Some not too sad stories

There are things in Sierra Leone that are starting to seem normal, but when we say them out loud it sounds ridiculous. I want to compile a few of those stories here.

The first is a story from Rachel. During COVID all of the outpatient services were constrained to one room in one building: Registration, Payment, Consultation, Minor Procedures and dressing changes, etc. There’s basically no privacy as every section is just separated by fabric curtains. A patient came in with a large laceration on her leg from falling in the market onto some exposed rebar. It became infected and she had to come back daily for dressing changes and wound care. Sometimes she would be screaming so loud with the dressing changes that we’d have to shout to hear our clinic patients. But nobody seemed to mind.

We use honey dressings for their antibacterial properties and this woman really needed it. They keep the honey in a plastic water bottle, but this bottle was running low. Since everyone pitches in, a lady from accounts grabbed the 20L container that we store the extra honey in. She used a scoop to fill up the small water bottle and handed it to the nurse. I watched as the nurse applied the honey to the patient’s wound. But when I looked to my left, there was the lady from accounts, standing right next to the patient, licking the honey from the scoop! (Why waste honey??) Can you imagine being a patient and watching someone eat the very thing a nurse is putting directly into your wound?!

Another instance is regarding our night security, Pa Brima. This guy works very hard. He has both day and night jobs most of the time. When he comes for his shift at our house, he usually changes clothes into something more comfortable for the evening that he doesn’t mind if they get dirty. One night we have other Americans coming over for dinner. As is usual, we decided a time for them to arrive. When Brima came for the evening, I warned him that they were coming at 7 PM. The appointed time comes and I hear a honk at the gate. I go outside and I see Brima opening the gate for the car. His shirt is half pulled on and wadded up around his nipples; thankfully his undershirt was properly positioned. He doesn’t have any pants and is wearing only boxers. Everyone gets out of the car and happily greet him because they know him from another job. Then we all go into the house. Nobody mentions it. It’s somehow normal for our security to be half dressed.

Lastly, a story from a patient in the ward. On one of our mobile clinics, John Max Conteh (one of the midlevel providers, a CHO), saw a child who was 7 months old and weighed less than 3 kg (6.5 lbs). This is the most malnourished child I’ve ever seen. This child’s name is Neneh (a girl’s name) even though he is a boy. The mother had so many baby boys die, that when she saw this one was a boy she gave it a girl’s name in hopes that whatever killed the others wouldn’t effect this baby. I sat next to the woman and baby on the bed and facing us was the husband sitting on another bed. I was asking them questions about their living situation, their other children, this child’s birth, etc. I asked if the mother was breast feeding and she was. I asked if she was making much milk and instead of answering the question, she just pulled her breast out of her shirt and squeezed it. Breast milk came out more like water than milk because of her malnutrition. But when she squeezed it flew out and sprayed all over her husband who was sitting directly across from us! I was the only one who was surprised by this, everyone else carried on the conversation as normal. “See, she’s making milk.” 

Anywhere you live, life can be sad and life can be strange. But the longer you hang around, the more normal things seem. I think this is how cultural blind spots are formed. But for now, I still relish the cartoonish absurdity of daily life.

What Kind of Week Has it Been

It’s only Tuesday but this week has already hit me hard with the reminder of how stupid Africa is. It’s stupid that by sheer chance you can be born into a country where death is so common, poverty is rampant, hunger is fierce, and illness is beyond healing. It breaks my heart. And if by sheer chance I was born in Africa it would break me. But these Africans are strong in so many ways. 

Here’s this week’s happenings so far:

A 40 year old man who is quickly on his way to death’s door due to multiple infections ravaging his body. Infections that could be easy to treat if it weren’t for his positive HIV status. HIV is treatable. And in this country the treatment is free. But the stigma behind HIV is so strong that even after meeting with the HIV counselor he denied it to my face that he had HIV. He told me the counselor tested him and it came back negative. I call the counselor to make sure I hadn’t misunderstood her when she told me he was positive. I hadn’t. He still denies it. HIV can tear families apart and leave patients stranded without family support. I hate the stigma behind HIV. It drives people to choose an early painful death over the possible judgment and abandonment they might receive from their friends and family. Africa is cruel. 

One of my favorite staff at the hospital is a young guy in his 20s that was laid off when coronavirus reared its ugly head. In order to keep his 'job prospects,' he still shows up to work every day. He begs food off of friends. Or if he is asked to get something from the market for work he is given money for transport (20 cents). He takes the money, runs to the market and back to make it the same speed as transport. Then he uses the transport money for food. He came to my house to help fix a leak in my water tank and I saw him take a half rotted orange from my compost pile and put it in his pocket for later. Africa is senseless. 

The second the young man walked into my exam room I knew he had a terrible infection because even with my mask on, the smell was nauseating. He pulled down his pants and I could literally see his intestines and stool coming out of his low abdomen. His scrotum was so inflamed and infected it looked like it could fall off. When further examined, every place his scrotum attaches to his leg is just rotting away. Africans have an amazing pain tolerance. There’s no way I would be walking and talking calmly like him – someone would have to carry me and I would be wailing. I don’t fully understand what causes people to wait so long to seek medical treatment. Fear? Lack of funds? Tried the witch doctor first? Any one of those you pick is directly related to having been born into this country. Africa is unfair. 

A family lost their 3 year old boy at 4 AM this morning. He had a hemoglobin of 3 (normal is >12) and severe cerebral malaria. The peripheral health unit without a blood bank or doctor, kept him for 48 hours before transferring him to us just before his death. Africa is heartless. 

And it’s only Tuesday….

“He will wipe every tear from their eyes, and there will be no more death or sorrow or crying or pain. All these things are gone forever.” Rev 21:4

Can’t come soon enough. 

Camping Degree

I graduated from Union College in Lincoln NE in 2011 with a BS degree in International Rescue and Relief (IRR). It was a great degree for me: international experience, networking with lots of like-minded people, met my pre-medicine requirements, and had exciting classes like ocean survival, high angle ropes rescue, and a semester overseas.

