First Day in Jordan

I came to Jordan to be a part of a medical mission trip with a Syrian and Jordanian-American group that formed to help assist with refugees living in Jordan, Turkey, and Lebanon with medical care. They organize a medical mission every six weeks and usually have about 20 people per trip in addition to five Jordanian staff.

In addition to my colleague and I there are four doctors, three nurses, two dermatologists, a local dentist, a psychiatrist, and about 15 or so other helpers, translators, photographers, and “humanitarians.” Most of these people are returning volunteers and they are from all over the world. 

It got off to an eventful start when we were coming through customs after landing in Amman and couldn't help but get stopped because of our 12 matching duffle bags full of medical supplies. We had all the proper documentation and duty-free status with certified letters stating that it was for humanitarian purposes only and intended for Syrian refugees--but it never even made it to the baggage carousel at baggage claim. We were left standing there empty handed when the thing shut off. 

After spending about an hour with the baggage handlers who finally felt satisfied, we still had to exit customs and ended up getting stopped again. After another 30 minutes they said they were keeping it and we could try to "come back tomorrow." Unfortunately this was all in Arabic so I was a little vague on the exact wording. In a panic, I pulled out all the stuff to show him that the vast majority of supplies were innocuous; things like diaper rash cream, baby blankets, sunscreen, and creams. Luckily, that worked, and we got it all out, including the medications, and raced to the van.

Today we went to the town of Madaba and were welcomed by a long line of Jordanian officials and members of Parliament in bright red and white head scarves. They had given us a large community center for the day and the different rooms were set up for medical, dermatology, dentistry, counseling, and humanitarian (which are mainly non-medical items like coloring books and toys for the kids who also played games together). In total, about 420 patients were seen today, roughly 100 in the dermatology room where we were stationed.

As I’ve been reading about refugees in Jordan, I learned that the vast majority of them, over 500,000, are living and roaming through the various neighborhoods of Jordan. Only a little over 100,000 are actually in the three official refugee camps and the vast majority of those are in Al-Zaatari, now the biggest in Jordan and the size of a major city here. The Jordanian government has recently severely restricted the numbers of refugees they allow in from Syria (due in large part to fears of extremists sneaking through) and had also cut off free medical care for Syrians.

What surprised me today is that most everything was some version of acne, sun damage, and extremely dry skin. There were a few more serious cases of scabies and some burns, but most people were just very uncomfortable, dry, itchy and burnt. Even though these people today didn't technically live in a refugee camp, they are extremely exposed and the weather here is quite harsh and sunscreen and lotions are quite expensive. While they sound like minor things, everyday things for us, these basic commodoties go a long way. As does knowing that people out there are looking out for them.

It's so hectic during the day that it's hard to spend the time to talk to people and hear their story. But everyone here has a story. This 8-yr old girl came in because she had scars on her face from when her town was bombed in Syria and her family just ran. Her father was killed and now it's her and her younger brother and mom living in a foreign country on their own. Grace, the dermatologist we are with, didn't have anything for the scars, but she listened to the story and hugged the girl, and just told her she was beautiful. They were buddies the rest of the day.

Tomorrow we’re going to another town about an hour and a half from Amman a bit closer to the Syrian border.

New Blog Posted to Huffington Post

http://www.huffingtonpost.com/andrew-maccalla/3-lessons-among-many-as-a_b_6789552.html

Freetown Hotels....

are strange! The first two nights we stayed in this place called the "Family Kingdom." Trying to think what was the strangest part. The families of deers wandering around? Ya, they were everywhere. Big ones and small ones. We think they were Dukiers, whatever that is. Unexpected to find at the hotel in Sierra Leone nonetheless.

The Family Kingdom also had this big creepy playground that in some universe might have been nice but since it was deserted and painted circus colors it felt like everyone had just left in a hurry. Like some post-war apocalyptic scene.

And perhaps strangest of all there was this big huge statue in the center of a fountain of Kong Kong holding a woman. Like, probably a 10 foot tall statue! It was so bizarre.

Tonight we're staying at "China Town Guest House." I don't see any other China town stuff around here but this place is totally authentic. There is a small pen in the courtyard outside the rooms full of ducks...and, they serve duck on the menu.

