Work, work, work…

BOOK: Transatlantic: A Novel by Colum McCann who also wrote Let The Big Worl Spin which I have put on the top ten best reads ever

THOUGHT FOR THE DAY: People praying jubilantly to God and Allah (perhaps less jubilantly, but with equal intention and fervor) might be one of the best arms of Health Promotion that we have. Note to self…contact religious leaders for intense training. Some may have missed the last one! From my balcony, the sound of fervor is deafening in a very good way. Can you hear them, Big Guy?

SONG: Yes We Can Can by the 17th Avenue Allstars

So the week has come to an end and the sun has risen on my second Sunday in Sierra Leone. It was just rising when I arrived last week, but I was sound asleep as it rose this morning, in my huge clean bed. No alarm to get me up for the early breakfast and departure for the office…loved opening my curtains to a day more or less belonging to me. Went out onto the terrace for my first cup of coffee and later snuck down to get my breakfast and bring it back up to the room. Breakfast is not a social meal for me! The abundance of fruit makes my GI tract a little over enthusiastic, but it will come into balance as everything eventually does. I ate it at my proper not-plastic table, in my soft upholstered chair. Is there still evidence of glee!?

I have actually gotten hand off training from 2 people as MSF is merging the work at many levels to trim things back from the Rapid Response mode to a sort of normalization of activity that will become the transitional and sustaining way we will hand over to the National staff. There have been 4 phones, 2 computers, 1 cash box and various other bits of hard and software. This is presently my 2 back pack system, in place again, and it presents as a sort of mule-load transport when I need to move from place to place. Fortunately the bulky cash box goes on my first morning stop, into the hands of my first team. This is the Survivor follow up group. The MD sees all survivors to monitor them for the list of after effects of their survival. Most conditions seem at this point, to be resolve-able including medical intervention within the existing health structure. Within this visit, each person and often a family member or 2, has a contact with the mental health component to work them thru the stress and stigmatization issues. HP speaks to them about any presence of community stigmatization or adaptation issues. If it is needed, we go out individually with them to do a community education followups that is most often just a supportive reassurance session.

There is also a team within this team that goes daily out into the communities for general, non-specific intervention and interaction. The challenge is in getting the staff to shift themselves from a teaching modality to a dialogue. We already know that almost everyone can recite the list we intitially went out to provide (along with multiple other players) for transition and prevention guidelines. The problem is that the message is surface and the gut connection to disease prevention has not yet been worked out in the individuals and groups in many of the city sections and rural areas. For me it is the “Yes, yes” factor. Like when you tell your mother or your boss “yes, yes” because you know that will shut them up whether you know what you are doing or even remotely plan to consider doing it at all.

I think it is in this context that I want to do training with the staff for community dialogue. One group has done the training and the other has not. Integrating them to broaden the teaching so there will not be boring replay or new info overload will be interesting. It is not in the West African nature or culture to “dialogue” in the way we need. Usually one person tells his/her very circuitous story and the the other person does the same. They might have exactly the same focus, but that is irrelevant. It is always simply the telling and retelling..and Ebola has become a boring story even tho it is still a very big threat. And this prevails from the simplest village construct right up to the president. I am beginning to wonder if it is not a part of the NGO mode now as well.

Moving forward in a sea of well intentioned, very differently funded groups with more so less specific goals, does not come easily into accord. And it does not move quickly either. It occured to one of my handover people that I should consider a plan to invite one of the top dogs in the latter group to come to my team of 50’s groups meetings. I will do that first thing Monday, once I figure out how to use the Nokia phone…was this ever an effective device????? I am getting a lesson on it today. Right after I figure out how to get to my email. Sigh

Yesterday I met for the first time with the 50 member outreach team and have gotten to know (over 2 days) the national supervisors for these 5 different field teams. Everyone in these teams is young and enthusiastic and very hard working. They work the slums of Freetown on a daily basis. They leave early and come back late. They still have some strong training needs but are willing to rise to the occasion in whatever way they can or are asked to do so. All I need to do is show up with what they need for that.