But the thing that sticks out in my mother’s mind is how much time I spent outside of the class room. She affectionately calls it my “Camping Degree.” If I ever come up with an unexpected solution or have some strange trivia at hand she will ask, “Oh, did you learn that from your camping degree?”

There have been several experiences recently that have brought this back to mind.

Prior to COVID, we would carry our laundry to the hospital every Friday and Ami would use those facilities on our clothes. But another solution needed to be found now with the hospital’s functionality limited. So I set out to hang a clothes line on our front porch. The pillars are far apart and maintaining proper tension for an entire wet wardrobe was difficult. So I designed a mechanical advantage system using carabiners, paracord, and some hammock straps. Unfortunately, I was one carabiner short. Here’s a picture of my ultimate improvised locking carabiner:

The Most Secure Clothesline on the Block ™

Access to running water is always a struggle here. The international travel and survival training helped me prepare for living in Sierra Leone. The other night it was raining hard and there was lots of water coming out of the newly installed gutter on the house. So I seized the opportunity and had an unlimited water shower with excellent water pressure.

Lastly, it’s always nice when dreams from the past come true. While I was purchasing gear for IRR it was easy to dream big. ‘I might need a 0 degree bag if I ever climb to basecamp on Everest.’ Or ‘I might need this expensive headlamp if a natural disaster destroys the power stations for weeks on end.’ 

Most of the rationale that I used for expensive gear never (thankfully) came to fruition. But in this instance it did. When shopping for a backpacking stove there were several options. The two I was torn between was the MSR Whisperlite and the Wisperlite International. They are basically the same except the international version can burn more than just camp fuel. It takes camp fuel, or petroleum, or diesel, or kerosene, etc. I thought to myself, ‘Who knows? Maybe I’ll be stranded in Africa somewhere and be super hungry. This could really help!’ And just like that, I bought the more expensive one.

Well, last Sabbath the natural gas for our stove finished and the backup was empty. As I filled the camping stove with fuel from our generator, I happily reminisced about my time at Union. I had proved once again, that my so-called ‘camping degree’ provided me with more than just happiness or meeting pre-med requirements, it performed as promised and prepared me for the future.

Six Degrees of Separation

I’ve never had an opportunity to really witness the theory that any 2 random people on earth only have 6 people connecting them. This theory states that if person A knows person B, who knows C, who knows D, etc. there are only 6 connections that need to be made between anyone, anywhere.

This week I had a young woman come to my clinic who had been referred to me by name, which is strange. Doctors in Sierra Leone don’t really know me and wouldn’t refer patients to me anyways. Past patients do spread via word of mouth, but usually they just send patients to the hospital, but not to me directly. She had my name written in a text message.

She presented to me with some longstanding neurologic condition that I don’t fully understand. At the age of 20 she began to have right sided leg weakness that spread to her right arm, then progressed to gross motor tremors. She was diagnosed with hyperthyroid and started on Carbimazole, but since then her symptoms have progressed. Even though going to college, her hands can barely grip the pen due to fine motor deficits. Her right leg can’t fully straighten. When I try to straighten it forcefully, it starts to subconsciously writhe like a fish out of water. There’s other weird stuff too, but that’s not the point of this blog.

After exhausting my medical curiosity, I asked about how she knew about me. She told me about an uncle in the US who knows a woman (whose name I didn’t get). This woman is the daughter of EJ Heisler, who I met at my in-law’s Seventh Day Adventist church in Bismarck ND. I met EJ last year and was thrilled to meet me because he worked in Sierra Leone, at Masanga Hospital, in the 1980’s. 

Let’s count the connections: My patient -> Uncle in the USA -> EJ’s Daughter -> EJ Heisler -> Me. 

Apparently there are only 4 degrees of separation between me and a random person in Salone. That’s crazy!

I was so impressed, that I told my friend CHO Abu about this strange connection that even stretches through North Dakota. His response, “Ah! I know Pa Heisler! He got me the job at Masanga that started my career. He was so kind that every month he would buy all the single men a bag of rice, cooking utensils, even matches to start cooking fires!” 

In the days since Abu told me that story, I’ve been struck with how long lasting kindness is. Pa Heisler has left such a legacy that a random sick patient can find access to an American Doctor. (A doctor who feels way out of his league, but has connections to neurologists in the States) But Pa Heisler’s legacy even extends to my own staff who remember him fondly and tell long stories about the effects EJ had on the country. I heard someone say recently, “There’s no such thing as luck. Only the effects of kindness from one stranger to another.”

Now a bit about the hospital. The government had contracted with us for 80 beds, but since our arrival the number of COVID patients hasn’t exceeded 15. Which leaves the majority of our hospital sitting empty. In a small building separate from the hospital we are running all of clinic, wound care, procedure room for suturing, and only 1 bed for admissions. Because we can’t utilize our facilities, there are no surgeries happening. We have to turn away critically ill patients, and there isn’t enough revenue to pay our staff. Daily, I have staff telling me how they are struggling without salary. But concurrently, almost every week, I see a donation come in through the website. I want to say thank you!

https://adventisthealthsystem.sl/

Our hospital couldn’t exist without your support. And whether you see it or not, your kindness has a long lasting effect that will be felt for eternity.

From the bottom of my heart, thank you for your kindness and generosity.

This is a screenshot from a video I helped Abu record to send to Pa Heisler. You can just see the joy on his face that these memories bring. 

8.3%

 8.3%

Sure doesn’t sound like much, but it feels like a lot. This year we will have spent one complete month in quarantine. Two weeks were paid after traveling back to the US in April and just yesterday we completed our two weeks after returning from Sierra Leone.

It sounds easy: sit at home and do nothing. The first two weeks had their challenges; we really wanted to see our families in person. But these second two weeks came with a whole new set of challenges. Mold, intermittent electricity, intermittent internet, and our water tanks running low. Theoretically, we are supposed to get water from a reservoir maintained by the government. This reservoir routinely runs out of water in the dry season, but it’s still the tail end of rainy season and we aren’t getting any water! Rumor has it that the dam is under repair, and has been for the last 3 months. Nobody knows when the water supply will return.

