Worker PTSD

It would be crazy to say that being here in Ebola land does nothing to your psyche.  I think of the hundreds of workers who have been here for some months, trying to make a difference in a terrible disease.  But most of us are not used to having 60-70% of our patients die, the statistic that seems to be relatively steady in our treatment center.  The only thing that gives us the impression that we are making any difference is by looking at the total number of patients, and factoring those into our psyche.  For example, the other day, we discharged 6 patients from the center in 1 day, but all of them were Ebola negative from the beginning, so they never had the disease.  So although it seems like some progress is being made, it is a false mirage, one that promises water without delivering any.  The disease itself continues its terrible rampage, and the benefit of our treatment center may be in getting those with Ebola out of the community, more so than actual benefit to those patients.  

So far, in this blog, I have avoided giving much personal introspection, and have made it more of a travelogue.  However, the individual cases eat at your insides, and linger long after the patients die.  Yesterday, we admitted the husband of “Fatimata” (not her real name).  She died last week, after the battle was lost. We thought that she might be the very first pregnant lady to survive the disease in our clinic, and for a couple of days, it looked like that she would make it.  But then, she rapidly deteriorated and died over the course of a couple of more days.  And so now, here comes the husband.  What about the 4 children who are at home, wondering if they will get to see Dad again?  One of his symptoms is hiccups and bloody diarrhea, and both of these are not good signs….I am certain that he will be positive, (he was) and the question is--will he make it home and return to his family?  ...This randomness of death and destruction plays with your mind.  I think of one doctor who was a pediatrician here who stated that he had certified more deaths here in 6 weeks than he had in his entire career up until now.  In Family Practice and ER work over the years, I cannot say the same, but the degree of deaths and percentage are like no other disease that I have seen. And so all of us are weary in a way that defies compartmentalization. We absorb all of this into our psyche and it wears you out emotionally.

We discharged “Mamood” earlier this month….Mamood’s mother had died in our center, and it appeared that the disease might escape the rest of the family, when a week went by with no problems...but I remember the day that Mamood and his father were both admitted to the unit.  Both of them walked in, but only one walked out--the orphan Mamood, at age 8 facing an uncertain future.  Will his village take him under their wing? It certainly seemed that way when they returned him to his village.  We hope that they will take over for his absent parents.  But what really will happen?  These are the questions that haunt, and we know that this same scenario has happened so many times over the past months here in Sierra Leone, Liberia, and Guinea.  

These are the questions rolling around in the back of the mind, as I trudge through the Ebola ward tonight.  The questions roll back and forth, and do not go quietly into the night..

Here are photos from the ETC.  Here is the main street in the compound

The Probable Ward across the red fence

Inside the medical tent, where charting and computer work is done

Looking towards the psycho-social department from the medical tent

The doffing station, where we take off our Personal Protective Equipment

This is the Suspect Ward in the background, and on this side of the fence, the donning station, where we put on our PPEs

Boots drying in the sun, ready for reuse

Pharmacy tent

On the road...

Over the past week I (Heleen) travelled across Sierra Leone. First to Pujehun, in the far south, then to Kailahun in the east. It was nice to get away from Freetown, the always busy city, where the Ebola messages are right in your face, non-stop: posters, paintings, radio messages, etc. etc.

Now I looked out of the window and saw beautiful wide rivers, birds dancing in the air, a mother playing with her baby, holding him high over her head, a child smiling and calling out “Pumwuy!” (white person), a little boy holding a goat (upside down) under his arm. Despite the dryness of this season, I spotted some beautiful flowers: bright red, purple, yellow… The Ebola crisis seemed far away.

But when taking a closer look, I noticed the differences with earlier visits: schools are locked up, playing fields deserted. In the markets all the stalls are empty. There is not much activity around the clinics and hospitals. We passed several Community Care Centers for (suspected) Ebola patients and one of the MSF Ebola Treatment Centers. Then there were the frequent checkpoints where we had to come down from our vehicle, wash our hands with a chlorine solution and have our temperatures checked. And anytime I looked out of the window my view got partly blocked by a sticker saying “Stop Ebola. Prevention is your best protection.” Ebola is real, also outside Freetown. In fact, Kailahun was the district where it all started.

