Re-visiting Ebola in western Uganda

Posted: February 29, 2008 in Blog

I recently spent some time in western Uganda, in the Bundibugyo area along the Congo border, reporting on the aftermath of a recently-ended Ebola outbreak. Here is an account of the trip, modified from the notes I took along the way:

Day One:

When I opened this notebook just now, the pages were gritty with sand from the beaches of Zanzibar.

Those beaches seems so far away right now. I’m on the Uganda side of the Congo border, in Bundibugyo. I’ve come here to spend a week reporting on the aftermath of an Ebola outbreak, revisiting it as the government prepares to declare the country Ebola-free. In all, 37 people were killed by Ebola and some 149 cases were reported, with the possibility that more went unreported.

We left from Kampala early this morning. Four of us and our driver piled into a pick-up truck for the drive—first, four hours west to Fort Portal on a good road, have lunch there, then nearly three hours more to get to Bundibugyo. The two towns are only about 25 miles apart, but it is a mountainous drive along a narrow, winding dirt road. In all, there are about 50 miles of road to cover that 25 mile distance.

The road made the Columbia Ice Fields road between Banff and Jasper in Canada look like a straight-as-an-arrow prairie highway. It was two-way traffic on a one-lane dirt road that hugged the mountain on one side, and dropped off sharply to the valley below on the other. All the while, we were also dodging goats, cows, people and trucks overloaded with up to 40 passengers.

When an oncoming truck would appear, both vehicles would come to a stop and slowly inch past each other, with one hugging the cliff wall and the other moving as close to the drop-off ledge as they could.

Oncoming truck

But at long last we arrived and are staying at a guesthouse here for about $6 a night.

After settling in that evening, I walked out to the guesthouse’s front porch overlooking the street, to find two men playing cards. I sat down to watch and learn the rules. Their English (at least in terms of them being able to understand my accent) was not great, and neither was my knowledge of the local dialect, so I just watched.

It was a variation of Crazy Eights they called “Pick ‘n Play”. Whoever got out of cards first won and the other would have to record the points value of the cards remaining in his hand. First to 1,000 points loses (sort of the same scoring as gin rummy). It took well over two hours for someone to reach that total.

It was fun, though, and we shared a laugh when the one guy showed me the back of the sheet he was using to keep score. It was an Ebola information sheet. Guess that’s a good sign, when the info sheets are being used to keep score in card games, now that peoples’ fears have subsided. “Ebola is gone,” he said, laughing as he showed me.

After dinner (matooke, rice and stewed beef), we came back to the guesthouse. The generator outside is humming as I write this. The guesthouse has power for a couple hours each evening when the owners turn on the generator. Like many isolated areas in Uganda, Bundibugyo is not on the power grid so those with generators have lights for a couple hours a day. Those without generators rely on kerosene lamps and candles. It is a reminder of what life is like for so many (only about three per cent of rural Ugandans have electricity), and also a reminder of how easy it is to be out of touch with the realities of that life while living in the comfort of Kampala.

In talking about the lack of electricity, one of my colleagues wondered why the region couldn’t get electricity from the river system on the Congo side of the border. My other colleague answered him. “That river is as flat as a bed,” he said. “How do you get electricity from a bed?” The way metaphors are sprinkled into everyday conversation here adds so much colour to the debates and shows a level of effort in those conversations that is so often lacking elsewhere.

Day Two:

The day began watching the sun rise over the Rwenzori mountains as I walked to the outdoor shower (with water so cold it takes a moment to collect wits before you jump under the weak stream of water coming from the shower head).

We went out for breakfast (matooke and stewed beef) and then began our day. After struggling to find local government officials, we went to Bundibugyo Hospital to interview workers and see where they had set up their isolation ward for handling the outbreak. We first interviewed the head nurse, who had been in charge of the hospital’s Ebola isolation ward. He was skeptical of some aspects of the response (the outbreak began three months before it was diagnosed as Ebola. Many died during that time) but he was proud of the local workers who stayed on throughout the outbreak and he explained how he kept working during the outbreak. “I had great fear,” he said. The first cases began arriving in August when, it is believed, a family in the mountains went monkey hunting, which is common here.

On that hunt, the family found a dead monkey (though some reports say it was a dead goat) and brought it back to eat. In the end, 16 of the 17 family members who ate it are said to have gotten sick. Five died, and it spread from there through the village, into the medical staff of the nearby health centre and eventually down the mountain to Bundibugyo town. The medical staff at that tiny 10-bed health centre treated the Ebola patients for three months without knowing it was Ebola, and also largely without any form of protection, even rubber gloves. The first health worker to get sick contracted the virus because he was asked to take stool samples of the patients without rubber gloves or a mask.