We had gutters installed on the house to try to regain some control over our water supply. These gutters drain into big blue barrels. When it rains, the huge surface area of our roof, catches quite a bit of water and the barrels fill up in an hour or two. We also have six 20L containers (they are called rubbers here) that I try to fill up while it’s raining. Once the rain has stopped, Rachel climbs on top of the 3000L water tank and I lift up to her the 20L rubbers. Twenty liters at a time we fill up the tanks. So far, we’ve collected about 6000L and are tanks are almost full!

I’ve written before about how easy it is for my self-worth to be wrapped up in work. This stands to be further tested as the majority of the hospital’s buildings are a COVID treatment center. Renovations are underway for some other buildings, but currently there isn’t even a location for more than one person to see medical/non-COVID patients. Are we currently living in Sierra Leone without a purpose?

I don’t think we are purposeless, but sometimes it’s hard to see. Just like one 20L bucket doesn’t look like it adds anything to a 3000L tank, I’m sure the Spirit can use us in ways that are imperceptible to us. But man, it sure feels like the default to live by sight and not by faith.

The House

 Here’s part two of the story: Arrival home.

 

We roll up to the gate at 1AM as the headlights glare off of the years of dust, rust, and brown paint. Fobbie honks the horn. No response. He honks again, nothing. 3, 4, 5 times before the gate opens to a bleary eyed Pa Brima. Fobbie jokes, “You sleeping Brima?” ‘No, no, no. I just had the radio on.’

 

We had heard that the lock was stiff and the rumors were true. It took 3 different people to get the door open. The house was immaculate. Our housekeeper, Abdul Jalloh, works so hard! His skill is obvious but boy does he work slow. I would imagine he spent at least 8 hours cleaning our house. Our first surprise came on changing the pillow cases. The pillows were covered in mold! They felt cool but not wet. Then the mattress cover had mold too! The book on the bed’s shelf didn’t show any water damage, the ceiling didn’t look like water damage. Weird. We put on clean sheets and collapse until noon the next day.

 

Inside the closet there were more surprises. My shirts were left hanging with the closet doors closed. The ones hanging with some space between them were fine. But where things became bunched there was mold between the shirts. Even inside our filing cabinet (our dresser) the folded clothes had some mildew looking stuff on them. The only thing we can figure is that we were absent during the rainy season. The humidity must be high for so long that even the air can cause things to mold. I haven’t been brave enough to try to use the laptop we left behind.

 

The most unfortunate thing to happen was the death of our backup fan. We have a battery that runs appliances on 110V so it will easily run the one 110V fan we brought. In our absence, somebody plugged the 110 fan into the 220V wall outlet. Dead. So for now, we don’t have a fan at night if the electricity goes out. Happily it’s super nice weather right now. There hasn’t been electricity for about 36 hours now and we aren’t missing the fans. Also, we haven’t bought any food that needs to be refrigerated yet. So that’s a blessing.

 

On the topic of food, Rachel has found some really exciting things in her pantry. We moved the majority of our food into totes for safekeeping in our absence. Inside the tote was a gallon ziplock bag, inside the gallon ziplock bag was an unopened brownie mix, inside the brownie mix was moving, living bugs! How do bugs find a tote, get inside the tote, then chew through two layers of sealed plastic to get our brownies‽ She had a mason jar with a screw lid and a few cashews in the bottom: mold city. A spaghetti dispensing tupperware with some dry spaghetti had a whole nest of bugs living inside. There was a tupperware with one of those buttons you push on the top that expands a rubber seal to secure the lid that was filled with nutritional yeast flakes: even a few bugs in there! Luckily they hadn’t set up a home yet, but this still seems crazy! Nature really is less tamed in Africa.

 

I know that all of this sounds miserable but we are truly happy to be back. We feel like we’ve returned home to our own space, something we (mostly) understand and feel comfortable with. We haven’t seen many people because of 2 weeks of quarantine, but it’s quite a blessing to reunite with the people here. God is good, even if he did make bugs and mold just a bit too aggressive.

The 2020 Return Trip

 We’ve made it back to Sierra Leone safely!

It was quite a trip and we’ve had some surprises on arriving home, so this will be split into two: travel and settling in at home.

 

It’s always a long journey, but COVID made it even longer this trip. It was relatively smooth, but long.

 

We left my folk’s house near Chattanooga at 6AM eastern standard time and drove to Atlanta International Airport. We were early because we had 4 checked bags all very close to 50lbs and I wanted to make sure we had time to rearrange if the gate agent was pedantic. He was actually very congenial and we breezed through and had a several hour wait for our flight to Chicago. In Chicago it was a 5 hour layover then an 8 hour red eye to Brussels in Belgium. In Brussels it was another 5 hour layover. Upon arrival we immediately found some chairs without arm rests, laid flat, and fell asleep. The next thing I know we are completely surrounded by people waiting for a flight. Of the roughly 30 terminals in our wing of the airport, we choose one of the two that had departing flights. Luckily, mandatory mask wearing means that you can sleep in public with your mouth open and not even be embarrassed! So I’m quite sure I looked totally cool while unconscious and draped over my luggage.

 

We were about to grab something to eat when they started boarding our flight 2 hours before departure! But don’t worry, we had some snacks still on hand because Rachel is always prepared. The queue was long and as we approached we could see 4 different people checking the mandatory documents: boarding pass, passport, visa, residency cards, negative COVID test less than 72 hours old, and some Belgian public health paperwork that needed to be applied for prior to arriving in the airport. As one might expect, that took quite a bit of time and many people didn’t have their paperwork in order. As the woman 4 people in front of us presented her paperwork and US passport, the gate agent asked her reason for traveling to Sierra Leone.

“For my grandmother,” she said.

‘That’s not a good enough reason.’

“But she died and I’m going to the funeral”

‘Do you have a death certificate?’

“No, she’s in Sierra Leone and I’m a citizen of Sierra Leone”

‘Sorry, it’s not a good enough reason to travel.’