There is a measles outbreak as well that has not reached catastrophic proportions. Fortunately the vaccine campaigns prior to the Ebola outbreak have not left the population totally defenseless. Over a year’s time however no further vaccines have been done for updates or initial vaccines for the newly born. And yes many have been born! For the vaccine deniers among you, I have a really big rant. The absurdity of what is being perpetuated in this effete, supposedly intelligent group, has failed so deeply to look with any world view at the realities. The tunnel vision (or head burying behaviors) rival the group of science deniers who are trying to place Creationism into school science curriculum!! And that is not even the tip of my rant.

And after all else, it appears that I will inherit the Mental health team as well as the 2 HP teams, bring the resounding total of those on my team to about 70. I am sorting out how we can shuffle some national supervision into all of this. I have 2 identified already and they too need leadership training. My shuffling skills are challenged…but it will sort itself out as long as I keep breathing in between each event…and probably during the events also. The psychologist leaves next weekend and says her team is autonomous. We will talk more about this…her and me.

AND then, there is a “lockdown” set in place for this week by the President of Sierra Leone, who claims that the last one was very effective, hence, this one is necessary. Think of being told that for 3 days you will NOT leave your house and the military will assure this…the effectiveness of this idea is just incredibly awful in the real world anywhere. The NGO’s are working on their plans, but ebola response teams were given passes last time this was in place and it will be likely the same this time. They are all able to move in the communities to assure that drinking water and food are in place. The military does house to house checks during this period, “extracting” the sick. There is not much addressing of human rights in these situations on the part of the government and they do not want us rattling their cages. Of course that is one of the primary components of an MSF intervention….I will keep you posted. And as looming as it sounds, every measure of security is on the ground and well-known to our staff. It is just very unlikely that it will be an issue other than complaints and local grumblings. The president told people that is is not a “lockdown” but rather for the people to consider it a “stay at home”. Wasn’t there that period of economic slump in the US that families were told that perhaps it was time for Staycations? But this is definitely not that!

Week one…check…Current goal/get to zero cases…indicators for success/zero cases.

Action points for today
1. post blog
2. work on needlepoint started in Cambodia about this time last year

3. Review most recent handover along with other handover and reflect
3. eat supper with team and sip a surprisingly good Sierra Leone beer called STAR.

Front of the HP office from under the shade


Our front door

My predecessor going thru the computer handoff


Where the huge hospital used to be. My current view

At the bar



How Many of You Will I Lose????

BOOK I finished Night Circus and felt like I was leaving a friend. This was a very visual, artistic book. It was an incredibly interesting change from what I usually take on. Thanks to Steph Metcalf for the recommendation.
THOUGHT FOR THE DAY: Some days it is good not to think
SONG: I Want To Live in a Wigwam, Cat Stevens

In all the stories of strife and sacrifice, I have a feeling I am going to lose a section of the “faithful” followers to “are you kidding?”

After all that wretched soul sucking travel time, we arrived at the house before sunrise. It was dark and so it seemed, appropriately to our exhausted bodies, that it was still the middle of the night. It was not. Breakfast had just been set up and there were eggs and crepes and fresh fruit and bacon and juice and coffee. Sat, who his the new director of logistics, and I sat right down and started in. We had picked up our room cards and decided settling in could wait. We thoroughly enjoyed breakfast. Eventually, a few of the early risers made their way down. It is Sunday and everyone has the day off. The psychologist and eventually the departing Health Promoter (I will take her place as of Wednesday) made it down. The general plan for Sunday is for one of the trucks to take those who want to go over to the beach for the day. Apparently there is truly a beautiful tourist drawing beach with white sand and turquoise water. A day there is usually followed by dinner at one of the restaurants that has met the MSF standard for food prep. Already, I can feel you out there talking under your breath about how dramatic we have made it all sound and…….really, a tourist beach!!!!! tsk!!!K

I will present my defense right away, and you can see if the case seems like sunshine up your skirt or a possibility! At the end of it all, if you think I am just out having secret vacations in resorts you have not yet found on your list of destination vacations, please don’t tell Peter. He really does think I am working. And I will let you know about that part after tomorrow or the next day, since I start work in the morning.

