Rain

The rain came yesterday morning.

We sat outside on our patio eating breakfast.  It had been a humid, stuffy night, and when I felt a cool breeze it took me a few moments to register that this was something new and unexpected.  I looked to the left, above the wall of our housing compound, and the sky in the east was black.

“I think it’s going to rain,” I said, and everyone turned to stare at the sky.

“It can’t rain,” said someone else, “It’s only January.  It isn’t supposed to rain until May.”

The clouds slid quickly and silently across the sky.  The light faded to grey.

“Maybe it’s the apocalypse,” said another nurse.

Quipped a third, “I am glad to be here with you all, here at the end of all things.”

Said a fourth, “Maybe this signals the end of Ebola.  Maybe the coming of the rain means Ebola is over.”

“I gotta say, if we get rained on right now, and then Ebola suddenly stops, I’m really gonna have to re-examine my personal theology,” I said, dryly.

– – –

A few moments later, the rain began its tattoo across the tin roof.

– – –

Driving out from town later that morning to a field site, I watched the car in front of us splash through puddles along the highway, listened to the wipers swish back and forth across our windshield.  I had believed Sierra Leone to green and lush before, but now, as the rain drizzled down endlessly, the landscape seemed almost to glow with intensity against the dull background of the sky.  The palm trees were topped with the deepest green, the underbrush of elephant grass and cassava a bright kelly green; the islands of gardens and the swamp rice so green and bright as to be nearly fluorescent.

I mulled over the nature of Ebola.  The latest UNMEER report listed only 117 new cases last week in the country; we read it with cautious optimism and hoped that we were seeing the end of the epidemic.  Our district actually had the highest number of cases in the entire country, higher even than Freetown, due mostly to a rapid series of secret and illegal burials that had brought a dozen new cases to our ETU.

As one physician remarked, “We are now working in the single worst area of the Ebola outbreak in the entire world.”

“So, wait, does that mean we win or lose?” I asked.

“Well, both.”  He paused, and shrugged.  “But mostly lose, I think.”

– – –

When the young mother arrived last week, her husband had already taken ill and was being treated at a different ETU in the district.  Isatu’s five-year-old son and eight-month-old daughter had been removed from the home before it was disinfected and quarantined, and were being observed for 21 days at a special care center for children.

She was never badly ill, and was frequently found sitting in a plastic lawn chair out in the sun, enjoying the warmth and eating the oranges the staff bought for the patients every morning from the vendors along the road.  I met her during a staff training day; I’d been pulled from the field team to help monitor a new cohort from the States.  A group of wide-eyed and slightly uncertain clinicians trailed along behind me, a mini army of aliens, as I chatted with her and the others in her ward.

I was not there the day her daughter suddenly spiked a fever and was rushed from the observation unit to the ETU.  But the nurse who was at Isatu’s side that morning told me that when her daughter was carried into the pediatric suspect ward, the child let out a sudden wail.  And more than one hundred yards away, through three sets of fences, Isatu’s head whipped around suddenly, and her hand went to her heart.

“That is my daughter,” she said, and walked to the fence.

– – –

Isatu stood by the fence for two days, listening to her daughter cry.  Amongst ourselves, we wondered quietly if she actually opened the gates and walked back into the Suspect Ward during the night to comfort her child.

An absolute rule of an ETU is that once you leave the Suspect Ward and walk into Confirmed, you never return to Suspect again.  The risk of infection to suspect patients is too great, and the last thing you want is to give your feverish malaria patient a nice case of Ebola.  The bolt on the gate between Suspect and Confirmed had rusted itself frozen many weeks ago from the chlorine, and so the gate remained closed but unable to be secured.  We’d all caught people wandering between wards, sometimes trying to reach family or friends, sometimes out of confusion, and we’d gently redirected them back to quarantine or safety.

We never caught Isatu in the Suspect Ward.  But if she did wander, we certainly would never have blamed her.