“But I was here in the airport last week and all the paperwork was OK except my COVID test was too old. So then I had to stay in Belgium for a week to get COVID testing. And now you’re telling me that all my paper work is not ok‽”

 

It was at this point that we were ushered, with much fear and trepidation, to another gate agent. She smiled nicely, reviewed our paperwork, and let us go without any questions. We were stunned. Why is it easier for white people to get into Sierra Leone than for citizens of Sierra Leone to get in? After sitting on the tarmac for 30 minutes, we see the woman board the plane. I guess she was persuasive enough.

 

 

 

The landing at the Lungi Airport in Freetown was impeccable. I took some pilot lessons years ago and landings are tricky. Even landings, like we had in Freetown, without any cross winds take skill. But I think the spontaneous round of applause from the passengers was more motivated by release of anxiety than from appreciation. We walked across the tarmac to the airport where anyone who didn’t use hand sanitizer was denied entry. The immigration queue was socially distanced and calm. The agent was happy to see foreigners returning. We walked down a small hall, handed in our contact tracing paper work (what was your origin airport, seat number, symptoms, etc.), had our temperature checked, all with reasonable social distance. At the next stage was the classic chaos I had expected up to this point.

 

 Everyone is arriving from internationally so there are just bags everywhere. The space is too small for all the people and bags. So it is literally impossible to walk without pushing into someone. Rachel stands off to the side with our carry on bags and I was only able to bring her things one at a time. First a cart for the luggage. Then I found our Away suitcase. Then I found one of our orange North Face Duffels. I waited and waited but never our trunk or other duffel going around on the belt. I eventually fought my way to the far side of the room and found they had been pulled off the belt by somebody else. Then I realized we had only done the easy part.

 

The queue to pay for the COVID tests (80 USD each) was, as they say in Krio, Choked Up. The line was made up with people and all their luggage carts and extended right into the middle of baggage claim. If I had to push people with my body to move through baggage claim, a cart seemed impossible. We ended up cutting the line with some nice Italian folks. That line was SLOW! From there we creeped through another line into another lobby where everyone was forced to abandon their luggage carts to join another two queues: one for free SIM cards and one to have the tests performed. The luggage carts really insured that there was no room to social distance. It was wall to wall. Our 3 hour disembarking ordeal came to a close with swabs up the nose. Happily, they were more gentle than the folks from Tennessee.

 

Now comes a 2 hour drive. Poor Mr. Fobbie had been waiting since 6 PM (our scheduled arrival which was delayed because of paperwork in Belgium) and we were just departing the airport at 10:30 PM. There’s a national COVID curfew from 11PM to 5AM. So at every checkpoint, the police officers are confused why we’re driving and it always takes some explanation. Only once did we have difficulty. There was a small village where the police weren’t letting anyone pass. My speculation is that so many people were forced to sleep in their cars by the side of the road that it helped the local businesses sell their goods. Two different police officers told us to just pull up to the gate and wait. Well, they never came to open the gate and I think they wanted us to wait till morning. But the third time’s the charm and we were able to get around.

We did the math, about 40 hours in transit. The next day we slept till noon.

 

Part two will be our adventures rediscovering our house.

Returning in 2020

It’s time again to return to Sierra Leone.

The borders were reopened recently and the protocols have been put in place for us to return: Negative COVID PCR less than 72 hours before departure. On arrival we get two tests, both a rapid and a more time intensive test. If the rapid is negative, we leave the airport and are allowed to travel as long as public health can contact us at a moment’s notice. If we test positive on the rapid test, we are forced to stay at the airport hotel until the confirmatory test comes back. We booked tickets a few weeks ago and have had the dates and the times changed multiple times. But for now, we depart the US on the 13th. 

It was obviously emotional leaving home last time to move to Sierra Leone, but I’m surprised how complex the emotions are this time. 

There were two weeks this trip when all 3 of my parent’s biologic children were living in their house with their spouses. We joked that my mother had given us a checklist growing up (Get good grades, go to college, find and marry the right person, find careers you’re happy with), but now that all of us have completed these checklists we don’t know what to do! So we all came home and moved back in. Seriously though, with 3 children who each have a spouse, 4 out of 6 of us have driver’s licenses with Mom and Dad’s address on it.

It has been both wonderful and lacking all at the same time. Weddings we couldn’t attend. Trips we couldn’t take. Friends and colleagues we couldn’t see. All due to COVID.

It’s like we had something great and unique, but we still want more.

On the other hand, I am so anxious to get back to Sierra Leone. Apparently I’m not a classic workaholic day to day, but months without seeing patients just feels too long. Sometimes we feel like this has been the most selfish 3 months of our lives. We buy stuff. We see family. We eat fantastic food. All of our time is for us and family. Especially without church, it’s easy to misconstrue our necessary rejuvenation as selfish or bad.

I’ve also faced something I’ve not needed to put words to before: self worth. It’s been revealing to me how much of my self worth is wrapped up in my identity and work. The western ideologic framework easily ties ones ‘worth’ to their productivity. What’s my worth when I’m a missionary doctor who ‘abandoned’ their post during the worst pandemic in 100 years? What kind of missionary spends 3 months with all their time focused on themselves? I feel far from being the ‘perfect’ missionary.

It sounds so easy to say ‘Your identity should be in Christ.’ Or ‘It’s Jesus who gives you your worth.’ I’ve spent a lot of time recently thinking about these trite things we say as Christians. Honestly I have no answers. And I can only imagine the pain that others are going through. I still have a job; I have a loving family that can house me for 3 months. I can only imagine the existential crisis that people are going through during this coronavirus time. I worry that the usual and easy trite Christian reassurances are going to look even more inadequate to a hurting world.

And this is just about the US. As I have been communicating with Dr. Kabba (the medical director) and Mr. Fobbie (the business manager) things are even harder for the hospital than I expected. 

In late May and early June, the government of Sierra Leone approached the hospital and requested that we collaborate. They could use our facilities and they would provide salaries, supplies, and COVID patients. The Waterloo Adventist Hospital would become the local Community Treatment Center (CTC) for the coronavirus. 

