On the Road to Sierra Leone

Strange transition from cold and wind in Portland, Maine, to the relative warmth of Casablanca, Morocco

Painting above my bed in the place we're crashing before leaving Maine... I'm not sure what this man's intentions are, but I feel mildly apprehensive!

Director Dunn helping to move the great big pile of advance team luggage (170 lbs of medical supplies)

Waves crash against the footings of the Hassan II mosque in Casablanca (this is the largest mosque in Africa, with a retractable roof, ability to accomodate >100,000 worshipers, the tallest minaret in the world (689') Inside the mosque, glass panels allow beautiful views of the seabed of the Atlantic.  At night a green lasar light points from the minaret, towards Mecca).

The mosque was completed in 1993 and has since seen repairs necessitated by the challenging nature of its exposed location.  Saltwater has migrated into the concrete and corroded hidden rebar.  This and over 100 loadbearing pillars were replaced in 2003 in a major repair undertaking.  The mosque now has what is in effect an outer waterproof hull beyond the original foundation, which protects the loadbearing elements from saltwater damage.

  Next to the mosque is a long seawall with a broad flat top.  During our layover, IMA's advance team joined a large crowd of locals, who seemed to have gathered not only to enjoy the sun, but also view a succession of daring human encounters with the sea.  Near our perch an angled white sand beach and a projecting section of coarse riprap worked in concert to funnel breakers violently against the seawall.  This funneling effect caused larger waves to rush up vertically against the seawall, break into fine spray over onlookers, and dissolve backwards into a churning wash of foam and undertow.  Local schoolboys made a game of running into the funnel, then racing back out just in time to avoid the potentially deadly action of the larger waves.  As we watched them, a woman in her 50's slowly made her way down the beach towards the funnel.  She was barefoot and bore a headscarf wrapped around a grapefruit-sized object.  Something was unidentifyably wrong with her expression, and mood she was projecting, as she slowly entered the funnel and bent, dipping the headscarf into a series of small waves that rushed in around her feet.  We saw an odd smile on her face, then one of the large waves came in and she disappeared beneath it.  We rushed down onto the riprap to assist her, balance thrown off by our heavy backpacks.  The crowd laughed and pointed, then fell silent as people grew concerned and started to rise to their feet.  We were joined by several local men, and together we helped the woman get back on her feet and up onto the safety of the riprap before the next large breaker hit.  She was not appreciative of the help, slapping away the proffered hands.  We were quite concerned about her and kept a discreet eye on her afterwards, as she stood on the roadway for a long while, looking quite upset and angry.  Eventually family arrived and joined her.  We never did find out what it was all about.

We continued our people-watching atop the seawall.  Occassionally a whistle blew, as mosque security chased off mischievous teens or the over-amorous young couples who tried to tuck themselves away into cool dark alcoves of the mosque.  Our next risk-taker made his way across the rip-rap below us.  He paused at the end of the seawall, stripped down to shorts, then produced and donned a pair of green flippers and small plastic goggles.  He had a short military-style haircut and had the lean, muscled look of someone who works for a living.  All eyes were on him as he entered the water and swam straight for a protruding corner of the mosque foundation, where a 6' wide whirlpool was created by each passing breaker. Somehow, he timed his swim to miss the whirlpool, and swam further and further out, ducking beneath each wave.  Finally he turned, and kicking mightily, caught a breaker and body-surfed in, almost to the beach.  Impression made, he then exited the water, doffed his flippers, and returned to his pile of clothing.  

I made a mental note to carry flippers with me while traveling in the future.

Sorting supplies for International Mutual Aid's advance team, Ebola epidemic Sierra Leone

Send a Medical Team to West Africa

IMA Advance Team Preparing to Deploy to Sierra Leone

International Mutual Aid's advance team has completed pre-deployment training, and visas and tickets have been arranged.  We will deploy December 30.

We be operating in Sierra Leone for several months.  Check back in for pictures and stories from our response.

IMA is now a 501 (c) (3) organization!

International Mutual Aid has received expedited approval by the IRS as a 501 (c) (3) organization!

Ebola: The Mutiplier Disease

In early November, as only a handful of international medical NGOs responded to the World Health Organization's predictions of exponential Ebola spread in West Africa, a small group of medical professionals in their 30's founded a new nonprofit group to fight the disease.  Follow IMA's story, from conception, through the incorporation/501c3/formation process, to advance team deployment to West Africa and work on Ebola, on my new blog:

Ebola: the Multiplier Disease: Taking out Healthcare Systems

http://internationalmutualaid.blogspot.com/

Ebola Heroes: Dr Ameyo Adadevoh

The Doctor who stopped Ebola in Nigeria.
Nigeria is a country of 170 million, 3/4 of whom live on less than $2/day.  Nigeria's health care system was not prepared to handle Ebola, but fortunately the disease was stopped by the clever intervention of one doctor: Dr Ameyo Adadevoh.

