Liberia Week #8

December 23, 2014

The days seem to be blurring -- not a real busy day but I was able to get the first draft of the medication order sheets finished and off to KC for formatting.  Also, have the formulary in transient to get cleaned up.  We still have problems with the wells and are getting no response from the well digger who was called Sunday evening. We continue to move on with unpacking, sorting and distributing.

Worked on resetting a large storage tent so it will be more accessible, began having morning staff meetings, prepared for community open house, etc.  At 5:00 PM the new arrivals requested a meeting to voice concerns after a meeting the previous night.  All the complaints were items that were being addressed, but being newcomers, they were not aware of the previous discussions.  Rene and I then met with the physicians and their concerns were mostly based on the unknown -- reasonable and not much different than our team when we first arrived.  A lot of "What ifs?" For tomorrow’s Community Walk Through, we have teams assigned to different stations so will let everyone see what we are doing. It will be much like what was done for Senator Coons.

Tomorrow I will meet with the new Pharmacist and talk drugs and help her get started and then after lunch meet with the physicians and also talk about drug management of patients.

Good phone connection but still no Viber.  I will call tomorrow afternoon and hopefully hear what everyone got from Santa.  I'm assuming that Christin, Ken, et al. arrived from Colorado OK, just too bad it is so late.  Jim is working on a "Goat Roast" for Christmas day, even with a few Club beers and banana wine (local brew).  And there is rumor that the Army is going to send up a Christmas Dinner as well -- we shall see.

Talk to you Christmas day –

December 24, 2014

A very productive day.  In the morning I met with the new PharmD who is going to be with us for three weeks.  She was very energetic and when I explained the drug protocol, formulary, order process, she seemed very engaged.  She saw her "pharmacy" and as the day went on, the construction people cleared out their stuff and she began moving in drugs.  Still missing a lot of promised drugs, almost all IDA drugs out of Holland, but we talked about filling deficiencies through the hospital pharmacist.  I finished the order sheets, sent to KC for formatting, and they came back absolutely perfect. After lunch, one more "walk through" which didn't happen but we did get 20 banana trees at my request to spiff up the place.  We will plant Friday.  In the afternoon, I met with the MDs and had a really good discussion of medical records, standard drug regimen, order sheets ( not quite ready), and formulary.  They were very engaged and really appreciated being introduced to the reality of medical issues that they will face -- lots of people sick with tropical illnesses but not likely ebola.  This is a great learning experience for those new to tropical diseases.

Just as were leaving, a guard showed up with two 5' long green mamba snakes they had just killed in the drainage ditch on one side of our ETU.  I'm ready to come home!  

We ended the day with a trip to the "Club House" for a Christmas Eve celebration before dinner.  Tomorrow is a day off so I will do laundry and actually think about preparing to leave.  Rumor is that we have a goat roast in the afternoon with palm wine.  Jim and I both agree that on Saturday, we will get up early and leave as soon as daylight.  We don't want to drive in the dark.

Hard to believe it is Christmas Eve - 90 degrees at 5:00 pm -- stinky, sweaty clothes and a cold shower before bed.  Another day in paradise!

December 25, 2014

It started with one more walk-through with the inside construction team - and every time we walk through, we change something so I am sure they are totally confused.  At least it will be my last time.  We got 20 banana trees, at my request, so will plant them tomorrow.  The rest of the morning was about cleaning out the pharmacy, getting printer cartridges, soap for the kitchen -- just busy stuff. After lunch, I read for a while then walked by the lab and was given a big piece of pecan pie that they had left over from their Christmas meal flown in at noon!  All of the military personnel are told not to leave the hospital grounds and to only eat MREs -- no local food or drink.  And they are here for 3-4 months, ouch.  At 4:00 we took parting photos of Merry, our pet goat, (bought for $60 earlier in the day) and at 6:00, we were told that we couldn't have our Christmas Evening Goat Roast without beer.  So we drove downtown and bought three cases of cold beer, with a case going to the cooks, a case for us, and one in reserve.  Then the roast began -- very flavorful but TOUGH and CHEWY.  It was supplemented with grilled chicken and fish, on the bone.  There was a lot of greasy finger food but good.  Unfortunately the Bush Devil did not show, the traditional equivalent to Saint Nick - a very tall person on stilts in wild clothing and mask.  He appears for celebrations -- but later we found out you need to book him a week in advance. Who would have guessed?  Then around 8:00 the cooks started singing Christmas Carols - they knew them all!  This was the only real sign of Christmas. I did get a puzzle from home but only one day to do it so may have to take it home with me.  I will be leaving all of my work clothes, shoes, underwear behind to give to patients coming out of the Hot Zone.  Mine are stained with chlorine burns but is better than some of the clothes they went in with and had to have burned.