But because the situation is so dire for the government, they are completely unable to adequately supply the hospital with enough PPE, medicines, fuel, or equipment to take care of the patients. There has been basically no money for salaries. And because all of the hospital was taken to treat coronavirus, there have been no facilities to see or treat the medical patients for revenues to pay the staff.

By mid July, there was only $500 in the bank which is no where near what’s needed to buy fuel, medicines, or even pay a portion of salaries. God always provides and we’ve received enough donations to pay the staff a fraction of their salary and provide a bag of rice. The SDA Mission has also offered the hospital a building to use as a small medical clinic in the interim. However, this building is so rudimentary it doesn’t even have electricity. God has continued to bless and a donor came forward to help us with partial renovations to at least make the space usable. And this is just a sampling of July's challenges.

Because things have been so difficult recently, we’ve updated the website to include a COVID donation section. If you’d like to donate please visit:

https://adventisthealthsystem.sl/donations/

Haiku 1619

Ideas rarely come to me fully formed. Even as I’m telling the patient what I'm thinking and recommending, the thoughts are still being born. Yesterday we drove through the Georgia countryside while listening to 1619 and arrived in my sister's friendly and kind neighborhood with 15 kids playing together on the street from different houses at 9:30 PM. Everyone we saw in this community on our evening 2 mile walk is black. It felt like home.

I woke up early this morning with a haiku fully formed in my head.

What is a human
Work, love, art, build. Robots can
How can we enslave?

Powerlessness and Power

We want to believe that we have control and autonomy over our lives.

I’m slowly learning the lessons of how little control we have over our lives. First we were evacuated from Sierra Leone by the Embassy. Then last weekend, I dove into some cold water to chase some sunglasses and came up with atrial fibrillation with RVR. This is a common disease, but only in old people. My heart rhythm didn’t return to normal for 2 hours, so I went to the hospital and was admitted overnight. No visitors allowed due to COVID.

Consistently, the podcast I listen to that most changes the way I view the world is Everything Happens for a reason by Kate Bowler. She’s a young woman and theologian who studied the Prosperity Gospel, has small children, and was diagnosed with Stage 4 cancer. Her podcast deals with how to find hope in desperate situations and how to provide strength to those in need. In her episode interviewing Ari Johnson, he discusses how pressing the need is for us to improve the lives of those around us. It’s a great episode, partly because he’s a doctor in Africa: https://katebowler.com/podcasts/ari-johnson-more-than-enough/

They wrestle with a topic that I think both individuals and our nation are struggling with. It’s so easy to feel like we have no control: heart arrhythmia, stage 4 cancer, systemic racism, crushing poverty, distrust of science and medicine, portrayal of Christianity as a right wing racist homophobic group. And this hopelessness is compounded by how invisible our individual power is. We have tremendous ability to influence the health and spiritual well being of those around us. Our individual actions form our communities and shape our society.

Ari Johnson said this:

“We vastly overestimate our own control over our own lives. We are not in control of our own lives. We can not control the outcome. I also believe that we vastly underestimate our power. We vastly underestimate our power. I believe we even hide from our power, because our own power is terrifying. We are terrified of how powerful we are, particularly our power in the lives of others. Our power to cause harm. Our power to cause harm and to hurt those around us.  And our power to heal. Both of those are terrifying.

The resonance of our actions both to hurt and to heal are so much bigger than we see and so much bigger than when we estimate, and it is terrifying for us to look at that because if we look at it… it takes so much courage to look at that because once we look at it, once we embrace how powerful we are, then we are responsible. And there’s no letting ourselves off the hook. We have to take action. There’s no other way.”

It's quite a dichotomy to feel our own powerlessness, but still be responsible for all those around us. But I believe it’s what Christ calls us to. Servants don’t have any control over their own lives, but are designed to benefit all those around them.

Now I don’t know exactly how to hold these ideals together: self powerlessness with power and responsibility over others. Regardless if it’s our global community, it’s the plight of the African American, my peers and community in Sierra Leone, people with different political beliefs, or my family and church family, I have a part to play either to heal or to harm. And I also know that regardless how little control I have in my life, in either health or geography, God will guide my next steps.

Quarantine

Well, we finally made it out of quarantine.

Our repatriation flight landed us in Dulles at 3AM. We went to the hotel and had an amazing hot shower and 2 hours of sleep before we went back to the airport to catch a plane to Detroit, then Atlanta, then Chattanooga. My parents drove to the airport with two cars and met us at the airport with a car loaded with food. We drove home by ourselves, waved to my sister who stayed on the porch with her 4 week old, picked up the dog, and drove to a cabin in the woods with no cell service or internet.

It was a both a blessing and difficult to be so isolated. Alone in the woods, in a beautiful cabin, with wonderful food, and a loving spouse is quite wonderful. But even though we are thousands of miles closer to home, we were even more isolated from our family than when in Africa.

COVID makes it easy to be paranoid. On our arrival we started to have worsening runny nose, small cough, but no fever. We stayed cooped up for a week and a half, during which time Rachel read 8 books. We called the health department, which is now doing screening for all who want it, and got tested. It felt like I was getting my brain tickled by that swab. After a few days, our tests both came back negative. All our symptoms were just allergies and we praise God for that.

It's wonderful to be back home and reunited with family. But after only 7 months, it still seems like we left some of our heart back in Salone.

Repatriation Flight

It’s been a chaotic week both emotionally and for our plans. After our decision to leave, we went to Freetown and paid $7000 cash to a travel agency. Less than 4 days later, the embassy says that there’s another flight that is completely different. They recommend we go and get a refund. “Money business” is always hard in Sierra Leone and I expected quite a fuss to get a refund. After all, this business had at least $315,000 come in and they were about to lose it all because the embassy changed its mind. However, it was surprisingly easy! I walked in, my hand written ticket was sufficient, and they took me to a small back room to count out the cash. The only thing they tried to pull on me was giving me some 20 dollar bills and not all 100 dollar bills. There is quite a drop in exchange rate between the bills, but I put up a fuss. After he acquiesced, I said “Thank you.” In the African style of directness he responded, “Why are you thanking me? You’re not helping me at all.”