Plus everything in the room, from the soap to the water heater to the plug pattern, is Chinese. Pretty amazing. It makes sense though. There is a lot of Chinese investment here in the mining sector and the Chinese CDC is staying next door.

To top it all off, in the restaurant tonight they're playing "Santa Claus is Coming to Town." Apparently is Christmastime in Chinatown in Sierra Leone!

I should say, they've both been very nice and comfortable. Just wholly unexpected!

Some early observations...

I’m generally very impressed with the response of the people to try and end the Ebola epidemic. Everywhere you go, your temperature is taken with an infrared thermometer. It happens going into a restaurant or hotel or office building, driving into a new town you have to stop at a checkpoint that’s usually organized and staffed by the community, and they make you stop the car, roll down the windows, and get everyone’s temperature. The thermometer is held up to your face for a few seconds, it beeps, and they show you your temperature. Since it’s in Celsius it took a few times to realize what was normal, or good, or not ebola. Apparently you don’t want to be much above 39 degrees, I think. And if you are, they’ll stop you, wait a few minutes to take it again in case you were just temporarily hot or nervous, and if you’re still high, you’ll head straight to an Ebola treatment center or community care center where they can now give you a blood test to determine if you have the virus. Just a month ago, the testing capacity was not what it was now, and so you’d have to stay and be monitored until your fever went down.

In another town directly across the road from our hotel in Freetown, in a town called Aberdeen, there has been a recent spike in cases in a small, extremely poor part of town. The Ebola response strategy there was to post the military at the edge of town (the other edge of town butt up against the ocean) and didn’t allow anyone to come or go. The word is that they’re being treated well—they get the food and money they need. But it was quite a harsh scene to drive by a town guarded by the military knowing that the strategy was containment even now that they’ve proven Ebola can be fairly effectively treated.

Generally though, the sense is that this is going to be beaten down to zero pretty soon. Even now, the daily case counts are down to about 12-14 per day, which is still high, but a huge drop from the 100s they used to report every day. And while people are still vigilant and cautious (I haven’t shaken anyone’s hand since I’ve been here…a right hand crossed over your heart is the preferred greeting now) it’s still hard to fight your human instinct to touch another person. Every time I’ve met someone, my instinct is to shake their hand, and it feels rude and awkward not to. Today when we visited Makeni General Hospital, a doctor we were with (who hasn’t been practicing medicine in some time) went up to a woman who had just delivered a baby and was in some pain. He touched her arm to see how she was doing after noticing a large pool of blood on the floor, and the other doctors immediately hollered at him, reminding him that he wasn’t wearing gloves. But it was his instinct, as it is most of ours. It’s what being human is.

We went inside the surgical ward where they perform five C-sections per day. Normally, what would stand out to me would be the fact that there was no surgical light, ultrasound machine, anesthesia machine, or sterilizer. But today what I noticed was the air conditioners were broken, and now that doctors have to wear full body personal protective gear during a surgery that could last hours and its 90 degrees in there, it can be stifling.

After we left this hospital, which clearly needs some support and are struggling against terrible odds of ebola and a total lack of equipment, it occurred to me that I had read a NY Times article about this hospital a few months ago titled, “A Hospital from Hell” and after re-reading it just now, I realized we were given a tour by the doctor quoted in the article. He was nearly my height, probably younger than me yet he’d been practicing six years, skinny as a rail, and what he kept saying was, “this is a referral hospital for the entire northern region of the country, can you imagine?”

Things are not all bad however. The midwifery school we visited today that we helped start nearly five years ago, is a beacon of light for the community and for the women who attend it. It’s been closed since Ebola but they are set to start up again in March and resume classes for the roughly 150 men and women who attend. According to many, the kits they get when they graduate that Direct Relief provides them a great deal of pride to receive it before going to work in their post.

And the labor and delivery clinic that we equipped is said by all to be the “best in the region, if not the country” thanks to the delivery beds, midwife kits, sterilizers, and other supplies were donated.

We’ll see what the next days have in store…

Final Leg

Sitting now on the plane for the final 20 minute flight from Conakry to Freetown. I've now been traveling for close to 30 hours starting with the airport shuttle at 4 am yesterday then a 5 hour flight from LA to DC, then 10 hours from DC to Brussels (thanks to a 3 hour snow and ice delay in DC), and now the 9 hours from Brussels to Freetown. When we arrive there, it's a ferry to get from the airport to the capital (apparently one of the only airports in the world cut off like this). The guidebooks actually say to take a helo flight from airport to mainland due to unreliable ferry schedules and theft-but our local contact says it's the way to go.