One more day in Tappita and then to Monrovia and Home!

December 27, 2014

Just arrived in Monrovia - left at 8:00 am and in at 4:00 pm.  Eight hours of roller-coaster ride but not a lot of traffic even on the better part.  Our back window blew out in the first hour so we are covered in red dust.  We are getting cleaned up and then going out for early dinner since no lunch.  I will try to call when I get in.

December 28, 2014

They plan to turn the generator off from 10:00 to 4:00 so I will lose the router and Wifi.  I will call on the team phone - 24 min. for 50 cents.  Not much happening -- a rest day from eight hours of bouncing in a car and preparing for eight hours of airplane sitting.   My itinerary came through so you can follow on it.  I will let you know when I arrive in Brussels and DC - my only challenge will be getting through the DC customs in time for the RDU flight.  It looks like I have almost 3 hrs so I should be good.  I am the only Tainted One from my group going through DC so maybe I will be the only one on the Brussels flight from West Africa.  

The word is that the official opening will be on the 5th.  That seems about right -- still a lot of work in the next week.  There is no chlorine to set up the different chlorination washing, the drugs are not all up, no training of the sprayer teams, etc.  but I think these things can be resolved in a week.  

I am very happy to be leaving and really look forward to getting home.  Wish I were flying tonight but I am glad to spend the day here and have the ride behind me versus traveling from Tappita today and flying tomorrow.  I have washed all of my dirty clothes and am sorting out what I plan to leave behind - pants, shirts, underwear, and shoes.  I will be light on my way out - I was actually the lightest on my way in.  Don't count on souvenirs - there is nothing to buy or bring home!

We did go to an Ethiopian restaurant last night. Jim was raised in Ethiopia, and it was very good --my first meal in two months that did not include a large helping of rice.  No meals today in the guesthouse but we will go out tonight.  

December 29, 2014

Pretty low-key weekend.  After the eight hours of driving on roller - coaster roads, having the back window blow out within the first hour and covered in red dust from there on, we made it safely to Monrovia.  Over the eight-hour trip, it was interesting to see the landscape change.  Tappita is truly jungle - tall mahogany and rubber trees, palms and banana trees, thick, green growth everywhere with almost no inhabitation along the roadside – here and there a rare collection of mud and stick houses with straw roofs.  No fields or crops - I can't imagine what they subsist on.  The women were all straight legged and bent at the waist cooking over a small fire or doing laundry in a pan and washboard. Kids were everywhere in tattered clothes but no sign of the men. Sometimes there were small paths into the underbrush going to where?  I guess the income is from rubber.  Then at Ganta, it begins to clear up and there were rows of planted rubber trees as far as you can see.  Much more signs of civilization on the road-side and the road is even paved and pot-holed all the way into Monrovia.  The houses now are mud brick with tin roofs and there are frequent small tuck shops with basics for sale. There still is no major commerce except for the rubber plantations.  Apparently Firestone owns most of this land -- thousands of acres.

Once we got to Monrovia we cleaned up and went to an Ethiopian restaurant.  As I mentioned, Jim grew up in Ethiopia, son of a missionary family.  His father was the water engineer for the area and sounds a lot like the Jim McGill of Malawi. Can do everything and is asked to.  The Ethiopian portion of the meal was very authentic and good but there was also some Liberian food mixed in.

Sunday washed clothes and packed, and I am leaving behind my chlorine burned pants, shirts, underwear, and shoes.  When you enter the ETU with street shoes, you have to dip the bottoms and this destroys the glue holding the sole to the shoe -- so eventually your shoes come apart.  Mine have begun to separate but are still functional.  If you are a patient in an ETU, all of your clothes are burned before leaving and you are given clean clothes so mine can be used as replacements.  The shoes can be re-glued locally.  In the afternoon we went to a small hotel on the beach and I sat in the shade and read while Jim was in a meeting on security.  From there we went to a small Lebanese restaurant where Jim and I split a pizza - my first in two months.  I am being reintroduced to Western food.

Later. . .

