Camp closed: desperation on the Syrian border

Mohammed is leaning on his crutches at the fence of the clinic. “Can you help me? Please, please can you help me?”

We go back with him to his tent. It is in a transit camp for Syrian refugees on the Turkish/Syrian border. And the refugees – about 3000 of them – have just been told they are being moved to another camp, an official, permanent camp, some 80 km distant. Tomorrow morning, at 10.00 am. So they must pack their bags and get ready.

The problem is, this camp is populated by refugees from a different ethnic group, with a completely different language and customs. And with the recently exacerbated enmity, a consequence of the ongoing conflict in Syria , most people are refusing to go. They fear for their safety there, despite the two separate, protected areas in the camp that have been established.

“We have only just arrived,” Mohammed tells us despairingly when he is back in his tent. He is there with his wife and three young children. “It was too dangerous for us to stay in our home town in Syria. And it was a long journey and took all my money – over $2500 – to get here. ISIS had just beheaded my father. I saw his head hanging there, in the square. My father’s head. He was a respected Imam and he refused to follow the edicts of ISIS…… so they beheaded him.

“We came here to be safe, for stability and security for our children. And now we have to move again! We cannot go to that camp, it’s too dangerous for people from where I come from.”

We hear the same story over and over, of people too scared to go to the camp. And they have taken so long to reach some safety here, so many displacements already. A woman sits on the steps of the clinic, her head in her hands, weeping. “What can I do, what can I do? I have eleven children to take care of, my husband was killed by a bomb in Syria. I’ve been taking food from the rubbish bins to get enough to eat….”

I have met one of her children at the ante-natal programme we’ve just started, a young woman nine months pregnant. I remember there are ten women in their ninth month, due to give birth soon. Not the time to be moving to a new camp. Nor to be sleeping on the streets.

“We will sleep on the streets,” is what we heard many times. People preferred to sleep on the streets – or even to try to return to Syria – to moving to the new camp.

Dark grey clouds are looming over the rows of tents and rain threatens as evening approaches. The feeling of desperation is palpable; our feeling of helplessness is equally overwhelming. Powerless to prevent the move, as we watch people piling whatever tiny number of possessions they have into plastic sacks, we do whatever small things we can to help them.   I ask our team of outreach workers to track down the malnourished babies we were supporting with baby formula; and we ladle milk powder into countless small pots to tide them over for a few days.

And we go from tent to tent, asking the refugees where they plan to move to, taking people’s contact numbers so that we can follow them up and maybe distribute some non-food items to them: tents, blankets, mattresses.

Such a small contribution in a maelstrom of wretchedness.

The next morning a wave of human misery enfolds the perimeter fence of the camp. A young woman, tears rolling down her face and two small children clutching onto her, waits beside her pathetic pile of belongings. Others are loading potato sacks of stuff onto carts. A tiny proportion of the refugees – maybe a couple of hundred – have decided to move to the new camp.

And the rest – where will they sleep tonight?

These are the people we in Europe have closed our doors to.

 

 

Hope After Homs: Rebuilding shattered lives on the Syria-Turkey border

“The wall collapsed on top of us – the children were crying with the pain of a broken hand, a broken leg. But we couldn’t leave the house to go to the hospital. There were snipers on the rooftops shooting at anyone walking outside. So we carried the children in our arms and crowded together into the bathroom, away from any windows, and waited.” Amal’s brown eyes fill with tears as she talks. I put my arm round her.

“Shall we stop?” I ask. “No, I’m all right, I want to tell you. It’s just that I remember so vividly…”

We are in a refugee transit camp on the Turkish-Syrian border. Amal arrived here with her husband and two young children, Ahmed and Gazal, three weeks ago, crossing the border from Syria in search of safety. Amal is a nurse, and five years ago, at the start of the war, she had a home with her family and a good job in a hospital in Homs. Now her world is reduced to a small tent crowded together with 500 others in a camp in this Turkish border town.

“We were living in the Baba Amr area of Homs, and it was early in the morning when the bombs started falling. There were tanks in the street as well, and snipers – we had to wait until noon before we could leave for the hospital. We splinted the children’s arms and legs with some pieces of wood tied on with scarves. My husband had a broken arm; he had to drive with one arm.”

Amal’s story is one of many. After five years of war, with half the population now displaced from their homes, there are thousands – millions – of stories like hers.

But that doesn’t make hers any less painful. “It was so dangerous. Soldiers would break into houses early in the morning, sometimes kidnapping women and raping them. That happened to one of my neighbours. We didn’t dare go out of the house. I saw one woman fetching her son to bring him home – and I saw him being shot, falling to the ground…” Her eyes well up with tears again, and mine do too. It is so brutal, so tragic. So seemingly never-ending.

“That day of the bombing, we never got to the hospital. We were stopped by soldiers who said if we came from Baba Amr we must be terrorists, and turned us back. And when we got back to the house, it was totally destroyed. We had nothing left. A neighbour told us that it wasn’t safe for us to come back, we should leave.”

