

d) Let them have a spin on the bike – they’re just kids who want to ride a bike, for Chrissakes

e) Don’t let them ride your bike – if one does, everyone will want to, and you’ll be there for hours.

f) Don’t let them ride your bike – it’s way too big for them, and what if one of them got hurt, then you’d probably be fired and also subject to a local justice system that you know nothing about and that might land you in a heap of trouble (you’ve seen the prison right down the road from where you live, after all)

g) Don’t let them ride your bike, and wipe it down with chlorine at the next opportunity – they might have Ebola!

h) Smile and say hi and carry on – you’re here for a legitimate reason, after all, and everyone has a right to take a trip downtown

i) Next time you have a morning off, stay at the camp – all you’re doing in town is exciting envy, an ugly feeling no one likes to feel

j) Next time you have a morning off, go back into town – it’s a global world now, there’s no turning back, and contact and communication are good

k) Next time you have a morning off, do whatever you feel like doing – if you imagine the little commotion you caused in town had any significance in the overall days of the people you encountered, you're dreaming

l) Once you are back home, put some work into finding an organization that is doing good, helpful, generous, committed and integrated development work here and give them a large contribution

m) Once you are back home, never come back here again unless there is another health emergency – the history of the West in Africa is a horrific tale of brutal exploitation, and there is no reason to believe we’re doing that much better now

n) Once you are back home, think long and hard before you come again – tourism dollars generally stay with a small elite, and just lead to increased exploitation and environmental degradation for everyone else

o) Once you are back home, start to plan your next vacation trip here – the beaches are beautiful, and tourism dollars help pump up the economy for everyone

p) Once you are back home, start to plan your next vacation trip here – it’s a global world (see j) and we might as well start getting to know one another

q) Once you get back home, never go anywhere more than 50 miles from your home ever again – given the changes to the climate and the planet, no one should be flying anywhere, ever, unless there is an overwhelming need

r) Remember what you learned the first time you went to India: Just because people’s lives look different than yours doesn’t mean they enjoy them any less than you do. Aside from instances of dire poverty (to the point of malnutrition and homelessness) and/or critical health problems, there are probably just as many happy people, depressed people, angry people, positive people, peaceful people here as there are back home. Get over yourself

s) Other: _________________________________________________________

The best answer is probably a – but anyone who has been reading this blog probably realizes by now that I’m too anxious to do that very well! Given that, my answers are probably: Wholeheartedly: c, e, h, k, l, n, and r. Less certainly: i and m. And I think about f and g, but try not to go down the road of that kind of hypothetical fear, if I can avoid it (that way madness lies).

And then there is q, which seems to me unimpeachably true, but which I have not found, and do not see myself finding anytime soon, the willpower to honor (see Elizabeth Kolbert’s wonderful writing on this subject, most recently in her New York Review of Books essay on Naomi Klein’s global warming book*).

I’d really love to know what others think.

* 'To draw on Klein paraphrasing Al Gore, here’s my inconvenient truth: when you tell people what it would actually take to radically reduce carbon emissions, they turn away. They don’t want to give up air travel or air conditioning or HDTV or trips to the mall or the family car or the myriad other things that go along with consuming 5,000 or 8,000 or 12,000 watts. All the major environmental groups know this, which is why they maintain, contrary to the requirements of a 2,000-watt society, that climate change can be tackled with minimal disruption to “the American way of life.” And Klein, you have to assume, knows it too. The irony of her book is that she ends up exactly where the “warmists” do, telling a fable she hopes will do some good.'

http://www.nybooks.com/articles/archives/2014/dec/04/can-climate-change-cure-capitalism/?insrc=toc

Artist in residence

February 26, 2015 - Another nice and surprising moment, a la the fishermen asking me to help them move their boat: When I got back from the ETU this afternoon, I went over to pick up my clothes at the laundry tent. There was a bit of a line, and as I waited, I noticed a notebook open on the table inside. I was casually looking at what was written in it, noticing a heading there, some lines there, when it dawned on me that what I was looking at was a play. And, indeed, there they were – character names followed by text; stage directions. The tent was being manned by one of the many semi-anonymous (to me - !) staff members here at the tent camp – people you see from time to time but whom you know nothing about, and whom you can’t even speak with easily due to the language barrier. This guy, like most of the laundry tent staff, had often seemed a bit abrupt and unhelpful, so that I’ve developed a mixture of mild anxiety and mild irritation every time I have to go up there. Anyway, when I got to the window I asked him, “Are you writing a play?” And he said “Yes.” And gave me my laundry. No less abrupt, no more helpful, and I still know nothing about him – but suddenly, a whole inner life opened up for a second. Not just a surly guy whom I don’t talk to – but a surly guy I don’t talk to who is writing a play. 

It’s kind of embarrassing that this sudden bursting forth of three dimensions – or of color, like in the Wizard of Oz – should have surprised and pleased me so much (I am beginning to realize that this blog is revealing more about my character than perhaps I would have chosen to show!). But I frequently don’t pay enough attention to the individuals around me, and less and less the more the distances – social, economic, linguistic, cultural – grow. It’s good to be brought up short.