This being my first trip to West Africa, and at a time when the Ebola epidemic is still keeping planes like mine full of aid workers (there's a whole team of 20+ people who've been with us since DC from Partners in Health) and post trip quarantines still in place for doctors, I'm not sure exactly what to expect between that and the reports coming out that new cases are rapidly declining and ebola treatment units are empty. I mostly expect to see things having returned to "normal" in Sierra Leone and Liberia but since I've never been, I don't know what normal looks like.

There will surely be new standards and customs for how people interact and touch each other, for how doctors and nurses see and treat patients, and how these folks see the international community that's descended upon them. One of the reasons ebola got so out of control here, is because the local medical providers never have had enough personal protective gear, things like gloves and masks and gowns that we take for granted, to prevent the spread. Now that has to be standard.

I'm here in my role with Direct Relief to first take stock of what we've done as an organization here over the past 6 months. As the largest private provider of medical supplies into the region since ebola, there's a lot to check on.

But more importantly,  it's to form some strong partnerships with local officials so we can formally commit to a longer-term high level of support to the region. This part of Africa already had some of the worst health indicators in the world, and now on the back of the worst ebola epidemic in history, they can surely use some extended support.

Thankfully, we already have some amazing local partners here, folks whose organizations are taking care of poor people on a daily basis, and they of course jumped headfirst into the Ebola response. We'll be spending the next two weeks with them.

After two days in Freetown meeting with the Ministry of Health and seeing the larger hospitals, we'll head out to Makeni, where we've supported all the graduates of the midwifery school with the tools they need to work and has unfortunately not re-opened yet since ebola. Then out to Bo overnight, the 2nd largest city in Sierra Leone. Then a helicopter ride to Kono district where we've been supporting a group called Wellbody Alliance for a number of years who have now teamed up with Partners in Health.

From there we'll take a UN Humanitarian Air Service flight from Freetown to Monrovia to meet with the officials in Liberia, as well as our colleagues at Clinton Health Access. Then a day tour with a partner Africare who supports a lot of capacity building and health care programs, and finally some time way out in the bush in Grand Geddeh with Last Mile Health, a fantastic Boston - based NGO that's taken Paul Farmers model of the community health worker to combat the childhood pneumonia, the biggest killer of children under 5 here.

More to come...

Distributions on Panay Island

I had the great pleasure to do some distributions to three hospitals today and I wanted to just share some pictures and info about the sites because they are doing great work and are truly amazing people and are extraordinarily grateful to Direct Relief for this support. They clearly hadn’t gotten much aid so far and when I told them we’d be supporting them for the longer term, they were overjoyed. Additionally, they are constantly running out of stocks (generally—not just after Yolanda) because hospitals are funded based on their bed capacity but they are always way over capacity and they don’t turn people away.

Barotac Viejo District Hospital had 6 feet of water flow through the hospital and had to evacuate 40 patients into the local gym before the storm hit. All their stocks were ruined. They are a facility licensed (and thus funded) for 10 beds yet regularly have 35-40 inpatients lining the hallways. 90% of their patients are “indigent” and cannot pay.

Sara District Hospital is the referral hospital for the area. It had its outpatient clinic totally destroyed and most of the roof blown off the in-patient ward. They are licensed for 50 beds but generally have 60-80 inpatients. They do 80-90 deliveries per month (including 6 during the typhoon) and 80% of their patients can’t pay. They are still running on generators.

Balasan District Hospital is licensed for 25 beds and today had 69 people admitted. Again, the hallways

are lined with rusty beds and people laying on the ground. They have seen a greatly increased number of pneumonia patients due to the high numbers of people living in tents and camps in the area. Again, because they have so many more patients than they are licensed and funded for, they are constantly running out of stocks and patients are left to buy themselves.

One last interesting thing about all these sites is they all have Bite Treatment Centers for dog, cat, and rat bites. Balasan has had over 100 bite victims in December alone and they give rabies vaccines to all of those people. I've never seen this before but it's clearly quite a problem--and a scary one since there is no cure for rabies if bitten and untreated.