So the family left for Deir-Ezzor, a town on the other side of Syria. “There was bombing and shelling there too, and the hospitals were attacked.” She tells me about her work in the emergency department.

“There were so many war-wounded, the most terrible injuries – from gun-shots, from the bombing and shelling.“ As she speaks, her face blanks over. “They brought in a man who was literally cut in half, just joined by his skin – from shelling by a tank.”

I wonder how this young woman – Amal is only 34 – can handle what she has seen. There is worse to come, though. As Amal talks, my Arabic translator gasps and buries her head in her hands. “Every day Islamic State brought people and beheaded them in front of us. Then they hung the heads up in the square. I didn’t want the children to see that. That’s when we finally decided we had to leave. And anyway, it was dangerous for us – they had already imprisoned my husband and my son twice, when they were walking in the street at prayer time…” Amal’s son Ahmed is seven years old.

How did she manage to cross the border into Turkey, I ask her. “I borrowed some ID from my family. And then we took a bus, so many buses: first to Damascus, then to Homs, then to Hama, then to Idlib where we could cross the border.

“We were stopped by the army on the way. They showed me a list of my brothers and sisters, who of course have the same name, saying we were wanted by the regime. I just pretended I was crazy, that I didn’t understand anything they were saying.” She laughs as she says this, and so does the Syrian doctor who has heard what she said. “We have this joke that everyone who comes from Homs is crazy anyway!

“The border was open but we had to pay. We arrived here completely penniless. I managed to keep my phone because I hid it in my son’s pants…” Amal laughs again. Her resilience is astounding.

As we talk, Amal’s five-year-old daughter, Ghazal, plays with a bit of coloured plastic near us. I ask her what she is most missing from the things she has left behind in Syria. “My bear,” she tells me. “She was big – this big…” She lifts her arms high. “She was white and red. And her name was Lulu.” I wonder if I can find another big white and red bear in this small border town.

Although Amal and her husband tried to shield their children from the worst, they are inevitably scarred. Both were injured in the bombing. And Ahmed, Amal tells me, has started wetting the bed. He’s getting support from the psycho-social team here in the camp.

Amal and her family are safe for now. Amal is using her nursing skills again: she has joined our medical team in the small primary healthcare clinic we have opened, together with the municipality, in the camp.

But as we talk I look along the rows of tents, at the dozens of children playing in the gravel: a small one climbing into an empty box from an aid delivery, an older group of boys finding a smooth space to roll marbles. Children who should, would, be in school. Their mothers sit in small groups at the entrance to the tents, just sitting, talking, waiting.

And I wonder: how much longer will they have to exist in this limbo? Amal’s name means “hope” in Arabic. A small glimmer of hope is all they have to cling on to.

From an insecure and dangerous present to an unknown future

It’s 10.30 pm, on board the Phoenix, the search and rescue vessel in the Mediterranean

Anna Surinyach/MSF

run jointly by @MOAS (Migrant Offshore Aid Station and @MSF. I joined a few days ago, in a mid-sea midnight transfer. Before I go to bed, I go up on the darkened foredeck and remember how it looked yesterday, packed with people crammed together on their blankets after having been rescued. I wonder how and where they are now, what the future holds for them, these 415 people from 20 different countries, among them Syrian and Iraqi, Eritrean and Somalian? They disembarked this morning in Taranto, in Italy, their hopes high, thinking the worst was over. But what problems still lie ahead of them as they seek refuge from their war-torn, repressive or poverty-stricken countries?

And then I look out to sea, to that vast, dark expanse of water and am glad of the full moon giving some light to it, and that for the moment the sea is calm. Because I am here on this strong, safe boat. But there are people out there, on this same stretch of water, travelling in fear of their lives in leaky, unseaworthy wooden boats. Tomorrow, or maybe the day after, we will be back in the rescue zone between the Libyan coast and Sicily. Who knows what that day will hold for us all?

**

The call has come in from the MRCC, the organisation in Rome that coordinates the rescues: we’re being directed to help two wooden boats with about 700 people on board. So it’s happening. Our adrenalin starts pumping. What are we going to find? What kind of a state will the refugees be in?

The MOAS crew – Igor, Antoine, Mimmo – lower the rescue boat (RHIB) into the water and set off with Simon, our Canadian doctor, to assess the situation. The rest of us, the small MSF team, stay on board the Phoenix to help prepare for the embarkation. I check the clinic to make sure everything is in order: the drugs, the oxygen concentrator, the monitors – we have no idea what we’ll need.