We toured the ward at the hospital where Ebola patients were isolated. It has since been disinfected and painted. A pile of bed frames and furniture sits in the yard, waiting to be disinfected or destroyed. Otherwise people will be afraid to use them.

Furniture used in Ebola isolation ward

Generally, this is a town waking up again. Businesses have re-opened and street life has returned. One of our colleagues who had been in the town during the outbreak said the difference was remarkable.

Following the hospital visit (where a well-timed allergy attack gave me a sneezing fit that led to a steady stream of Ebola jokes. Ha. Ha.) we drove up into the mountains to visit the area from where 91 of the 149 Ebola cases came. It was a stunning drive through the mountains. Up there, life is different. There are fewer organized communities. Paths lead from the road through dense bush, to small clutches of mud-brick homes, largely isolated from one another. On the hills above are plots that have somehow been farmed despite being horrendously steep.

We arrived at the health centre where the outbreak began. It is a simple, but well-built facility.

Kikyo Health Centre

It has only a maternity ward consisting of 10 beds and nothing else. So the outbreak was worsened when, not knowing it was Ebola, patients were mixed in this small room. (Likewise at Bundibugyo Hospital, as many as 300 patients were in the 100-bed hospital at any given time, leading health workers to admit the cramped quarters contributed to the outbreak).

The head of the health centre, Julius Monday, was very animated in taking us through the experience.

Julius Monday

It is a miracle he did not contract Ebola. Six of his workers did, and one of them died.

I asked him whether he’s thought at all about how he managed to avoid getting Ebola.

“It was by God’s luck that I survived,” he said. “And maybe by my habit of washing hands.”

In this part of the country high in the mountains, where electricity, newspapers and mobile phone service are 16 kilometres away through the peaks and valleys of the Rwenzori Mountains, radio reigns paramount when it comes to communication.

It was no different on Nov. 29th, when major news was due to hit this community just as soon as someone turned on their battery-powered radio.

Government officials that day announced that what had previously been thought of as a “mysterious disease” affecting dozens of people high in these hills was in fact the deadly Ebola virus.

To those who had been living here amongst the virus for months not knowing it was such a serious outbreak, the news came as a shock.

“When I found out it was Ebola I didn’t eat for three days,” Monday said.

Monday said he did not receive the news through the Ministry of Health or any other official means of communication. Instead, someone heard the news on the radio and came running to the health centre.

The health centre, as well as health facilities in the surrounding region, were soon flooded with Ministry of Health and humanitarian organization workers who established isolation wards and instituted treatment methods using equipment and resources that had been unavailable to local staff during the months they battled the outbreak on their own.

Following the visit to the heath centre, we next walked to the village some 500 metres away where most of the affected families live. One family had 10 infected, seven of whom died. Another had 16 infected, five of whom died.

We visited a family where four were infected, three of whom died. The three were middle-aged men, and brothers. One had 26 children and three wives (one of the wives, who gave birth to 18 of the children, was also infected but she survived). We interviewed the wife who survived Ebola about her experience, what it felt like, etc. It’s a truly terrible disease. She also spoke about the stigma, as people still fear coming near her.
Ebola survivor

The one surviving brother is now responsible for the three orphaned families as well as his own.

After these interviews, we returned to Bundibugyo for dinner (again, rice, matooke and stewed beef) and an early bedtime. Without electricity there is little to do at night.

Day Three

“I’m an Ebola survivor!” we heard being shouted behind us as we walked away from the hospital in Bundibugyo. “Do you want to talk to me?”

Here we were, walking along the dirt road from the hospital to the district offices when behind us we heard this voice. We turned to find a man walking briskly to catch up with us. He had heard there were people at the hospital talking to Ebola survivors and he wanted to talk to us.

We stopped, and under the shade of a tree, listened to his story.

img_5467.jpg

He is a nurse who cared for three of the early Ebola cases (two of whom died). Days later, he too became sick. In fact, he began feeling symptoms the same day a team of investigators arrived to examine the prospect of Ebola. Feeling feverish, he greeted the visitors (the hospital’s medical superintendent was already sick with Ebola so this man had to fill in to greet the team). By the time they left later that day, he was having bloody diarrhea and vomiting. He was immediately put into isolation, figuring that he would soon die.

“The experience I had in isolation was so rough because I did not expect to make it out of isolation,” he said. “All my fellow patients were being rolled out of isolation in body bags.”

Today we interviewed three survivors, all health workers and all people we stumbled onto randomly. They’re all back to work now, but the memories remain fresh, especially of their co-workers who died and of family members who became infected because of them. All were, to varying degrees, frustrated by how long it took to officially diagnose the illness as Ebola.