After death

February 26, 2015 - My colleague and I walked into a patient’s room today and found her dead. This has never happened to me before. She was an older woman (her paperwork said she was 35, but, even accounting for how hard life can be here, this is not possible – we thought maybe 65) who had come in a couple of days ago and almost certainly did not have Ebola. She had a swollen belly, a puffy face, and was having bloody bowel movements and perhaps bloody spitup, as well. Although bleeding CAN be a part of Ebola, it is relatively rare, and the rest of the symptoms don’t sound like it at all. Plus, her first blood test was negative (since the test happened within 3 days of her most recent symptoms, though, it is not considered definitive). One of my colleagues, a “hospitalist” (doctor who takes care of patients on the floor of a hospital), and thus someone much more experienced with trying to diagnose unknown conditions than I am, thinks she may have had cancer. In any case, she had been unwell for some time, it seemed to us. 

It is weird to say it, but it wasn’t an unpleasant experience. That is – I wish she hadn’t died, and I am sad for her and for her family. What I mean is – given the fact that she was dead – that it had happened, and we weren’t going to un-do it – moving her on the bed so that she was lying straight, and then pulling a shroud over her to cover her until the team that takes care of bodies could come – I was, in a very small but still real way, thankful to be able to do it. Maybe, back when we did this in the house and didn’t call in a “specialist,” many people felt that way? Or maybe it is just some quirk in me – I definitely have a kind of awe of death, the thing that “makes these odds all even.” But it can’t just be me – there are so many things in the culture – “Fear no more the heat of the sun.” Or – does anyone else have a connection to this one? – the bass aria toward the end of the St. Matthew Passion, “Mache dich, mein Herze, rein”? It’s a piece of music that doesn’t make “sense,” and yet it makes sense. It is after Jesus has been crucified, so the whole horrid story has happened – the people have turned on and failed to save the person who loves them the most; he has been tortured and killed. And then this extraordinarily peaceful – in fact, kind of happy – music starts playing, the text saying “I will bury Jesus myself.” The implication in the song is “I will bury Jesus inside me; he will continue to live in me” – but I’ve always thought that just something about the simple fact of burying him – of taking account of reality, of what has happened, and then dealing with it, straightforwardly, respectfully and kindly – might be part of it, too. After the crisis there is peace; let’s let our dealing with it allow that peace. Since I’m not part of her family – since I don’t have any knowledge of her, no personal emotional investment – maybe this little thing is something I CAN do, gracefully, at a time when it might be harder for someone close to her - ? 

In any case, the family wouldn’t be allowed to. Even though I don’t think she had Ebola, she, like all unexplained deaths here, will be treated AS IF she did – just in case. People who have died are EXTREMELY infectious – basically, if you think of dying from Ebola (as opposed to recovering from it) as being, in the end, overwhelmed by the virus, you get the picture – by the end, the virus is just running riot – you are full of it. So they err WAY on the side of caution, to prevent possible spread.

Which means that what (as I understand it) people over here consider respectful treatment of a body – washing it, preparing it – is not allowed. In fact, families cannot usually even see a “suspect” dead relative – they may sometimes be able to be present at the burial, but they must keep a good distance, and the body will be enclosed in a body bag as it is placed in the grave (in a special area, dug very deep – again, to avoid infection). I gather that this has been (not surprisingly) very, very hard for people to accept – my sense is that a not-insignificant portion of new infections comes from people who, either out of ignorance or because they just couldn’t bear to do otherwise, have taken part in ordinary funerals, instead of the “hygienic” ones that the disease demands.

So, anyway – without being able to act with any particular knowledge of this person, without the care that someone who loved her would offer, without being able to spend much time on it, but nevertheless respectfully and kindly (and without cant), I helped get her ready for burial. Like I say – I am glad of that.

Mid-course

February 25, 2015 - As of today, I’m at the halfway point of my work at the ETU (and 2/3 of the way through this whole posting, including training). The unit only has six patients tonight. Well, really, five – one is a baby who almost CERTAINLY has malaria (which we’re treating) and not Ebola, but whom we need a negative PCR on to be able to allow to go. He (and his mother, who has no symptoms at all) are holed up in a separate building in the “suspect” area which has not housed an Ebola case for at least 10 days, with instructions to basically stay away from everyone else! I’m very hopeful we can avoid giving them Ebola while we wait for the test – which we really, really hope will be back by tomorrow afternoon.

But, anyway – a low patient census, which allows us to do our work with a thoroughness which is very satisfying. Unfortunately, however, Sierra Leone as a whole has had between 12 and 16 new cases a day over the last 4 or 5 days. That’s higher than last week, when the average was closer to 10. And if you have deduced from the above that most of the new cases aren’t in our area, you are correct – a lot of them are near Freetown, in fact, always concerning since spread in a city is everyone’s nightmare. The higher number of cases per day may end up being a statistical blip, of course. And, even if it continues, it might represent hopeful as well as discouraging facts (i.e., it might be better case-finding by public-health teams, not a higher incidence). But you can’t really call it encouraging. Again, it brings you up against how hard actually ending the epidemic, for good, will probably be.

PS, March 1, 2015 - Here are links to a couple of articles discussing the difficulty of actually ending the epidemic here. Very, very interesting reading:

http://www.theguardian.com/world/2015/feb/27/ebola-sierra-leone-village-lockdown-31-new-cases

http://www.nytimes.com/2015/03/01/world/africa/nearly-beaten-in-sierra-leone-ebola-makes-a-comeback-by-sea.html?_r=0