“Ali, Ali!” I hear someone call. I rush to the embarkation gate at the side of the boat – and Mimmo hands a tiny child up to me from the RHIB, his big brown eyes wide open in stunned amazement. (I later learn that at about the time I am holding this little boy in my arms, the world is being shocked by the photo of little Aylan Kurdi, drowned on a beach in Turkey.) The small boy is quickly followed by a seemingly endless stream of exhausted, bedraggled women and children. We welcome them on board: life-jackets off, hands filled with a rescue package containing water, nutritional biscuits, a protective onesie, towel and a pair of thick socks. Gabriel, our comms person, checks everyone’s age and nationality. The RHIB goes backwards and forwards to the leaky wooden vessel, to bring people back to the Phoenix. The lower deck quickly fills up; now we’re starting to place people on the upper deck.

Soon we have 332 people on board, nearly all Eritrean, 28 of them young children. They trickle into the clinic for medical attention: dehydration, general exhaustion, headaches, insulin for a diabetic who hasn’t had any for too long. They are escaping from a country with political repression and arbitrary arrests, of enforced national service that lasts a lifetime. To get onto that leaky boat on the shores of Libya, they have already travelled thousands of miles, and many of them will have suffered in detention centres in Libya as they wait for their last chance saloon, an unseaworthy boat in which they will risk their lives in the hopes of a better future. Why do they do it? Why would a father risk the lives of his wife and small children? “Because to remain is worse, it’s a living death or even death itself, ” was one reply.

Soon the decks are quiet, as everyone collapses onto a blanket; and, packed side by side, mothers curled round their children, with no spare inch, they sleep the sleep of total exhaustion.

The next morning the clinic is already busy by 6 am, as people come in looking for relief from headaches, fever, sea-sickness, skin infections, respiratory tract infections, general aches and pains. We treat them all as best we can, and constantly walk between those crammed together on the deck to make sure there is no-one who needs attention.

One young girl stays in my mind. She is sixteen, and she is travelling alone. I will call her Miriam. She has a high fever due to pneumonia, but we can treat that with antibiotics. It’s not too severe. What is worse, what worries me more, is that she can hardly walk. She is limping, dragging her right leg. She speaks little English, but manages to convey to me where it hurts, and why: “I was beaten, here and here and here,” pointing to the back of her calf, her thigh, the bottom of her foot, “In Libya.” I am told that this happens in the detention centres, where the smugglers are attempting to extort more money from these already poverty-stricken and oppressed people. I give Miriam some tablets for the pain; but I can do little for the pain in her mind. I hope that when she disembarks in Italy, and we hand the rescued people over to the authorities, that she will receive the care she needs and deserves.

The day goes past in a blur of consultations, of making up baby bottles and handing out nappies and dry clothes, of checking pregnant women, of treating people with sea-sickness as the sea gets rougher. I see Miriam again, and am glad to find her fever is down; but her leg is still painful. On the upper deck, our nurse MJ is helping the young men make a huge chequers board to keep them amused and occupied; on the lower deck, one of the journalists is playing games with the young children.

Another night and another morning. Italy is approaching. Soon, Will, our emergency coordinator, is giving a talk to the crowded group: information on what happens on arrival, and some indications of what the process for them will be. The decks begin to buzz with excitement.

And then something happens that takes my breath away. A young woman, her head swathed in a bright pink scarf, stands up in the centre of a group and starts a rhythmic chanting as she sways and moves in time to the tune. She is joined by another woman, and another; soon the whole deck seems to be clapping and singing this repetitive tune. Their faces are wreathed with smiles; they are singing of hope, of relief, of joyful expectation. I can control the lump in my throat no longer, and tears pour down my cheeks.

Later, when everyone has safely disembarked, I go to the upper deck and stand in the stern, looking out to sea. And suddenly spot a small padlock, locked onto the protective netting. This is the deck where the refugees have been. One of them has put it there. Like the padlocks lovers lock onto bridges in Paris, in Stockholm, it glistens there in the evening light as a symbol of hope, of hope that a new and better life is beginning.

Heading Off Into The Refugee Tragedy in the Med

27^th August 2015

The phone wakes me early on the morning of my departure. I’m heading for Malta, to join up with the MSF/MOAS team on the Phoenix, rescuing people attempting to cross the Mediterranean in leaky, un-seaworthy vessels.

It seems that yesterday yet another leaky, unseaworthy vessel was the cause of another tragedy. “We may have to reroute you to Rome,” John, our logistician in Malta, tells me. “The team has gone out on a rescue, a big one, over 40 dead….. we’re not sure yet where the boat will land.”

I think of the terror they must have felt as their boat filled with water, or capsized –I haven’t heard the full story yet. And I know that only desperation would have forced them onto that perilous journey across the deep waters of the Med. Desperation with their lives in Somalia, Eritrea, Syria, Afghanistan, Libya: war-torn, anarchic, little-hope places.