We do all the paperwork to sign up for the flight and then begins the preparations to leave. Decide who to give our office keys to, increase security to 24/7, arrange for someone to intermittently sleep in our guest room, put all the important items under bed sheets to protect from dust, eat everything in fridge and freezer, and leave money with the appropriate people in case we need to arrange for something.

Friday comes along and we had arranged for the driver to pick us up at 6 AM. He arrives at 5:30. While driving to the airport there were multiple checkpoints where everyone was forced to either use hand sanitizer or to disembark to wash hands. The airport had 2x mandatory hand washing stations and temperature checks. We were literally the first passengers to arrive. I’ve never been so early for a flight before: 8:30 AM for a 1 PM departure.

During the check in process I spoke with a woman from the Embassy. She described the logistical nightmare of a repatriation flight as there are never direct flights from Freetown to the US. So the Sierra Leonean government had to discuss with the US Government, who had to get specific FAA approval. After lots of paperwork we arrived at the departure terminal and hunkered down with the Herreras and their 3 boys. We played cards, Minecraft, group games, ate lunch, shared our homemade snacks. The hours ticked by to 1 PM, no plane. 2 PM no plane. The plane had two other stops prior to us to pick up other Americans from other West African countries and it finally arrived by 3 PM. No one was allowed to disembark and they began fueling. Over many hours we would queue to board, then a delay; sit down for a few hours then queue again.

Based on rumors from staff overhead in the bathroom, initially there wasn’t enough fuel. After the fuel situation resolved, then the fuel door couldn’t be properly closed. It was decided that the plane was unsafe and that the local staff couldn’t be trusted to verify the repair was done properly. An announcement was made that we were stuck for several more hours while another plane was sent. Less than 10 minutes after this announcement, at roughly 8pm, it was announced that the plane was safe and we were leaving.

Our waiting time in the airport far exceeded our flight time to cross the Atlantic.

We arrived in Washington DC slightly before 3 AM. Everyone was wearing masks, but there were no handwashing stations and no temperature check. Just driving in Sierra Leone had more hand wash check stations than the major transit hub of the US capital. Due to our late hour, we didn’t see anyone from customs. The man at immigration asked us, “Have you been in contact with anyone with fever and cough?”
I replied, “Well, I’m a doctor.”
We stared at each other for a few seconds before he inquired, “Anyone in the last two weeks?”
I stared silently back as both of our discomfort was become more and more visible. I offered, “We’ve been screening people for Coronavirus and we never had any cases that needed testing.”
He looked relieved, shrugged and quickly waived us on without another word.

We arrived in our hotel with enough time for a shower and 2 hours of sleep before needing to return.

Due to being underpopulated, our original flight from DC to Atlanta to Chattanooga was canceled. Our trip now is DC, to Detroit, to Atlanta, to Chatt. All the airports are like ghost towns. It’s quiet and peaceful. Currently we’re sitting in Detroit and we’re happy to be back in the US. But we keep thinking about the welfare of Sierra Leone and we’re going to be very happy when our 36 hours of travel is over.




The Fernandos and Herreras in Freetown's Lungi International Airport

Travel Agents

We slept well last night, even without electricity. This morning the flood of messages brought us both comfort and more confidence in our direction. We prayed and discussed some more and then went to Freetown to book with the travel agent.

We handed over $7,000 (almost all our cash) to a stranger in a small sweaty office off a side street who gave us a hand written receipt for “Air Ticket” without a flight number. He took our phone numbers and told us that the flight left at 8AM on the 10th, maybe…
This is probably how the rest of the world books flights, but man it was weird.

There’s still several opportunity for God to close doors to keep us in Sierra Leone.
Firstly, the flight needs 150 people to make it viable for the company. As of this morning the flight had 95 and rumor has it that the booking closes tonight, but it might be extended to Wednesday. However, the entire country is on lockdown Sunday through Tuesday. We might be stuck unless another 50 people get scared.

Secondly, if we show Coronavirus symptoms in the meantime, they won’t let us on the flight. It is peak dust season and we each sneeze about once per day. Maybe I should start taking Zyrtec as a ‘mental health drug.’

We feel like it’s in God’s hands now. We also feel immense gratitude and support from all the connections and people we’ve become close with over the years. Even some mentors to our mentors spoke up, which was a pleasant surprise. To hear from all of you in our time of doubt has certainly been a blessing.

Love you,
James and Rachel

Donning and Doffing

It’s official, COVID 19 is here. The air, land, and sea borders were all closed 3 weeks ago. But this week, on the 31st of March was the first confirmed case. A Sierra Leonean who had been in France, but then returned to Salone. He had been in quarantine and at the end of his time, still tested positive. Somehow he had 130 contacts during that time. There’s also rumor that he was actually discharged before testing positive. But rumors truly are vicious in this place.

The second positive case came a day later, completely unrelated. A Dr. Bell who is a pillar in the very small medical community of Sierra Leone. She’s a pediatrician who sees inpatients and clinics across both government and private hospitals. She lectures at university and medical school and also sits on all the most important health committees at the highest levels of government. She had no travel history, no exposure to the other case, and in the two weeks prior had interacted with literally thousands of people. In just 24 hours, it’s quite apparent how far the cat is out of the bag.

So in our hospital, our basic preparations were further escalated. We have a small amount of supplies left over from Ebola: Tyvek suits (picture big plastic onesie pajamas) and goggles. All the elastic on all the masks and gloves have been destroyed by the African heat. Regardless, we have pushed on ahead with re-training the staff on donning and doffing PPE. (Putting on and taking off personal protective equipment). I say ‘re-training’ because many of our staff continued to work at this hospital through Ebola. Taking off a suit incorrectly could literally end your life.

It’s amazing how physically mimicking something brings up so many stories from the past. Mr. Abu told me many stories about how terrible the fear was of the red zone. But after going in and out countless times, how life threatening became normal. Apparently when reaching for the zipper at the neck of the Tyvek suits, it was common to hear people shouting “Jesus! Jesus! Jesus!” If you reach too far and you touch your chin, it could all be over.