Now, first thing, and the one that I think is the strongest pillar of my defense…Ebola takes a toll on tourism! If I was someone else, that would be ‘nuf said…but I am not!!!

When all the homes in a community are presenting high risk for the disease and the “wide open spaces” where we could pitch tents and live in the place painfully while we work, become security risks of the highest order. Beliefs that the white people were bringimg the disease in in their sprayers and fear-mongering messages in order to take over the country, harvest organs from bodies and sell them for profit…well lets say, that gathering us all into a little tent village is precarious for the defense and security team. So the guys start looking for space for us to live in and LO! not a hotel in the place has a single guest and there are no bookings on their foreseable flight rosters of the airlines coming into the country since the Ebola epidemic came into play. Yep there we have our solution…bingo. Put those MSF workers in the hotel with walls around it (rich tourists don’t like seeing the poor people in the surrounding neighborhoods) and post the gaurds and call it a compound. See how that seems reasonable????

Now, in Liberia (Foya, where I was), where tourism had not yet hit the rural farmland villages, there were a few places that loosely referred to themselves as guesthouses. They had the appropriate walls…however one of them was actually a whorehouse. Sex for hire took a big hit too with the Ebola factored into the economy. P The main gathering room in the “Royale” there had an interesting construct of lights (christmas types) and mirrors. I had been in Guesthouse 2…a lackluster little compound which we were never allowed to leave unless we were in an MSF truck. We had one other with an assortment of rooms and a little kitchen, but nothing to write home about.

Here in Freetown however we are hardly in a struggle to adjust to our living space, unless we are in the group who loves living in pain…I am not in that group. And all the fear about coming back to the white rice, bread, ketchup and mayo and beer diet (you NEVER get diarrhea)…ladies and gents, our 2 cooks Josephina and Serafina are on my highest list of perfectly wonderful people. The crepes for breakfast were so light and perfect…what else could there be ahead…

We get a per-diem in MSF based on the cost of living in the area. We can go out and buy everything we want and eat alone if we want or we can make a set contribution to the householls kitty and cooks like Seraaphina and Josephina cook all your meals for you. Is there any question?

Everyoone in the group does confess to a bit of guilt with the living quarters, but the work has been hard enough for even the toughest among them to justify it. As we are moving to fewer and fewer patients, the work is changing. We need to figure out in places like Sierra Leone where we do continue to have new cases, just why we have not traced them and how we can do it better. We need to teach better and smarter. We need to figure out how the messages will stay with the other public health institutions so that if a case comes in after zero case level has existed for more than 42 days. We need to assure as much as possible that the local health institutions will know how to manage and respond. The whole community will need to know and understand immediately what to do and what not to do. That is the tricky part of what we are part of now and there is a lot of “competition” that I will explain later. Again, I go in for work tomorrow and I will have a much better feel when my predecessor leaves on Wednesday.

In the meantime I actually am trying to figure out how not to jump up and down in pure glee as I step into my room with clean sheets…with sheets at all, in contrast to Foya where we got these poly synthetic pieces of material with a faux burnt velvet overlay. I have my own bathtub and double sinks… My dilemma will be which one will I wash in next?…maybe I will brush my teeth in one and wash my hands in the other. Who the hell knows. It is time for me to go to supper…I will post the pictures later and move on…leaving you to consider how we disperse donated dollars. Do you want to see me living in a blue plastic teepee or a travertine tiled hotel room…cast your vote.

My room #119

View across this huge room to my terrace (note the possessiveness)

View to the left

View to the right (big church activities nearby for entire Sunday morning)


In the Middle

BOOK: still going page by page, slowly thru Night Circus. Sleep creeps in so quickly…will I ever finish this book. It is still good.

THOUGHT FOR THE DAY: Death comes unexpectedly! It was a line from Pollyanna when the preacher was harranguing the parishiners with fire and brimstone. Pollyanna registered the facial expression I can still recall….varies between “hmmm?” and “today?” given my particular day. I cannot figure out if all the lurking sensations and feelings are indicators for “today????” or simply, “hmmmm?” I will have to wake up finally to figure it out.