I think back to my time working with MSF with Syrian refugees in Turkey, in 2012. Medically-trained Syrian refugees were staffing our clinic, and I remember the stories they told me. Of the bombs falling daily near their homes, of friends and family members killed, of there being no choice but to escape. Of exhausting, terrifying treks to the border, one with a pregnant wife and small child, all with no possessions but a small suitcase. “I don’t think I’ll ever be able to go back to my country,” I remember one consultant, a very qualified, highly educated man in his 50s, telling me. He and the others are just some of the 4 million people who have had to flee Syria to save their lives, most of whom will now have been living in overcrowded refugee camps in the countries bordering Syria for three years. Maybe some of them are now attempting to reach Europe in the hope of a better, safer life.

Or maybe some of the refugees from sub-Saharan Africa I met in the aftermath of the Libyan conflict, in 2011, have been attempting the crossing. They came from countries such as Somalia or Eritrea, had been working in Libya and forced to flee by the conflict. Unable to return to their home countries, they were stuck in refugee camps. They, too, told horrifying stories of imprisonment, beatings, even torture in Libya.

I think back to my time in South Sudan where people, bombed in Blue Nile State in Sudan, had trekked through the bush for up to three months, living on berries, arriving in South Sudan so dehydrated and malnourished that dozens just died on the side of the road.

It is with the plight of these refugees in mind, these people whose faces I remember so well, who I think of as I set off on this trip to help rescue yet more hundreds, thousands of people who, through no fault of their own, are forced to leave their countries. We have a humanitarian duty to help them. Not just in saving their lives in the Mediterranean, but in helping to provide a secure future for them. What right have we to lock ourselves safely up in we’re all right Jack mode in Fortress Britain?

I don’t know exactly what lies ahead of me. I hope I’m prepared, physically and mentally, for this trip. I’ve done a fairly arduous sea-safety training, which entailed me leaping from a height into water, dressed in a survival suit, and clambering into a wobbly life-raft. But I don’t think anything – not even seeing people dying miserably from Ebola – can prepare one for finding 52 people dead in the hold from asphyxiation, as my colleagues did recently.

But I’m glad that I can be there to help these desperate people with my medical skills in whatever way I can.

REACHING ZERO: Bringing the epidemic under control

Fatmata and Idiatu were smiling, happy with the new clothes we had brought them. Their old ones had been burned, along with the mattress they’d shared with their mother before she tested positive and died from Ebola. Their small, mud-brick house had been disinfected with chlorine spray by the decontamination team, and infected clothes and mattresses removed and burned. A local NGO was supposed to be bringing replacement mattresses; hopefully they would be here soon. I’d be sure to check up on that and to make sure they had food and water too.

Moses, the contact tracer for the area had also arrived at the girl’s house. One of a band of scores of dedicated volunteers, he would monitor them, and all other contacts of the positive cases in the surrounding villages, for the 21 day maximum incubation period of the virus. “I come every day to check on them,” he assured me. The family had recently been supplied with thermometers, so were able to monitor their temperature and report any fever, or any other symptoms, to Moses. He would then pass that information to the local Ebola command centre, which would despatch a case investigation officer to the house. If the person met the criteria, an ambulance would be sent to take them to the Ebola management centre for testing.

For now, all four members of this household in the village of Masanga were well and as the outreach team, we’d do everything we could to help them stay that way. Nick, the water and sanitation expert on the team had already supplied them with a home hygiene kit, offering different strengths of chlorine solution for hand-washing, clothes washing and general hygiene. Did they remember how to prepare these? We did a quick check and they passed the test easily.

It was time for the health promotion message. Emma and the team had prepared a drama, concentrating on the transmission of Ebola, staying healthy, and the importance of the early reporting of symptoms.   We still don’t know everything about Ebola but it is thought that people who come for testing and treatment in the first stages of the illness, when they have a lower viral load, have a better chance of recovery. This was something we wanted to emphasise, early isolation and treatment could not only save their lives but could also prevent them from infecting their family and spreading the virus further. We soon had a large group gathered round, in front of the house, the team swung into action. Ibrahim did a great display of vomiting and soon the crowd was roaring with laughter. What had they been saying? My mastery of Themne wasn’t up to that but Musa, the hygienist, enlightened me: they’re discussing safe sex, Emma was pretending to refuse sex without a condom. As the virus can stay in semen for up to three months after a patient’s blood is negative, this was an important message to get across.

The peak of the epidemic seems to have passed in Sierra Leone. At the height of it last year, those carrying the virus were taken by ambulance to the only treatment centres in the country, often more than 10 hours away. Many never returned to their villages, and died hundreds of kilometres from their family and friends. The Sierra Leonean people were scared. Superstitious rumours got around that health workers themselves were spreading the disease, maybe even harvesting organs and people became too frightened to get into ambulances, where the chlorine spray used to help control infection was believed to be poisonous.

But now communities have seen people taken by ambulances and return to their villages as survivors, again and again. They are no longer scared of the centres, but realise they offer the means to survive Ebola. In the talks that I gave to communities, the health promotion messages appeared to be understood and accepted.  And families mostly – although naturally reluctantly – now call the burial teams when someone dies, instead of following the traditional funeral rites when the family washes the body, which has been one of the primary sources of transmission across West Africa.