After today it is also especially clear how easy it is to trace how so many of the victims became infected. First there was the family where 16 were infected, and from there so many of the cases are linked to those who were in the health centre at the time of the initial cases, or who attended the funerals of the initial victims.

It was at one of the funerals where a businessman from Bundibugyo is suspected to have become infected. He was the first case in the town and it spread from there, through health care workers, their families and other patients.

We wrapped up our work in Bundibugyo about 11:30 a.m. and set off for Fort Portal.

The drive back to Fort Portal through the Rwenzori mountains was, again, spectacular. Fort Portal is so close to Bundibugyo but because of the cascading series of ranges, the road winds and winds its way up, and then down, the ranges.

First the road took us north along the base of the mountains, to the spot where we could enter the mountain pass. From there we climbed, and climbed, giving us a fantastic view of the Congo spread out below us.

Looking up at the mountains from below, the odd plume of smoke and a scattering of gleaming iron sheet roofs suggest some population in the mountains but once you’re up there you see it is teeming with life.

Few live in settlements, but instead are spread throughout the hills, in valleys, on steep banks and on the tops of ridges. It is this mountain population that is thought to have been the source of the Ebola outbreak.

The west side of the mountain range looks out over the Semliki River, all elbows as it winds its way across the valley. And on the other side of the river, the Congo. When we stopped at one point I stood on the perch, looking out at the Congo sprawling below us, and thought of all the tales I’ve heard and read about that land. All those stories give it a sort of mysticism that few other countries, except maybe Cuba, can match.

Overlooking the Congo

We saw evidence of the Congo reputation of lawlessness in Bundibugyo. There you can buy an Asian-made motorcycle brand new for $500. The Congo has such weak public institutions that importers and exporters thrive on an unregulated market. As such, these motorcycles are also brought into Uganda from the Congo. Most are unregistered and sound like a broken-down outboard boat engine when they run. The police station in Bundibugyo is full of seized bikes.

Anyway, back to the trip to Fort Portal, I spent much of the drive snapping pictures, but even then I missed taking some shots because I was too mesmerized by the landscape in front of me— the rolling hills, the hairpin corners on the road built for one car at a time but forced to somehow make room for two, the farms built on obscene angles and the old women carrying 50 kilogram sacks of grain on their backs, supported by a strap looped around the sack and tied at their foreheads.

We carry with us memories that will stay with us for the rest of our lives. But it’s a peculiar feeling to be caught in a moment that you know you’ll remember for the rest of your days, and realizing its significance. You try extra hard to soak it in, picking up every detail in every fold of every hill, while wishing the driver would slow down, slow down, to make it last longer. Instead, you barrel along, being thrashed about (I have the bruises to prove it) in the back of this battleaxe of a pick-up truck.

We are staying in Fort Portal tonight, in a guesthouse that charges $4 a night. This one has electricity so I can charge my camera batteries, cell phone and laptop. The room here is nice, even with two living room-style chairs, a wooden desk and chair.

Another day of matooke, rice and stewed beef. I enjoy eating these foods almost daily in Kampala. But here, where there is no other choice but to eat steamed bananas and stewed meat three times a day, I find myself looking forward to a nice, familiar, meal when I get back to Kampala. Though, even as I say that, I know I’ll miss these foods when it comes time for me to head elsewhere.

Day Four

We covered a lot of ground today to get back to where we began the day. After meetings with several local government and health care officials in Fort Portal, we took a quick look at the site of the town’s isolation ward in its hospital. Then lunch, then on the road, north through a national park to Kamwenge district some 65 kms northeast of Fort Portal. The drive was beautiful, through tea estates planted in rolling hills like one giant hedge carpeting the land. Then we were into the park. The immediate change was stunning. In the blink of an eye, we were surrounded by immense, thick tropical forest. There were so many layers of growth that hardly any sunlight graced the space between the ground and the forest canopy above. It grew immediately much colder (though that’s one nice thing, among many others, about this trip, is to be back in cooler temperatures because we are high in the hills here).

But this thick, impenetrable forest, from which many families of red-bummed babooms emerged, was so different from the landscape that surrounds the park.

Though beautiful, the lands around the park are now largely devoid of natural growth. Instead, what makes it beautiful is the clumped banana trees planted in small valleys surrounded by tea plantations, cassava and sugar cane farms peppered with the modest homes of those who work the land. It is man-made beauty, versus the park’s beauty, so dense that it would seem to repel any human efforts to alter it.

Yet that is what this whole land used to look like. Even one of the Ugandan reporters I’m with remarked on the contrast. “Ah, overpopulation, he said.

The country is largely rural, with only two million of its 30 million inhabitants living in Kampala’s only city, Kampala. But despite this rural demographic, there are few unpopulated areas. In all the driving I’ve done around the country, I have seen very few unpopulated areas of any size, save for the parks and some of the rebel-affected areas.