SONG: On The Road To FInd Out by Cat Stevens

At some points along my way, regardless of the chosen destination, every doubt I have ever had about my capabilities (physical, emotional and intellectual) will converge and LURK. That is such a perfect word. They gather as a little gang and lurk and slink and skulk around in the core of my little being. This usually happens when it is still dark outside.

The sun rash I got in Costa Rica from an apparent allergy to the sunscreen, still has bumps and itchiness that I long to gouge at. I am sure in this doubt phase that it is some new and as yet undiagnosed form of skin disease that will make me red, bumpy and scaly for the remainder of my life. There is a quirk in my back that seems to be hyper-tightened ligaments. They spread over the hip bones and make me wonder if maybe I will bend over and then never be able to straighten up ever again. EVER! The shin splints from walking extra miles everywhere I go because I get lost in any place, time and language I find myself in, remind me that my legs could just randomly give away and I could find myself in an impossible heap on the streets with onlookers that will not know what to do with me. A current favorite self-doubt is that in the middle of any given discussion, explanation or session, my entire mind will collapse and I will not be able to remember my name (I find name tags not all that unattractive at this stage). I have recently developed a steady and persistent set of allergies that make sneezing fits and a runny nose commonplace. Put me near a perfumed human in a vaguely enclosed space and it feels like my eyes have become free-floating entities. I can convert that worry to the belief that momentarily I will be overtaken by sudden-onset glaucoma and blindness. Any one of these things, when I enter this fear/doubt spectrum, could result in unexpected death. See how it is that I relate to Pollyanna!?

As for reality, I am heading for Geneva today. No one has given me an agenda so I am not sure if I will be there just this one day or maybe more, before heading to Sierra Leone. The conference/training I just completed here in Brussels was intense and very informative. It was the first time for a group of people to come together in this type of venue. Everyone had at least one, and in most cases 2, rounds of mission in Ebola in this outbreak. The hope was that we might begin to define more clearly, some of the tools and methods that have grown, like Topsy, out of the fly-by-the-seat-of-our-pants immersion in treating and stemming the spread of Ebola. Yesterday, we were able to take a specific topic, “Security,” which is complex in any application of MSF work, and try to factor in Ebola. Talk about serial and exponential intensification! There is nothing in this disease that is not complex. Thinking in detail takes on an entirely new meaning. When you are dealing with volatile situations, there is a strong need for “what-if'ing” backwards in an event to figure out what could go wrong and what you would do about it. One page of concepts becomes 10 without even getting through the very first teeny little steps. While it is daunting, the collaboration to make it clearer and define it more effectively is so genuine and pure. It is what makes working in the situation reasonable. You are looking from one person to the next and finding nothing but insightful, unfettered and unselfish willingness to make it right.

So, I am now in front of my gate and the plane will begin boarding in 20 minutes. The cab driver was enthusiastic about me using my French and at 6am, with only one other person present, I definitely felt more fluent. One day it will come! It is, as always, just about getting going. Since everyone here mostly speaks perfect English, it gets way to easy to default to it. The sun has come up and the gang of demons has begun to go dormant. I had a breakfast. The concierge at the hotel had already plied me with dark, intense coffee. Oh the kindness of people!

Photos are from the breakfast at the airport restaurant and on to the arrival in Geneva and the office there. I did not have to have as many briefings and they were spread out nicely. I got to have dinner with a nurse I had worked with in Liberia and we reminisced over the good times in Ebola there!! Then we moved on to her perspective on the Sierra Leone mission where she was about a month ago. A little kvetching and a little laughing and philosophizing.