So finally, after terrifying months when the disease was spreading like a bush fire, the epidemic appears to be waning. The increased number of available beds has meant that people are admitted more quickly, increasing their own chances of survival while at the same time avoiding spreading the infection to their families. Our management centre has a laboratory working alongside it, so cases can be confirmed within a few hours. And all that, along with extra agencies and volunteers on the ground enabling the system of contact tracing, surveillance and quarantine to be carried out, has helped to slow the outbreak to the lowest levels since last July. But as even one new case can spread the disease to ten or more others, we cannot be complacent. We need to get it down to ZERO.

I left my colleagues continuing with outreach work, making sure every positive case was followed up and properly investigated and continuing to emphasise the basic health promotion messages that really do save lives. There’s still so much to be done in West Africa. As well as controlling the epidemic, there are hundreds if not thousands of orphans who need homes and families, those who disappeared at the peak of the epidemic need to be traced and the food insecurity caused by the epidemic needs to be managed. But at least this seemingly unstoppable behemoth, this viral monster that trails such primeval fear in its wake, is beginning to be brought under control and at last, there is hope.

The Return of an Ebola Survivor

Today Mama Sesay went home.

Having come into our Ebola Management Centre three weeks ago, with a positive blood test, she had slowly become increasingly stronger, her symptoms had gradually disappeared, and her blood test was now negative. Giving her that result was the happy task of our mental health team; and after further counselling and advice from them, she was ready to rejoin her family and community.

In my new position as part of the Outreach team that will help to monitor and control the epidemic out in the villages, along with the Health Promotion team I accompanied Mama Sesay on this great occasion. With a survival rate of less than 50%, she was one of the lucky ones. She’d come to us before the disease had become uncontrollable, before the haemorrhagic symptoms had started, before the viral load was so high that we would not have been able to save her. As it was, we were able to help boost her immune system so that she could fight the virus and overcome it.

As we drove Mama Sesay home, I thought with sadness of a young boy who had not been so lucky. He had come into the Centre a few days ago, so weak and breathless that he had to be carried on a stretcher out of the ambulance. He gave his age as fourteen, but looked about ten. As he sat weakly in the Triage area for a quick assessment, Robi, the doctor in charge of the running of the centre, with massive Ebola experience, shook his head. “He won’t make it,” he said sadly. For some reason I had an intuition that this boy would somehow beat the odds. So I was devastated when I came on duty the following morning, looked at the board where all our patients’ numbers were displayed, and couldn’t see his. And then I saw it. With a circle and a cross beside it. Under the heading “Morgue”. Robi had been right and my misplaced optimism wrong.

But now we were on a good news journey. The land-cruiser bumped its way down the dusty, red road, lined with tall grasses and clusters of palm trees. Makeshift barriers, in place since the “lock-down” to prevent people moving from village to village, were raised to let through our vehicle, with its well-known emblem. Apart from little children calling out “Opoto!” (white person) as we passed, the villages were quiet, houses locked and shuttered. A sign indicating the Primary School pointed towards a building that was silent and empty. Schools have been closed since the start of the academic year, the only teaching being carried out over the radio.

As we neared her village of Yoni Bana, Memuna Sesay let a small smile creep over her face. But her happiness at returning must have been marred by grief: grief for her mother, who had died from Ebola in her home, grief for her pregnant sister who had also died. She had been caring for her mother along with Memuna, and pregnant women are exceptionally vulnerable.

But there was still a large group waiting to greet Mama Sesay as we drove up, and as she stepped from the land-cruiser clapping and cheering erupted. As her three small grandchildren ran up to hug her, she beamed. It was a good moment.

One of our Health Promoters gave a message in the local Themne language, explaining that Mama Sesay was completely free from Ebola, that she no longer carried the infection and she had a certificate to prove it. He continued by reiterating the general Ebola message of ABC – Avoid Body Contact – and of reminding people that they should call the Alert line if anyone showed any of the symptoms of Ebola. This would go through to the District Command Centre, and a chain of reaction would begin.

After shaking her hand – the first contact I had had with her without being protected by PPE – with many waves and cheers we left Mama Sesay, happily back once more in her community. An Ebola Survivor.

Too many deaths……. and a bright ray of hope

A chance to survive…… this is what I said we were offering those stricken with Ebola, in this rural area of Sierra Leone, when we opened our Ebola Management Centre about two weeks ago.

Dozens have passed through our doors since the opening. Many have walked in on their own, concerned about suspicious symptoms; still more have arrived by ambulance, referred from other centres. Some have already been confirmed with Ebola; the rest have been assessed, and, if meeting the criteria, admitted as suspected cases while awaiting analysis of a blood test by our laboratory.