On the morning of the third day, Isatu’s blood test came back negative.  She had survived Ebola.  Her daughter’s blood test came back positive.  The pediatric team carried Isatu’s weak and lethargic daughter through the fence, and placed her in her mother’s arms.

– – –

Isatu chose to remain in the ETU to care for her daughter.  She held her, cleaned her, fed her formula, breastfed her.  We knew of a case in Liberia where a survivor mother had cared for her infected three-month-old child, and the child had survived.  The physicians at that ETU believed that antibodies in the mother’s breastmilk might have contributed to the infant’s survival.

At our ETU, not a single child under the age of one had ever survived Ebola.

– – –

I remember the first infant I saw dying of Ebola.  The mother had survived and was improving slowly, but the infant continued to have fevers of 40*C or higher each day.  I was training with the pediatric team, and as we worked with a school-age child, a sprayer suddenly rushed over to us.

“Something is wrong,” and he pointed to the mother, who was staring in horror at her child.  We walked over, and realized the baby was seizing violently, eyes rolled up, arms above its head, knees flexed, back and neck arched.  The baby was so stiffened by convulsions that the mother was having trouble holding it.

We drew up a tiny dose of IM Diazepam and gave the child a shot in the leg, and then the lead pediatric nurse practitioner and a national nurse sat next to the mother and spoke quietly to her for a long time.  The seizures were a very bad sign, they said.  Her baby was going to die.

She picked up her child, clutched it to her chest, and began to wail.  Unable to be still, she stood and paced back and forth in front of her ward, screaming, tears rolling down her face.  Every few steps she would peer into the lapa she had bundled around the baby, but the baby remained still, locked with seizures, eyes staring blankly at the sky.

She wanted no comfort or interaction from us after that, so we left her to her grief.  As I stood in the doffing station washing my hands, I looked back through the fence into the ward.  She was sitting in a chair in the relentless sun, rocking back and forth, her child in her arms.

– – –

We discharged her from the ETU two days later.  Her arms were empty.

– – –

Isatu’s husband also survived Ebola, and came to our ETU every day.  Isatu carried her daughter to a wooden bench we’d placed near the chain-link fence in the red zone, and her husband sat on a bench in the green zone on the opposite side of the fence.

They did this every day, for hours.

Then he would return home to care for their son, and she returned to her ward to care for their daughter.  I do not know how she or her husband contracted Ebola, but their daughter most certainly contracted it from Isatu.

Ebola is a vicious, heartless disease.  It is a disease that you pass along to another person because you cared for them.

It is a disease that kills people through love.

– – –

Late in the afternoon, the day before the rain came, Isatu’s daughter started to bleed from her nose and mouth.  Hysterical, Isatu placed her daughter into a nurse’s arms, and walked to the fence for the last time.  She spoke to the national nurse standing on the other side in the green zone.

Let me go home, she said.  Do not make me stay here and watch my child die.

We unlocked the gate.  Isatu stripped out of all her clothes, washed herself with soap and clean water, dressed in the new clothes we brought her, and stepped out of the red zone and into her husband’s arms.

Much later, the night shift nurse covered the body of an elderly man with a lapa, and then covered with body of an elderly woman with another.  The universe saw the inequity, and within hours had balanced the scales.  An orphaned ten-month-old died quietly and alone.  And, finally, just before dawn, Isatu’s daughter exhaled through bloody lips and was still.

– – –

The night shift nurse stood in triage as the rain started, listened in mild surprise as it tapped on the roof, watched as little clouds of dust jumped into the air when the water hit the dry earth.

“Strange that it’s raining in January,” she remarked to the day shift nurse.  He nodded absently, and looked up as another clinician came in the door.

“There’s someone outside, asking about a patient.”

The day shift nurse peered out the triage door.  There, on the other side of the fence, standing together and watching him with bleak eyes, were Isatu and her husband.

He sighed, and took a deep breath.  Then he stepped out from shelter, and walked towards them through the pouring rain.