In one of the villages I chatted with two teenagers, a boy and a girl selling oranges and sweets. They told me they have no idea when their school will reopen, but “If school opens tomorrow, I will go back,” the boy said determined.

In Pujehun I met with the Save the Children staff. We brought out large sheets of paper and started describing the Ebola crisis through the eyes of a child: no school to attend, not being allowed to touch your friends, hearing non-stop Ebola messages on the radio, seeing graphic pictures displaying the symptoms of Ebola, hearing people talk and use unknown language: quarantine, contact tracing, swab taking… As farming activities were restricted, many families faced hunger and malnutrition. Children saw the ambulances come and go. An SCI staff commented: “they will say, ‘that ambulance took my mother and she never came back’…” People in strange suits came to the village to remove the dead in plastic bags. Some children survived Ebola but were no longer welcome in their communities.

The next step was to think: how would children feel about all these things? Another long list was made: sad, afraid, confused, abandoned, stigmatized… And then the last step: how may children behave when they feel like this? Some withdraw, some cry, some wet their beds, others struggle with concentration, while there are also children who become irritable and start fighting a lot.

It was a very helpful exercise which opened our eyes to the psychosocial impact of the Ebola crisis on children. We can’t change what has happened to the children, and may not be able to change what is happing to them today. But together we can make efforts to help children come to terms with the stressful events they have experienced. That’s what I hope to be doing over the next few weeks…

My visit to the Kailahun Field Office was cut short when I came down with food poisoning. Never a great experience, but worse in the era of Ebola. I was not allowed to work and had to spend most of Thursday in the staff guest house, resting and drinking lots of ORS. Thankfully my temperature remained within the normal range and today I was able to travel back to Freetown. Please keep me in your prayers as I further recuperate…

On the road...

Beautiful rivers...

This is the road to Kailahun - a district with a population of 465,000!

Temperature check

The dusty town of Kailahun, a district capital without paved roads...

Put to shame...

We have so much, so much, so much

We have so much, so much, so much

We have so much, so much, so much

To be thankful for!

We have our nurses, to be thankful for…

We have our doctors, to be thankful for…

We have our children, to be thankful for…

Etc.

Everyone was dancing as they were led in the song by a nurse preparing to work in an Observational Interim Care Centre (OICC).

I was at the world’s first ever Unicef training on OICCs. I’m not sure that’s something I would naturally feel thankful for… OICCs are places where children are kept who have been in touch with Ebola patients (for example parents, brothers, sisters) and who have no other place to stay. For 21 days they are kept apart as much as possible, and cared for by women dressed up in plastic suits… If one of the children becomes sick with Ebola, the 21 days start all over again for the rest of the group.

Among the trainees were several survivors of Ebola. Since they most likely have developed immunity from Ebola, they are much sought after as carers in OICCs.

We started the day with sharing our experiences as child caregivers. I always feel slightly self-aware in an exercise like this. In Sierra Leone, to be my age and not have given birth to children is highly unusual, and for local women an area of great concern and stigma. But the slight uneasiness I felt soon vanished when a sweet-looking lady told us: “I used to be a mother of two, but I lost them both to Ebola…” And another woman: “I used to have eight children, but I lost them all to Ebola…”

And yet, these women were there, singing: “I have so much to be thankful for…”

We rush to emergency areas around the world to tell people how to cope with loss and grief. And are put to shame…

Together - at a safe distance :)

So today Jon was able to swap a shift with a colleague and come to Freetown for the weekend! We were very happy to see each other again - although we have to keep a safe distance, which means: no touch! We are having a good time talking through the experiences of our first 10 days here, drinking good coffee, eating good food, and planning our wedding! 

So here's a picture of "happy us"- maybe pushing the distance a little, but still no touch! :)

We'll be going out for dinner this evening (in one of the few places that are still open) with some friends and are hoping to attend church in the morning before Jon leaves again for Lunsar.