With results taking just a few hours, the Canadian Winnipeg laboratory saves days of uncertainty and worry for the lucky ones who can walk out to freedom. Freedom from the dreaded disease, and, carrying with them a certificate proving that they never had Ebola, freedom from the stigma that survivors sadly carry with them.

But survivors……..that’s what we’re waiting for. Too many of our patients are arriving when the disease has already progressed too far for us to be able to save them. We can offer them relief from the pain, good nutrition if they can eat, rehydration if they can’t. We can offer preventative treatment of other illnesses, such as malaria. We can offer psychological counselling from our mental health team, who along with our health promotion team will do everything possible to trace family members, and thus avoid the “disappearances” that have been all too common.

And we can offer them some dignity, both in living and, too often, in dying. It’s this dying that’s getting to me. Every death is a death too many; but one that really hit me was an 18-year old girl, Asata*. One afternoon when I was on duty Puk, the leader of our mental health team, told me that Asata was saying farewell to her mother, aware that she was dying. Asata, her mother and a brother were all in the same tent of Confirmed cases. Her father had already died. This disease is destroying entire families.

The next morning when I came on duty, Fatmata, the mother, was looking tired and subdued. “Asmata died in the night,” I was told.   Fatmata must be wondering if her son will be next – or if she herself will succumb. So far they seem to be strong. Let’s hope we can help keep them that way.

But all our efforts could not save Mabinty or Ibrahim. Last night I worked my first 12-hour night shift for many years. I thought it would be tough, that I would struggle to stay awake, even with the stimulation of the cold night air as we sat outside the tents of the High Risk zone between “ward rounds” when we donned our protective equipment – PPE – to monitor and assist patients. But the physical part was easy compared with the emotional struggle. Mabinty and Ibrahim both died in the early hours, just a couple of hours separating their deaths.   After more than a decade as a nurse, I ‘ve seen many people die. It’s always, of course, a great sadness. But these deaths from Ebola are uniquely horrid.

When Ibrahim started bleeding from his mouth a couple of days ago, I asked a colleague with a lot of experience with Ebola if people could ever recover once they had started haemorrhaging. “Hardly ever,” she told me. So I knew the end was in sight. Helping him rinse the blood from his mouth, and so make drinking some water a bit more pleasant for him, looking in his eyes as I did so, established a human contact between us. Today his eyes were so distant, his expression so remote, that that contact had already been lost. My mind was more or less attuned to the inevitability of his death, but certifying his dead body a few hours later was still painful.

It was the same with Mabinty, whose death I had to certify just a short while later, when I came in with the team to give out medications, and found her slumped forward from her previously supported position. Mabinty had also been haemorrhaging, and was struggling to breathe. I will always be grateful that my colleague, Marlieke, had gone with one of our national staff to make her more comfortable just an hour or so earlier. With those who are dying, this is all we can do. She died alone, with no family beside her. I hope that we brought her some relief in her dying moments, in spite of being strangers dressed in yellow space suits.

But I don’t want this entry to be all about death and dying, to dwell on the negative. There are happy moments too, like the unexpected reunion between two brothers. Seven-year –old Alie had been admitted a day or so ago into the Suspect tent, along with his uncle. When I came on duty the next morning, Alie was in the tent on his own. “His uncle died last night,” I was told. So little Alie was now alone. But then an eleven-year-old boy, Abdulia, sitting outside the next door tent of Confirmed cases and separated by a barrier, looked across and saw Alie. “That’s my brother!” he said in amazement. So they were able to chat to each other. And when Abdulia was envious of the big shiny radio that his little brother had got, provided by the mental health team, of course Abdulia was given one too. Now we just have to hope that Alie’s test will prove him negative, and that we can help Abdulia fight this Ebola virus and survive.

Then we have a nearly full “convalescent” tent, patients who are not haemorrhaging, who are definitely improving. “I would like to move to the other tent,” Mohammed said to me this morning. “Why is that?” I asked him, thinking most likely it was because he was in the tent with Ibrahim and Mabinty when they died. “Because I am getting better,” he said firmly. I hope we can move him today.

Also on the positive side, the fact that Mabinty and Ibrahim died with us means that many family members, acting as carers, have been saved close contact with a very contagious Ebola sufferer and thus becoming victims in their turn. And although it’s likely the families may not be able to attend the burials, avoiding the dangerous traditional burial practices which lead to dozens more deaths is a public health message we struggle to get across. We will do all we can to let the families know the location of the graves, so that they can visit them and pay their respects.

In the end, this is the most we can do. Just offer a chance to survive; and, if survival cannot be, as compassionate and dignified death as possible.

STOP PRESS!! Our first cured patient was discharged today! She had been admitted the first day we opened, her blood test showing a high viral load. But now, fourteen days later, her blood test is negative and she is ready to go back to her family, friends and community, an Ebola Survivor. We are all celebrating in the Ebola Management Centre of Magburaka!

