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Ebola Diary: On the Ground in Sierra Leone, Part 5

— Last installment in a CDC fellow's account of her experiences tracking the spread of the Ebola virus in West Africa.

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Kimmie Pringle, MD, an Epidemic Intelligence Service officer with the CDC and board-certified emergency medicine physician, began a 4-week rotation in Sierra Leone on the morning of Sept. 24. In this five-part series, which began Sunday, she describes her experiences as they happened.

Pringle's mission, along with 11 CDC colleagues, was to track the spread of the Ebola virus and to break the chain of transmission between contacts. This meant traveling to isolated villages where foreign healthcare workers were not always welcome, accepting heart-breaking decisions to keep staff and patients safe, and leaving far sooner than she would have liked.

From the moment Pringle's journey began, she never stopped trying to understand the harsh, beautiful, and complicated world she'd stepped into. Pringle witnessed the anger, fear, and suspicion pervasive in parts of West Africa, particularly in regions that have experienced years of violence and loss, but still she saw hope.

NOTE: This "diary" has been edited for length, clarity, and the security of certain individuals. When names or places have been changed those changes are indicated with an asterisk. This installment was actually written shortly before Part 4 but eloquently sums up Pringle's experience.

Looking Back

Oct. 15, 2014

A few days ago I saw a 4-year-old boy sitting in one of those plastic chairs ubiquitous in low- and middle-income countries, towards the edge, with his thin legs dangling not even close to touching the ground. He wore an oversized, faded, torn T-shirt; the neck opening shifted to reveal his left shoulder under which was pinched a thermometer. I was struck by his stillness in the shadows of the triage tent.

Garrett* from WHO told me the boy had been brought in from his community, where he'd been rejected, even though he was asymptomatic. Both of his parents were at another international aid organization's site in the treatment center. A report said that he fell on his arm running. The surveillance team learned this when they arranged for an ambulance to come pick up the boy.

Garrett, a microbiologist by training, is clearly perplexed. "None of the nurses will touch him, [even though] he's asymptomatic. No one will x-ray his arm to see if it is broken."

I try to look at his arm from a distance, knowing that this is a mere exercise. We search the hospital grounds for an extra sheet or t-shirt to create a makeshift sling. In the WHO office we find a wheel of colorful fabric in a dusty box and I hold the fabric taut as Garrett initiates a cut with a key. We folded the square of fabric in a triangle pattern and find rusty safety pins in a different box. Now all we need is a nurse to put it on him.

I almost volunteer, and then sideline the urge. The rational part of my brain realizes that this boy is unlikely to be contagious, but did meet the case definition of a probable case, given his Ebola positive parents. Though appearing asymptomatic, children are poor at using words to describe illness (a problematic part of the case definition) and often a pediatric history is based on subtle changes in the child's behavior reported by the parents.

We find a nurse who dons PPE to place the sling on the boy. After testing negative, 6 days later I learn he had an X-ray, which revealed a greenstick fracture. Two days later he was still not casted. Put in the Ebola Holding Center he continued to stay there. It's unclear who was feeding him. Still without symptoms, the boy was finally moved to the international aid organization's "Hotel" where recently recovered survivors share a space with asymptomatic orphaned children still within their 21 days of being a contact.

It's strange sitting in the periphery of clinical care, and there are times that I struggle with it. It's a larger risk than my current work, but I miss the satisfaction of seeing an individual patient through a critical illness. I do not miss the sadness of losing someone.

As an epidemiologist, creating a change in a larger system has been challenging. It's hard to see the result of your individual contribution, but frustration with the ER at times feeling like a revolving door of illnesses resulting from systemic issues motivated me to pursue the Epidemic Intelligence Service fellowship.

I think the power of this experience for me derives from witnessing the depth of the suffering felt throughout the community. It is with this type of sorrow that one can see the extraordinary characteristics in other people: The resiliency of the human spirit, openness to accept and advocate for patients and survivors otherwise ostracized from their communities, patience to connect with communities who still don't believe in Ebola, kindness shown to a never-ending rotation of international workers, dedication to your community and country (to the point of working without weeks of pay), and the strength to have lost so much yet continue on with resolve.

Though I will remember the suffering I saw this month, I will not focus on it.

And I'd like for you to spread the message in the U.S. that we should stop listing what Sierra Leonians don't have, but instead focus on what they do have. Certainly, they lack stuff, there is abject poverty here. But we should focus on the characteristics of the people. They possess the intangible qualities needed to get the job done: intelligence, passion, energy, commitment, and heart. They just need help implementing an organizational structure, and the resources to run that structure.

As I begin to gird for my journey back to the states, I won't focus on the sadness of leaving behind my friends, only that I gained new ones. I certainly won't miss the afternoon film of sweat that coats my skin and causes prickles on my back every afternoon, like ants crawling all over me, or the bucket flush toilet at the office, or water like sewage, or the almost exclusive consumption of granola bars for lunch. I yearn, for water pressure, electricity during the day, air conditioning, something on the menu other than beans and rice, my apartment, my bed ... my husband.

I'm sure the questions will come, "What was it like?" For me, it may best parallel when nonphysicians asked me, "What was it like becoming a doctor?" How can you capture such highs and lows in a simple paragraph? All. The. Studying. The delight of delivering your first baby; witnessing a young father with twins die unexpectedly; the immigrant worker mangled by a machine; or the cancer patient who dies beautifully, even peacefully surrounded by loved ones. The long hours, absolute exhaustion, examining your first patient on the floors as a student, feeling lost as an intern, and then slowly over years gaining confidence.

It's beautiful, it's ugly, and it's hard. I also learned in clinical medicine to compartmentalize and move forward with work despite emotional distress. Terrible things happen to really good people; I came face to face with the random injustices and tragedy daily in Rhode Island. My time in Kenema brought all of these parallel experiences forward, in a condensed time period. And instead of happening to individual patients, it happened to a community. Much like the strong bonds formed with my co-residents, mentors, nurses, techs, clerks, and other emergency department teammates, I formed similar bonds with the surveillance officers, nurses, psychosocial team, and social mobilization team of Kenema as well as workers for international organizations. Like experiences in the ER, those that I had in Kenema can be isolating, and only a few people are truly capable of understanding.

So, when asked, I'm not sure what I'll say, but I will try to focus on the positive, because it exists, at least in Kenema, if you're willing to look.

This five-part series began Sunday.