Things seem to be getting a little better with the Ebola crisis. We hope that this will continue and that we can soon call this crisis history. 

Much love from both of us - we are grateful for your prayers!

FEAR

   I sit here on the backside of another day here in Sierra Leone, after working during the early shift at the Ebola treatment center.  I enjoy the sunlight, which here at this time of year lasts until close to 7 pm.  The harmattan season has been nice here in Sierra Leone to bring refreshing breezes and cool weather at night, making the night shift almost cold at times in the medical tent.  A jacket is advisable, that is for sure.  And I contemplate that emotion called Fear.  
   I think that I will capitalize it during this blog, because Fear is a hard taskmaster.  It is like a many headed monster that once you get one part beaten down, another rears its head and attacks with just as much ferocity.  I am guessing a bit like fighting an octopus, or playing that video game where you bop things on the head with hammers....Fear will change behavior and inhibit a person.  The Bible talks about ‘Perfect love casts out fear’ and yet we struggle with it in our lives over and over.  We tend to fear the unknown, or fear what we do not understand, or even in cases of those with panic disorder, fear Fear itself.  None of us are immune to Fear.  Right now, in America, people are very fearful of the Ebola Virus, even though only 4 Americans have been infected, and only 1, a Liberian with US citizenship, has died.  It is natural for Americans to fear a disease that seems to be hard or impossible to control, and so many laws have been put into place by fearful people, trying to control that Fear.  But in coming to Africa, I felt that I was somewhat immune to that myself.  My familiarity with Sierra Leone and West Africa might allow me to skip some of the elements of fear that would normally beset a newcomer..

  But welcome to the real world.  I found that traveling throughout Sierra Leone actually made me feel more secure, because it seemed as if people were going about life as normal.  People on the streets, hawking their wares, Okada (motorcycle) drivers still driving insanely, and shops and markets continuing to sell.  So, I was quite surprised at several of the fears that I had, as I worked at the Ebola Treatment Center.  The first time back on the ‘hot’ side of an Ebola treatment center, even though my involvement was limited, I could feel the fear creeping up into my throat.  How will I survive?  Or will I even pass out, not being able to breathe, protected by a full body suit, goggles, and apron, and no exposed skin anywhere?  The fear was palpable, a presence that threatened to strangle, even to throttle you.

  A different type of Fear for me here this time is an insane worry about every little symptom, something that often goes completely ignored in another context.  I don’t worry about symptoms of my body, particularly in America, but here I go down through my mental checklist of what is normal, and what is not normal with Ebola.   It is common to get loose stools in this environment with different foods, but now, “Is this the first sign of Ebola?” Or waking up at night sweating on a hot night, and wondering, “Was that from a fever?” Or a bit of dizziness--is that the first sign of illness?  Even though none of these things are rational thoughts, there they are, particularly in the middle of the night, when all fears seem to be worse.  Or for the first couple of days, due to decreased coffee intake (2 early cups only per day), I started with headaches in the afternoon.  Well, headache is a symptom that we ask every day in the clinic of each patient, “Yu ed, de at?”  (your head, does it hurt?), and so is that an early symptom.  So, another worry..

   As with all irrational fears, it doesn’t help to use reason, because they are of course irrational.  So reasoning will not help to quell the anxiety that you feel, or the tightening of your throat muscles.  But time and experience do help.  I know now how protective the suit is of any virus getting through.  And I know that there have been no cases of illness after 4 months of work in Liberia and Sierra Leone in the staff of IMC.  And it does help to calm things down, to rest, to sleep…”He leadeth me beside the still water”.  I don’t think God wants us to worry, but he also brings peace.  He doesn’t deliberately lead us to the areas that are very troubling.  He is able to quiet us down, even if the circumstances are not quieting.  So, God becomes the stabilizer, the Rock, or the Anchor to which we hold.  Thanks be to God..