*All patient names have been changed in the interests of confidentiality.

 

A Week in the Life of…..Construction of an Ebola Management Centre

Sunday:

As soon as you touch down in Freetown, Ebola hits you. Or the awareness of it. Health forms to fill in, chlorine handwashes before you even enter the terminal building, zapped with a temperature gun before you step outside.

Public health messages and precautions continue throughout the city: big posters announcing that Ebola is Real so ABC: Avoid Body Contact! dominate the main thoroughfares. Chlorine handwashes are at the entrance to restaurants and supermarkets – but even so, I’m careful not to touch the doors with my hand. Even as medics, we have never been so clean, so hygiene aware. And we’re all getting acclimatised to the No Touch Policy: no touching even amongst the team, no hand-shaking when you meet someone. Instead a crossed arm against your chest.

The Ebola Management Centres in Freetown are overflowing. But in spite of this, in spite of this silent killer in their midst, life appears to be carrying on more or less as normal in this city of 1.2 million resilient west Africans. Markets are functioning (out of bounds to us, how can you shop in a market without touching?), roadside stalls appear to be doing a thriving business, and on the long beaches that border the city nets are being pulled up by young fishermen.

Tuesday:

And then we make the four-hour drive north-east to Magburaka, the site of our new Ebola Management Centre. It’s a vast expanse of incredible activity. With the help of about four hundred workmen, the team aims to construct the management centre in about twelve days, start to finish. There aren’t enough beds in the area for all the ebola patients, who have been enduring nightmare ten-hour journeys to the nearest centre. Many have not survived the trip, and the ambulances have been arriving with corpses amongst the severely ill and distressed patients.

So we are pushing to get the project up and running. Already the site has been levelled and cleared, enormous warehouse tents are up, as are the tents for the patients, offering 100-bed capacity. The laboratory tent is in place; so are the tents for health promotion and mental health counselling. Trenches have been dug for drainage, latrines have been established. Now labourers are constructing shelters for showers, roofs for the central walkway.

Wednesday:

Today we train the new medical national staff in the use of PPE, the protective personal equipment that you have to wear in the high risk zone. Everyone knows what it looks like now, it’s been shown enough in the media: the spaceman-like outfit of bright yellow impermeable onesies, masks, hoods, goggles, gloves, white wellington boots. And a heavy rubber apron on top of everything.  With temperatures in the 30s (and they will be higher in the tents) it’s almost unbearably hot inside them. Everyone pours with sweat.

We go through the ritual of dressing and undressing with the help of a dresser, who watches to make sure that everything is put on correctly, that not one square millimetre remains uncovered and vulnerable. One square millimetre is all you need for the virus to enter. The most dangerous part is the undressing, taking off the clothing that is now covered with the deadly – but invisible – ebola virus. You are watched and advised every step of the way: now wash your hands, now take off the first pair of gloves, now wash your hands……..chlorinated water is in abundance everywhere as although the virus is deadly once it enters the body, outside the body it can be killed by chlorine.

Everyone is tired at the end of the day; but we’re a step nearer to opening a safe management centre, with staff who know the ropes. Before I go to bed, I look through application forms for further health workers. Pitiful comments jump from the letters: killer virus……orphan…….no education, no hope.

At least we will be able to offer a ray of hope.

Saturday

The site is a frenzy of activity: carpenters with saws and hammers and planes, electricians assessing complicated boards and hooking up lights in all the tents, water and sanitation engineers ensuring the chlorinated water supply system is working well. Gravel is being raked over the red earth, fences of orange netting are being erected to delineate the low risk from the high risk zone, suspect cases from probable and confirmed. From Monday onwards, when we will accept our first patients, we won’t be able to enter the High Risk area without being covered with that hot, weird, rather scary yellow PPE.

Tomorrow we have a dry run with all the medical and hygiene staff, so we need to finish all the work today. Five hours to go…..or maybe we’ll work through the night. I’m working with the medical team, helping unpack and organise the drugs, assemble the canvas and metal beds, get in place all the rest of the medical equipment needed in the centre.

Everyone is busy with his own task: it’s a great atmosphere of team collaboration. Will, our project coordinator, is walking around with a look of slightly anxious concentration as he checks the whole site. He started this whole project fifteen days ago. He must be feeling pretty satisfied with the result.

Sunday

We show around some visitors from the organisational Command Centre, where the British Army is collaborating with the local authorities. “Puts the Royal Engineers to shame,” one soldier comments, when I tell him this has all been constructed in 12 days.

We have a final walk-through under the star-studded night sky. Everyone is exhausted after a long, tiring day – indeed, a long and tiring fortnight. But we’re all elated that we’ve achieved it, we’re ready to open.

Tomorrow we will receive our first patients, already confirmed with ebola, and currently in one of the holding centres where patients wait for a bed in a Management Centre. And we will give them the chance to live, to join the small band of Ebola Survivors.