Tacloban-One Month Later

All you have to know to understand the scale of the devastation in Tacloban is that the people of this area, families who have lived their entire lives here, are leaving by the thousands to go start their lives in entirely new cities. The destruction and loss makes it all too overwhelming. The island of Cebu, a 45-minute plane ride away, is now receiving around 2,000 people per day and there are now dozens of evacuation centers set up around town.

When we met Marafie Garfin, the Chief Nurse at Bethany Hospital in Tacloban, she had been working feverishly, doing everything she could to get their hospital back into some version of what it once was. Of course she wants to re-open in order to start seeing patients again, but more importantly, to she wants to show her staff and patients that they did not have to leave, that they could work to rebuild what was once an amazing hospital, the place where Marafie has spent her life.

Photo: Jodie Willard

The people in this area are used to typhoons. Indeed, there were over 20 typhoons this year alone, but none have compared to Haiyan. Marafie said that in her whole life on Tacloban, and in the decades before when her grandparents founded the hospital, there hadn’t been a typhoon that brought a storm surge more than a foot or two. In fact it was so rare, that Marafie believes that one of the reasons why so many people in Tacloban were unprepared was because they were calling it a typhoon with an accompanying storm surge, a term many people didn’t understand. The sense is that if people heard the word tsunami, which is what it effectively ended up being, they would have fled to higher ground, remembering the Indian Ocean tsunami in 2004.

Marafie said that when the storm hit, there wasn’t anywhere to go. At first they brought their staff and patients upstairs but the wind was so strong that it blew the roof off the hospital. When they went back downstairs, there was eight feet of water gushing through the hospital. Electricity and water were cut off. Nurses in the dormitory next door were clutching onto a pipe to avoid floating away. People who didn’t have a solid hand-hold were literally slamming into the side of the hospital. One boy was trying to climb up to the second story window from outside the hospital and was hit with a flying piece of tin roofing material and died.  

When we visited the hospital a week after the storm, the remaining staff were working to clean out the lower floor of the thick layer of mud and water that was caked all over everything—the medical equipment, supplies in the pharmacy, even hospital beds were all being removed and cleaned in hopes that some could be salvaged. There was only one patient left in the hospital; a 72 year-old man injured during the typhoon who remained alone in this devastated hospital alone because he had nowhere else to go.

It’s easy to understand why people would want to pick up and leave. Hard memories, massive loss, and an overwhelming sense of uncertainty of not knowing where to begin. And in the first week after the storm, people weren’t able to get food, water, shelter, or medical care so they had no other choice but to leave. There was some blame placed on the national government and international aid organizations for the delay in responding (and not being adequately prepared in the first place). While some of those criticisms are warranted, it also has to be understood that at the exact time when the aid needs to arrive, is the time when the airports, sea ports, boats, roads, bridges, warehouses, and hospitals are damaged. And it takes time to mobilize the massive amount of food and water and medicine and then figure out how to get it into these badly hit areas when you can’t fly or drive around.

In the last 30 days, Direct Relief has been able to mobilize over 100 tons of critically needed medical supplies and start the distribution to the hospitals all throughout the Visayas. We have already distributed life-saving antibiotics to areas in northern Cebu and parts of Panay Island where no one else has delivered large volumes of medical material aid. We’ve also been able to bring in two shipments to Marafie at Bethany.  

Photo: Jodie Willard

All of this was done using the support of corporations—medical manufacturers who donated the items, FedEx who donated the air-freight, even companies in the Philippines like DB Shenker, Ayala Business Group, and International Pharmaceuticals Incorporated (IPI), who have donated our local trucking, lodging, and warehousing to enable us to get these essential items into the hands of the nurses and doctors treating patients in these hard-hit areas of the Philippines.

Thanks to the hard work of our staff and the support of these companies, 100 tons of medical material valued at over $10 million (wholesale) is currently being distributed to the affected regions of the Visayas where highly trained doctors and nurses are working hard for their patients but sometimes lack the essential materials to do their job effectively.

In the end, it’s the people of the Philippines who are going to be in charge of rebuilding their lives and their homes. It’s a Filipino crisis—not an NGO one. But the international community, with the help of local businesses and corporations can do a great deal to fill in some of the gaps and work to bring the residents of Tacloban back home and get Marafie’s staff back into the hospital.