On the eve of another virus, far more contagious than the past, it’s hard to know how to move forward. What is faith? What is arrogance?

There’s one more flight home: a charter flight from the US Embassy. The emails tell us that if we don’t take this flight, we are here for the duration. Your home country shouldn’t have to come rescue you if you decided against repatriation and were warned. It’s a surprisingly difficult decision.

Pros – Run home to a country where there are actually ICUs. The government has the ability to intervene for its citizens. Your family won’t worry about you as much. Your life isn’t as much at stake. The entire administrative committee agrees we should go. Everyone we ever talk to says we should go. There’s only one shot left.

Cons – ‘Well Africans, we came to help you. But now that you need us we’re running away.’ There’s the guilt of abandonment. There’s the shame of not running towards trouble like so many missionaries before us. There’s only 4 ventilators in this entire country and the government officials are keeping the best hospital to themselves. If we contract the virus, Rachel and I will be admitted to different wards, unable to see each other for 2 weeks. All while being subjected to 3rd world medicine. We’ve been here for 7 months and homesickness and culture shock are a real thing. If we get trapped without flights home for another (potentially) 6-12 months, are we going to get so burned out we don’t want to return to Sierra Leone?

This is different from Ebola. During Ebola our hospital was overrun with support. Cuban doctors, British generators and infrastructure, Sierra Leonean government supplies and buildings erected. But now, every country is concerned about themselves. Foreign aid is unlikely. Even with confirmed cases, the government is yet to dispense any aid to hospitals.

There are just so many questions we can’t answer:

-       Did we come to Sierra Leone for such a time as this?

-       If there isn’t international support and the country runs out of medicines, do they even need doctors?

-       Is God asking us to risk our lives or did He give us unified counsel from everyone we ask and one last flight home?

-       Maybe we stay to help, then burnout and never return. Can that be a successful mission, even though we didn’t stay our 5 years? Is burnout a part of God’s plan?

-       If we become truly ill, is it even possible to medevac in the middle of global infectious pandemic?

-       How desperate will the people become when Sierra Leone is hit by the global economic downturn complicated by an already inadequate health system?

-       Once we leave, how long will the borders be closed? Will we even be able to return in the next year?

-       Are we any safer at home? Especially if the truth is that we’re just afraid and don’t have even a mustard seed of faith. Are we running away from God’s will?

Rachel and I want to do the right thing, but we don’t see any right answer. The chorus of advice is unified, but we’re not at peace. We have less than 24 hours to make our decision, all with the knowledge God will bless us regardless of which path we take.

African Exclusive

There are some experiences that almost solely happen in Africa. People think about wildlife, poverty, malaria, safaris, clicking languages, polygamy, etc. There are other experiences that are just so outside the imagination, it’s hard to even predict.

With all the Coronavirus talk, the government officials came to the hospital for an impromptu “sensitization” lecture. Of course, they came at 4:30 right as everyone is supposed to be going home. Then it takes 30 minutes to set up and is just a bunch of people reading directly from slides. Regardless of how boring it is, I’m a bit nervous. Things aren’t finalized with all our paperwork, government officials always pick out the white people, and all the staff is also at the meeting. It’s a packed house. In the middle of all this, Ami comes over and starts tapping me on the shoulder quite insistently.

Before I go on, let me describe her a little bit. Ami has a fiery personality and with her things are either great or terrible. She’s either dancing or sulking. She speaks such deep Krio that even after 6 months here, I still can’t understand her most of the time. She insists on speaking to me in Temne, even though it’s clear I have no idea what either she or I am saying. Here’s a picture of Ami with Rachel last Sabbath. I’ve never seen her wear such a great hat.

 

So Ami is insistently tapping my shoulder. I try to brush her off, but she won’t be deterred. She whispers something into my ear, that I have no idea what she’s saying. Then she shoves something into my hands. At this point, whatever is going on with Ami seems super important. I turn towards her and open what is in my hands.

It’s my underwear.

Ami is our laundry lady and it was laundry day. She must have found them and she decided that an all staff meeting with all the government officials was the best time to bring back my lost unmentionables. That evening I walked home with a conspicuous bulge in my pants pocket while trying to imagine any situation on any other continent, where a woman would hand me my underwear in the most important meeting of the week. I decided that I’ve had a once in a lifetime experience.

Strange Encounters

Things that would be strange in the US are totally normal here. I notice it daily, but thought I would jot down a few instances.

I'm walking through the hospital and a nurse pulls me over, "I need you to meet someone." I think it's a patient's family or one of her friends. Instead, she leads me to a white person (a rarity). She says, "Hello I'm Paula. I'm a cardiologist from Italy." She asks if I mind if she gives some recommendations about one of our admitted patients: a 50 year old woman who came in with blood pressure of 240/120 who had been on IV antihypertensives combined with triple oral antihypertensive therapy for 3 days without any effect. What a perfect consult for a roaming cardiologist!
"I hear a mitral valve regurgitation murmur, have you considered lasix?" Firstly, I have no idea how she heard that with the nurse's stethoscope. Secondly, in this country I'm always happy to have a second opinion from any non-witchdoctor. Because I frequently want to have a cardiologist around, I ask "How long are you in Waterloo for?" She casually replies, "Oh, probably another 4 hours." I wonder if she could see the disappointment on my face. Unfortunately I didn't have another consult for her within 4 hours, but I certainly did within 12. Either way, both me and the patient were blessed by the roaming cardiologist.



A few weeks ago, right as the coronavirus fears were really picking up, we had a Chinese man walk into our hospital. He asked how many masks he would be allowed to buy. Now normally we don't sell medical supplies. But we have thousands of masks that it'll take us years to use and since we struggle to make payroll, for the right price you can have almost anything. After he made the purchase and left, Dr. Kabba noted, "I hope he doesn't know a coronavirus patient."
The next day he came back, wanting several hundred more masks. Then rumors started flying around the hospital. Is he hiding a coronavirus patient from the government? Is he trying to protect himself and his compound without telling anyone? Well, we're desperate for money so we sold him the masks. But when he arrived back on the 3rd day in a row, enough was enough.