MSF Geneva office

There is only one other person going out on this trip – a logistical guy – and by the time we finish the marathon connections we will know more about one another than we ever dreamed we would or would not want to know. Airport waiting – 2hrs; flight time – 2hrs; airport time – 5hrs; flight time – 3.5hrs; extraction from airport and transfer to boat – 1hr; boat – .5hr; drive to new home – .5hrs. Unaccounted time that we just don't remember – 1hr. It becomes a lot of sitting on thumbs time and as romantic as it may sound, Royal Air Moroc and Casablanca (airport) are not to be dreamed of in anyone's world. It is like flying Southwest in steerage to arrive in El Paso Airport and then spend a LOT of time there.

The yellow is always the thing that tells the story

This is actually a briefing...but not for me


Le Rouge Restaurant where a simple $20 basic breakfat was the cheapest thing in town


Sort of selfie...waiting for the train to get to know


In and Out

BOOK: No time for reading anything but updates and info on Sierra Leone and what I forgot to fill out to update my files for MSF and the HR/Finance team. I hope to finish Night Circus in the days coming.
THOUGHT FOR THE DAY: Was there a thought?
SONG: Here I Go Again


At least with the theft of all our worldly goods, there was little that I had to wash when we got home. I put one bag to rest…a teensy little thing. Nothing to unpack and no bag to put back out into the shed…wah, wah, wah! We had heat, a washer and dryer and our beautiful bed! There was need for a fire in the firelace on all but one day and there has been lots of time to be spent at the computer which makes me realize how difficult desk jobs are on the body and soul!!!! Tonight however, March 7, I have all my things packed, one last go-through to make sure all the papers are in place and when my passport came in from the MSF office at 3pm this afternoon, I was able to start breathing again and know that schedule changes and frantic last minute adjustments would not be needed.

For those of you who might not be aware, MSF work has a “luxury” side bar for me that I may not have mentioned before. To get anywhere by vehicle while I am on mission, there is a driver. I am not allowed on a motor bike, I do not drive nor do I have to know any more than the name of the place I am going. If we are not confined to the compound, we generally get a bicycle. Memories of bobbing and weaving through Cambodian motos and trucks has left an indelible imprint on me. Fortunately, muttering the F wrd in constant undertones while biking is not recognizable for other driers or pedestrians. Terror was a featured emotion. The driver does the rest and usually verrrry well. There is a housekeeper in our house setting who does our laundry. There is a person who cooks our meals and shops for the ingredients. Now, there are occasions where rice is the only available food group, but I am pretty sure this is not the case in the Sierra Leone site. At any rate, the point is to make sure you have no reason to avoid your work. It is a brilliant plan as far as I am concerned.

The 2day seminar I will attend in Brussels will be with other people who have worked in Ebola as well. I am hoping for it not only to be a refresher for the skills and safety, but possibly a large segment on the side of creating new ideas to put into operation to assure some improvement in the community perceptions and acceptance. The day of briefings in Geneva will be on Thursday and then I will head to Sierra Leone on Friday.

Somewhere inside me the balance is working itself out to give me equal measures of confidence and creative uncertainty that will provide a dynamic point from which to work effectively. I really like this kind of work. At the core of nursing there is always ‘observation’ that goes on and continually needs to be re-viewed and revised. Clinical practice is all about what you see, and then figuring what the next right thing is, to move along the wellness continuum. I feel like a true Public Health zealot, having done it both in Cambodia and Liberia through this past year. The immigrant kids coming across the US border were also about the same challenge. How to teach kids about preserving their health in an entirely new culture. It is for me a sense of being at the point where something gets plunked into the smooth water in a pond and you get too begin watching the pattern of ripples move out. Those ripples are an incredibly big deal.

For now, I just finished a poor imitation of a Philly Cheesesteak sub but it was filling and the caffeine in the coke will hopefully keep me awake while I read the historic information I downloaded on the history of Sierra Leone. I forgot to go out in search of something about the culture and medical practice…a few too many exercises on the computer. But there may be time to go looking while I am waiting for the flight out of Dulles. I am hoping for some good movies on the overnight flight. It will be in the upper 50’s in Brussels and Geneva. And the jungle is in its hot season so there will be sweating.

I hope Spring starts coming out for everyone of you. There are some mighty strong buds on the plants in our bluebonnet patch. Be well and happy. I love you all.