Ebola Treatment

Ebola Treatment Centers

What does it mean when I say I am working at an Ebola Treatment Center?  Well, I wasn’t completely sure that I knew when I got here, but have a much better idea since being here in Lunsar for the past 4 days.  So this blog may be a bit more technical than some and I hope you can forgive me for that...The Ebola treatment centers set up all over Sierra Leone are new encampments, and there are many different ones run by different organizations.  The one here in Lunsar where I am staying has been up and running for the past 2 months, and is the busiest one in Sierra Leone run by International Medical Corps, a US and UK based organization that gets its support from many different areas.  Here is there web site if you are interested  https://internationalmedicalcorps.org/section/about/mission#.VKo8wVWJOuY   Some of the focus of IMC has been shifting from Liberia, where the epidemic is decreasing, to Sierra Leone, where it may still be increasing.  There is also a brand new treatment center in Makeni, less than an hour down the road, but due to the fact that it is new, and (I hope, maybe a lessening of the incidence,) it is not very busy so far.  I think they had all of 3 patients 3 days ago, which must be boredom city, as they have an even greater staff and capacity for 100 patients.

The team is staying at a resort motel, that has been hurriedly opened,  also in response to the crisis.  Resort may be a bit generous, but the accomodations are comfortable, and quite livable.  In fact they are still cutting down trees, to make way for the buildings, and the construction is a bit rough around the edges, since it has been built in haste, but it is still a work in progress. Here is one photo of my place of abode..

 All the workers are housed in separate compartments for obvious reasons, and there is a no touch rule in effect.  We have transportation to and from work, a distance of 4 miles or so.  The Ebola Treatment Center (ETC) is the medical option in this area for Ebola patients, and currently has about 20 patients or so.  When you get into the van to go into the ETC, they always take your temperature before you get in the van.  When you get to the work site, you are met by a very friendly but firm greeter, who once again takes a temperature..and if you are over 37.6 C I believe, is the cutoff, you get to remain outside the compound.  Yesterday, when I had been standing out in the hot sun for a half hour or so while we received an ambulance, my temperature on my forehead went up to 39, so I had to take a break in the shade until it came down to normal, which it did very rapidly.

So, in the ETC, there is a “clean side” and the ‘hot side”, and there is no mixture between the two, unless you are wearing protective equipment.  Before entering the clean side from the outside, you have to get the bottoms of your shoes sprayed off, which you do by balancing on one leg as they clean one side, then switch to the other one as you step across the red line into the ETC  Once inside, the first thing you do is take off your clothes, and put on their scrub suit, along with a big pair of rubber boots, which will be the outfit for the rest of the day.  You wear the protective equipment any time you go into the hot zone, and because of the restriction of the suit, can only be in it for 1-2 hours at max, and that is strictly enforced. The outfit allows no skin contact with any fluids, as the goggles cover the eyes, and the suit with the cap cover everything else, along with 2 sets of gloves. On the clean side, there are still many washing stations which you wash in a chlorine solution before any major change.  So there are many tents set up, a cafeteria, a kitchen, a medical tent where the doctors and nurses do their charting, a wash tent, a laundry room, and then the donning and doffing stations.  I guess the British influence gives those names, but the doffing, which is the most important in a sense, is where you take off the outfit.  That has to be done in a very precise manner to avoid having any contamination of the skin.  I am still learning that process, although I have done it every day since I have been here, but you do get better and with less travail as time goes along.

Patients are housed in 3 wards, Suspected, Probable, and Confirmed.  So all of the confirmed patients are in the same area.  Unsung heroes of the Ebola epidemic are Ebola survivors, many of whom volunteer to be caregivers in the Ebola wards.  Particularly with young children that are separated from their parents, or whose parents may have died, there is a need for someone who can stay back there and “look normal” and don’t have the restrictions that everyone else has.  One lady there has lost everyone else in her family, and so when asked why she volunteers, she said, “after all my family died, and I survived, I went home and cried for a month.  And then I realized that I could help others, so I volunteered.”  It gives new meaning to working through your grief, doesn’t it?  