Dr. Kabba notified the Ministry of Health, who called Immigration, who requested backup from local police. Soon the hospital was swarming with uniforms. Any man in a uniform is instantly interested by an Apoto (white person), and it's not always for good reasons. So Dr. Kabba recommended that Rachel and I make ourselves scarce. In the end, they discovered that he was just a shrewd businessman making a pretty profit in China. There was no risk of exposure. But with all the police around, they needed something to do. So they accused the hospital of selling government supplies. Dr. Kabba, Mr. Fobbie the business manager, Augustine the clinical supervisor, and Danquah the chaplain all got hauled to the police station. For several hours they were held and asked multiple times about exactly which staff member did the selling and where the masks came from. Once they learned it wasn't government cheese being sold, they still wanted to arrest a staff member. Dr. Kabba said, "If you want to arrest someone for alerting the Ministry of Health for the good of the country, you can arrest me. I was the one who gave the ok to sell the masks. I'm sure the news will find this story interesting." Needless to say, nobody was arrested. But I saw a lot fewer patients visiting the hospital that afternoon. I'm starting to believe the local version of "No good deed goes unpunished" is actually translated: "No one who calls the police in Africa goes un-harassed."

Hello!

Every day as we walk to the hospital, there is a 4 y/o boy who lives across the street. He loves to yell “Hello!” to see our reactions. Usually I wave; if he persists I use two hands; if he perseverates I even try to wave with my feet and hands simultaneously. It doesn’t matter the circumstances: rain, sun, big trucks, weekends, he always greets us.

Last week the mother called me over and told me that he was sick. I walked across the street and they pulled up a chair for me. I sat in their front ‘yard’ (really more dirt) while they tried to find him. I looked him over and he wasn’t dying. So I didn’t commit to free consultations or medications like they wanted, but they also didn’t ask outright. I noticed a deep dimple on his tongue at the same place I’d expect his frenulum to attach from underneath. I asked about it and it’s been there since birth. I asked if he talks ok and the mother gave him a firm nudge (that in the US would be ‘hitting’) and commanded him: “Talk!” Under those circumstances, nobody would have anything to say. So I squatted down, shushed his mother, and said “What’s your name?” He responded, “Ishmael.” Sounded good to me, so time to have a little fun. “What’s my name?” I asked with a smirk. I honestly didn’t expect any response at all. He smiled back at me, waved his hand, and said “Hello!”

The small crowd that had been gathering laughed, as it was obvious I’d been out played by a 4 year old.

Spiritual Battles

The longer we stay in Sierra Leone, the easier it is to see the spiritual warfare.

Every time that someone moves into a new office in our hospital, the staff gather for a prayer of dedication. It didn’t seem unusual to me, until the office prayer was delayed for several days due to busy schedules. The staff member refused to move into the new office until the prayer. I asked around and learned that it is often dangerous to be promoted. Jobs are so rare, everything is seen as a zero-sum game. So, if someone is promoted they become a target: threats, poison, curses, etc.  Spiritual attacks are so common the phrase, “I’m going to Waterloo for you” means that you’re headed to Waterloo to find one of the many witchdoctors to order a curse on someone. One of the reasons people are so happy to work at a Christian institution is they feel some safety from these attacks. Prayer is protection.

I had another case where a young Muslim man (maybe in his 20s) came in unconscious. Nobody from his family could provide any conclusive history. On physical exam, it was clear that he wasn’t completely unconscious. I would lift his leg and after letting go, it would slowly return to the bed. I told the CHOs, “I don’t know what this is, but you need to be thinking beyond just physical. In the States, this would be a psychiatric issue.” I ordered a bunch of labs, all normal. I ran some IV fluids and just waited.

Oh, I did have to tell the family I didn’t want them rubbing raw garlic all over his body. Who knows what else they did at home.

After several hours the nurse came to me and told me that the family wanted discharge. “What‽ Do they want to take him home unconscious?” The nurse responded like I should somehow know without being told, “No, he woke up and feels fine.” I pulled the patient into Mr. Abu’s office, because I didn’t trust my Krio enough to dive into psychosocial issues alone. Without the family present, I delved into all the sensitive issues: Sex, HIV, Drugs, Anxiety, Abuse, Depression. All negative. As I dug into psychosis, I got an unexpected answer: “Does your mind ever play tricks on you? Do you see and hear things other people don’t see or hear?” “Well, no. But 7 nights ago a Devil came to me in my bedroom.”

He told me that more than a week ago, he went to the ocean. He was swimming while wearing a hat, and he lost his hat into the waves. With fear in his eyes, he described how he was unable to retrieve the cap. (Demons and beliefs relating to water are very common here). Then after a few nights he was asleep and a Devil woke him up and presented him with two identical caps. “One of these caps is yours, one is mine. Pick the correct one or you will be sorry.” The man grabbed the one on the left. “Wrong!” the Demon shouted, as he started to cackle and dance around the room. Then he vanished.

For several nights, the Demon visited to ‘torment’ the man: ‘You’re going to die’ ‘I still have your cap’. Then the next few nights he slept well. Later he was in town, walking down the road and the Demon appeared. “Give me my cap right now! I need it!!” The man pleaded, “I don’t have it! I’ll go home and get it right now.” “Too late” screamed the Demon and the man went unconscious.

It was at this point that I realized my mouth was hanging open a bit. I asked him, ‘Have you told your family about this?’ He hadn’t. I asked him if he would benefit from a Christian prayer and he declined. Mr. Abu and I encouraged him to tell his family so they could provide ‘Muslim Prayers.’ He left and I never saw him again.

In the States, Demons and spiritual battles are the last thing anyone thinks about. Here, even rashes can be attributed to spiritual curses. I’m learning more and more that the truth lies somewhere in the middle. I need to keep an eye on the Great Controversy, while also leaving room for a contact dermatitis of unknown origin.