My Ebola Diary

So, finally, I’m off. This time on Saturday I’ll be on a plane to Freetown in Sierra Leone, to join the more or less 3500 MSF staff, national and international, who are fighting the largest, most deadly outbreak of the Ebola virus we have ever seen.

I can’t wait. I’m leaving with the support and love of family and friends, even if they would nearly all prefer I wasn’t going. Especially my three children: all grown up, but scared for me, although they understand my motivation.

With nearly 16,000 confirmed cases of Ebola to date across West Africa, over one third of whom have died, I question if I am scared myself. I was glad to see one of our doctors, recorded on Panorama, admit that he thought it wouldn’t be natural not to be a bit scared, or at least apprehensive. So yes, I am. After an excellent preparatory training, learning about the epidemiology of the virus, of the modes of transmission, of infection control, I’m very aware of the dangers we will be exposed to. I’m also aware of the precautions we need to take to protect ourselves; and I’m aware of human fallibility. A needlestick accident while taking blood. Letting my exposed skin come in contact with the virus-covered protective clothing as I remove it after being in the isolation unit.

The training gave us a good practical preparation, and I feel prepared physically. I know what I need to do. But am I prepared psychologically? How will I cope with the inevitable tragedies, the orphaned children, the appalling, lonely deaths of young and old alike, where the only human contact is from strange creatures dressed as aliens? This will be, I think, my twelfth mission with MSF, and I have seen my share of death and destruction in the war zones of the Central African Republic, of Libya and Syria. But tragic as those situations were, somehow I feel this will be even worse. I think it’s because of the unpredictability, the invisibility of the virus, the bereft isolation of the dying.

But as a nurse, fully covered in Personal Protective Equipment (PPE) I will be in a position to support them, the most vulnerable. We cannot cure Ebola, we can only give supportive treatment. We can help people fight the virus, rehydrating them; and, if they cannot fight it, we can help them feel less alone, and have a more dignified death.

So it will be a very rewarding, if challenging and exhausting, six weeks. Not being with the family for Christmas, for the first time since my first child was born 34 years ago, will be strange and sad. But compared with doing nothing when people’s mothers, fathers, sisters, brothers, children are dying, day by day, on Christmas day itself, well. It’s a small price to pay.

Returning

 

It’s hard, returning.

Just over two months ago, I pedalled through the green countryside of an English spring, and wondered about the unknown world I was headed for: the Central African Republic, spiralling out of control with ethnic-related violence.

And now, as I walk down a wooded Devon lane splashed with pink campions and the last of the bluebells, with the sound of the surf breaking on the beach below me, I try to adjust to the peaceful world I find myself in once again. A short flight has transported me back to a different planet: to a world not punctuated with the daily rattle of gunfire, with heavy armoured cars filled with troops rolling past, with endless tales of tragedies, of families slaughtered, of whole villages wiped out, their remaining inhabitants hiding in the bush. A world where I don’t hear a woman, expressionless and hunched, telling of being gang raped. Where I don’t see men damaged, physically and mentally, by torture too appalling to relate. Where women rarely die in childbirth, where wounds don’t fester till limbs need amputating, where tiny babies don’t die from malaria because they can’t get medical assistance in time.

But this was the world I was living in, 100% immersed in as in a bubble, the outside world increasingly sidelined. Now that I’m back in that other world, what should be my “real” world, I am finding it totally alien. I am no longer sure who I am, where I fit in, where I belong. Outwardly I must look much the same: a bit thinner, a lot more tired, a bit older in these two months, but basically the same, the same mother, the same friend. But inside – how can I be the same? I almost feel I’m two different people, the Ali who lives in the English countryside and blends in, albeit chameleon-like; and MSF Ali.

“I can’t do normal,’ said Juliette Binoche, or words to that effect, acting the part of a war photographer in a recent film and trying to fit in back in her Irish home. Normal seems so – well, abnormal. And it’s hard to relate to people who haven’t been through these experiences, who cannot visualise what we have seen and done, and so are hardly interested. “I sometimes want to say I work in a biscuit factory making Jammy Dodgers,” a dear MSF friend of mine said recently. “Anything to avoid having to say those three letters, that no-one can really understand.”

So how do we cope with this returning, this adjustment that we must all make? What is the secret to being able to live successfully in two such very different environments, moving between the two and adapting to each, but remaining grounded and integrated? This is my tenth mission, but I still find the adjustment hard. I want to absorb all I have seen and done, be aware of all I have learned, allow it to reshape me, not break me.

It seems there are no easy answers, no magic potions. But today, as I lay in the evening sunshine on a shingle beach, it gradually felt as if the swoosh of the breaking surf and the gentle sea breeze that swept over me were amalgamating the fragmented parts of myself, uniting them into one whole. A whole that has changed, but is stronger, richer and wiser.

And ready for another mission.