Another unsung hero of this epidemic is Brussels Airlines, and Moroccan Airlines.  They are the only commercial carriers to continue flights to Freetown, and they have been the ferry for the hundreds of workers who have come to the area.  The fight would not be possible without them, I am afraid.  I don’t think the UN would have stepped up to get people down here.  My flight was almost all aid workers coming to help with the epidemic, and it seems like that is continuing.  So they have been invaluable in this process.  Also to be commended are the many who have given up time with family and friends to help fight this terrible epidemic.  

So, that is a technical explanation of what is a mulifaceted approach to fight the disease.  There are many aid organizations working here, and I believe at this point, Sierra Leone has enough ETCs to treat everyone with the disease. If it can be stopped, this is a good start...We continue to pray to that end.  

Arrival (Heleen)

After eight months of Sabbatical I arrived on African soil again… I am sitting on a little veranda at my hotel in Freetown. It is so good to feel the warmth again, to hear the familiar sounds of Freetown at this hour, and to call out greetings to passers-by: “Gud-ivnin-o. Api Niu Ia!” (Good evening! Happy New Year!).

We made an early start Wednesday morning, as my sister and brother-in-law took us to Brussels Airport, leaving at 6.00 am. It was a huge blessing to be taken there by car and to share a cup of coffee with them before we said good-byes. I still don’t like goodbyes, but what a difference it is when you walk away with someone on your side, someone holding your hand, someone who says a prayer for a safe travelling, and offers a shoulder to sleep on. I am grateful…

Anticipating our four months of no-touch, we sat close together, stole a few kisses, and asked questions: Will you tell me if you are not well? (yes, that’s me, trying not to sound too anxious…). What are your dreams for 2015? (That’s Jon, always positive, helping me to look beyond the next few weeks…)

The arrival in Lungi was chaotic as usual. Added to the usual hustle and bustle, there were now buckets with chlorinated water to wash our hands, forms to be filled about our exact whereabouts over the past few weeks, and about any symptoms of sickness over the past few days. Our temperatures were checked, passports stamped, and off we went to collect our luggage. It took a while before our suitcases showed up and our contact persons identified themselves and got us our tickets for the water taxi. If I hadn’t made the bus ride to the water taxi before, I would have thought we were abducted and taken into the bush. But soon the beach showed up, and while waiting for the boat Jon and I briefly met up again. Finally, a quick goodbye: “I love you!” and off I went on the boat to Freetown, while Jon had to wait for his turn.

After a quick stop at one of the Save the Children’s houses the driver who picked me up took me to the hotel where I was supposed to spend my first few night(s). Typically overpriced and underserviced… There was no water in the taps so I ran down again to ask about it. A few minutes later the water started coming, a brown-yellowish solution… I kept it running and after a while it looked good enough to take a bath! Then I turned off the air conditioning (far too cold for me!), opened the windows to let in the tropical breeze and crawled under my mosquito net for a good and long night of rest…

At breakfast this morning I met some Save the Children’s colleagues who had arrived overnight to work in Logistics and Sanitation. Thankfully, these professionals more than agreed with me that the hygiene standards of the hotel were far below what is required for this Ebola-affected era. So I was not sad when I was told to check out before leaving for the office. The rest of the day was full of surprises, maybe more so for the country office than for myself, as I had not been expected and it turned out that my position doesn’t really exist! However, they were very happy to have me and there is plenty of work to be done, so they have started putting everything in place for me to join the team. 

In the afternoon I was taken to a better hotel (the one where Jon spent his first night) and as of tomorrow I should have a room in one of the Save the Children’s staff houses. Internet is not really working here, so I’ll have to post this tomorrow at the office. But my search for a new SIM card was successful this afternoon. My phone now works and I just found out that my beloved has arrived safely in Lunsar, where he will be posted for the next few weeks. His arrival wasn’t without surprises either, but I leave it to him to tell you more about that.

This evening I read Matthew 1 and realised that our engagement is actually not that complicated if you look at Joseph & Mary’s. Their “no-touch-period” lasted a good bit longer and was surrounded with shame and rejection, while Jon and I receive so much support for our decision to say “yes” to the call for help. Again, I am grateful…