It is almost time to leave for the airport to come home.  Looking back on the time, did I do the work I set out to do? No. Did I do the work at hand? Yes.  I came to care for ebola patients -- the highest priority at the time.  The country of Liberia was being overrun by ebola and there were few willing to step forward to stem the flow.  And, with all the concerns in the US, the best way to protect our country was to stop it at its source.  If not, it would grow to be a major global-health crisis -- for us and every other country.  

Liberia had done a miraculous job of meeting the challenge.  Initially, in August and September, there were people dying on the streets and healthcare workers were dying, too.  But, Liberia started a nationwide public education program that included closing schools, stopping large group meetings, providing “no contact” warnings, and, most importantly, implementing safe burial practices.  The tradition of the family bathing and kissing good-bye to the dead loved one was banned.  At first, cremation was the recommended alternative, but this was so foreign among Liberians that it gained no acceptance.  

Then, community-based burial teams were created and no-touch burials were begun.  Likewise, health care workers were taught to practice universal precautions.  So by the time foreign aid workers showed up in the form of new ETUs, the rate of spread had already started to decline.  By the time I arrived in the first week of November, the occupancy rate in ETUs had dropped to less than half and once I started seeing patients, it was a trickle.  The remaining cases were basically in Monrovia where people lived in close contact.  So providing direct care to Ebola patients was not a necessity. Yet, I had the opportunity to diagnose and treat many suffering from the tropical diseases I have previously seen in Africa and ones not always recognized by my US colleagues.  We saw a wide variety of illnesses - from terminal TB to progressive liver cancer, even a lady with diabetic coma.  Everyone was sick, just not ebola.

But ebola is not eradicated.  What we are seeing are small outbreaks in more and more isolated settings.  There remains a need for Fast Response teams to go out and cast a broad net in these areas and pull in locals  for evaluation as many individuals have signs or symptoms.  The threshold for admission is much lower in order to catch any who might have the disease in order to not let them stay in the village to die and expose others.  So the role of the ETU went from a care facility to a screening facility.  

After working for several weeks in the Kakata ETU, it was the experience and the recognition of this shift in pattern of care that I felt would be beneficial in the setting up of Heart to Heart’s ETU in Tappita.  The unit was designed in the US, construction was assigned to a private international construction firm, and oversight was provided by the US Army. This was to be a new model for care funded by USAID.  Therein lay the problem -- four agencies trying to work together, none with any experience with ETUs.  We had no one on the ground with more experience than three days in an ETU.  So I volunteered to use my experience and insight for the final phase of construction.  Thus, this was not the work I had come to do, but it was the work at hand.  

The time spent was very worthwhile since I had much to share.  The Tappita ETU is now scheduled to open in one week and I believe the facilities will be operational and the staff properly oriented.  Is the ETU now needed? Definitely. There is still the need to screen and look for the isolated case of ebola as well as train National staff on proper precautions.  Ebola will be back; as long as there are porous borders with Guinea and Sierra Leone, there will be a flow of ebola into Liberia.  Nimba County borders both countries, so it will remain a future route of ebola as Tappita sits right at the crossroads. Just last week, four cases came from Guinea and three of those have died.  One victim was the motorcycle transport that carried the others across the border.  What if he had been coming on down the road to Tappita?

Is ebola the worst disease ever? Seven thousand have died from ebola but malaria kills two million a year.  Is it to be feared because of its death rate or speed of death?  With good care, many can be saved and we have moved towards giving that level of comprehensive care -- not available at the onset.  For speed of death, I have cared for many in Africa that died faster from malaria  -- a child playing in the morning, onset of fever at noon, seizing and dying at 5:00 pm. And, the mother who is induced by the Gogo and put into premature labor for 48 hours, eventually coming in for emergency care in shock from a ruptured uterus. And, AIDS is not called slims disease by accident – it is the long, slow, but too often certain death of African men, women, and babies.  Death and dying are not uncommon when working in Africa.

Maybe the speed and coverage by our news media of ebola has made it so feared.  With good resources, it is a manageable disease.  Unfortunately, the impoverished countries of Africa do not have the resources to stop ebola completely unless they build/rebuild the entire healthcare system.  I do believe that this is one of the US governments’ commitments and I know Heart to Heart, my sponsoring organization, is interested in moving into that phase of providing better health services to the people of Liberia.  

Maybe I can come back and be part of the future.

Thank you to everyone who has supported Betty and me in this endeavor.

Signing off from Monrovia –

George Poehlman, MD, MPH