In a country where the average woman has more than seven children, control of land can, has and probably will lead to riots. (In the region of the Ebola outbreak, women have an average of 12 children.)

Soon enough we were out of the park and eventually we reached Kamwenge to interview local people there.

The district had a tough year in 2007. Just as they were overcoming an outbreak of the Marburg virus, Ebola arrived next door and they went back on high alert.

“We thought Marburg was bad enough, but then Ebola, with the same symptoms as Marburg but much more deadly, arrived at our doorstep,” one person I spoke with said. Luckily, they had no positive cases of Ebola.

This side-trip illustrated the logistical differences of journalism here. Elsewhere, to get this perspective I likely would have picked up the phone to call these officials (they had no Ebola cases, but we were interested in hearing their thoughts on having two threats of infectious diseases in one year). It’s always, always, always preferable to do interviews in person and to do those interviews in the appropriate setting so you learn more about your interviewee and the subjects of which they speak. But often in the course of reporting a story you simply cannot get to everyone in person. For a feature article that may have four or five people quoted in it, you can do 20-plus interviews (on this reporting trip alone, we have interviewed over 30 people and I have more than 160 pages of notes). Inevitably some of those interviews will have to be done on the phone if you have any hope of meeting your deadline.

But here things are often done differently. I’ve only done a handful of phone interviews, and only for the briefest of interviews. Anything remotely in-depth must be done in person. As such, stories that back home might take a few hours to report instead easily take a day or two here, spent booking interviews, going to wait for appointments (an appointment for nine a.m. can easily become 10, 11 or later), go through greetings and then the interview. It makes reporting a story on a tight deadline a difficult task, but it also makes the reporting experience a richer one as you get to know the people you are interviewing and learn much, much more than you would if you only picked up the phone to interview them.

So it was today that we set off on a 130-kilometre round trip drive to do what was essentially a 20-minute interview that might add a line or two to an article. But what we learned was worth the trip.

Day Five

One last night in Fort Portal and now our last day of reporting to be done, in surrounding regions that did not get Ebola but established isolation wards and otherwise worked to make sure the virus did not spread further east.

We had skipped breakfast to get an early start to the day, so we stopped for lunch hungry for a good meal. Unfortunately our stop came in a small trading centre where the only place that still had food had only two dishes on offer: stewed liver or steamed bananas covered in a boiled cow intestine stew. The others had liver; I enjoyed my steamed bananas.

And so the trip came to an end as we continued our drive back to Kampala, arriving in the city mid-afternoon. Whenever I leave the city for even a few days, I feel like I forget the environment in Kampala: the hustle and bustle, the pollution, the dust, the tall buildings and luxury hotels. Just that morning I had woken up in a guesthouse room that was reached by teetering along a narrow cement ledge down a dimly lit outdoor hallway that was quite far removed from what I found upon returning to Kampala.

Hallway

The quiet, if not a bit cramped, room, the chats with other guests coming and going from the communal outdoor bathroom and shower, the laughter of friends, old and new, sitting up until late in the night in the guesthouse’s courtyard— there is no room for complaints about cold water, limited electricity or bugs that go crunch underfoot during the pre-sleep hunt around the room, when there are so many rich experiences to be had in this environment. And so many experiences to convey to others, near and far, so that maybe, just maybe, someone who has never been here, can get a taste of the complex blend of richness and incredible challenges that are the foundation of life here.

I’m not only talking about the isolated up-country villages and towns. The guest houses, the meals in slapped-together shacks, the smiles, gestures and clipped conversations with those who sit on the other side of a language barrier (or sometimes simply a shared inability to process unfamiliar accents)— all these elements exist here in Kampala and are the things of everyday life (except the language barrier) for so many of the city’s residents. But for many of us who come from elsewhere, Kampala is work, friends, bars, a mix of local and international foods and an otherwise fairly comfortable existence.

But there is so much more to it. And at times the best way to better understand your environment is to leave it for a while, to come back with a different perspective.

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Comments
  1. PS says:

    Very interesting. I wasn’t in any mountainous areas of Uganda, but even the roads in some of the flat areas are “slow” ie ruts 3 feet deep, at least.

    Your recollections make it clear to me how so many people have the view that life just happens to them. No wonder. The areas of Uganda I visited were poor, but the struggles may be less than what you write about.

  2. Rya says:

    I am completely fascinated by Ebola survivors and Africa & Biology in general, so this was a very interesting read. It must have been amazing to talk to Ebola survivors, I cannot imagine how nice it would be to just talk to them and learn about their experience.
    Leave me an email if you ever want to discuss Ebola/Ebola survivors with anyone. I could go for hours.

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