In August 2014 an international traveler arrived in Lagos, at a time when all federal hospitals were on a labor strike. He collapsed at the airport, and due to the similarity between the general symptoms caused by Ebola and many other diseases, he was misdiagnosed with malaria by the first doctor he saw.  The following day Dr Adadevoh, who had never seen an Ebola case, suspected EVD and ordered a blood test.  She insisted on keeping the patient isolated, even while under pressure to release him so that he could attend an ECOWAS conference.  The patient's test came back positive for EVD.  There was no functional isolation ward in Nigeria, so Dr Adadevoh created one in her hospital.

Through this surprise exposure to an EVD patient, Dr Adadevoh and several of her coworkers became infected.  Dr Adedevoh succumbed to the disease on 19 August 2014.

Due to her early action, Ebola in Nigeria was halted at 20 cases.

Photo from "Remembering my Aunt, Dr Ameyo Adadevoh, who stopped Ebola in Nigeria" http://www.nytimes.com/2014/10/17/world/africa/because-of-ebola-ambulance-work-in-liberia-is-a-busy-and-lonely-business.html

Ebola Heroes: Foday Gallah

Monrovia Ambulance Driver, Foday Gallah, featured as one of Time's People of the Year: Ebola Fighters: 

"You don't want to know what Ebola feels like. If you're not psychologically strong and God is not on your side you will drop before you are taken for treatment because the pain is too great... I had known I would get it eventually. A lot of great doctors and nurses on the front line have died. They tried to be careful but Ebola still got them. I had carried so many patients in my ambulance and seen so many die in my arms... "

"I was {in the ETU] for two weeks. In the same tent as me in the treatment centre, a two-month-old baby died from the disease. And I lay listening to a lady who cried until she died..I don't know why I survived....I went back to my job, part-time, at the beginning of December...Now, ambulance crews are working 24 hours a day. When people are dying you need to be all over the city. It's hectic, our workload has tripled and we don't have enough ambulances in Monrovia to deal with the disease....Most of my friends now stay away from me because of my job."

Quoted from BBC News "My Fight Against an Invisible Enemy" http://www.bbc.com/news/magazine-30418759

Ebola Heroes: The Teenagers of A-LIFE

Even as Ebola raged through the seaside Monrovia slum of West Point, many residents denied the existence of the disease.  In August, dubious crowds broke into a West Point Ebola holding center and "freed" the patients inside.  Many residents believed Ebola did not exist, at least not in West Point, and that perhaps the entire outbreak was a fabrication, made up by agents who wanted to steal funding, harvest organs, or conduct experiments on humans.

But on Sept 17, a group of 200 teenage girls, and some boys, marched through the tight streets of West Point, promoting Ebola education through song.  This was the official start of A-LIFE: Adolescents Leading an Intense Fight Against Ebola.  This drive for public education, the name, and the organizing of A-LIFE was all done by Liberian girls age 16-19.   The girls of Liberia, a country with extremely high rates of sexual violence, are no strangers to hardship.  Yet in West Point, they were leading public education efforts.

After learning of the girls' efforts, local UNICEF leaders provided them with safety education and basic PPE.  It is likely that ongoing public education efforts such as this are responsible for the dramatic decline of Ebola cases in Liberia.

Well done, A-LIFE members!

Photos from UNICEF, http://www.thedailybeast.com/articles/2014/10/29/meet-the-liberian-girls-kicking-ebola-s-ass.html

Ebola Heroes: Gordon Kamara

During the peak of the Ebola epidemic in Liberia, when ETUs ran out of space and patients died outside, waiting for beds, Gordon Kamara continued his work as an Ambulance Nurse in Monrovia.  He worked on one of only 15 or so ambulances covering a city of ~1 million during a public health emergency.  At times he arrived at the ETU with a patient, only to be turned away because there were no beds available.

Mr Kamara also worked as a combat medic during the long Liberian civil war.  "“It is nothing compared to this, The bullets you can get away from. Ebola is hidden within our own families.”

Mr Kamara has isolated himself from his family for their protection.  “It’s a very lonely virus... Not just for me, but for the entire country. We are all together, but all alone.”

Quotes and picture from NYTimes "Ambulance Work in Liberia is a Busy and Lonely Business"  http://www.nytimes.com/2014/10/17/world/africa/because-of-ebola-ambulance-work-in-liberia-is-a-busy-and-lonely-business.html

Ebola Heroes: Dr Martin Salia

Dr Martin Salia died on 17 November in isolation at the Nebraska Medical center.
Dr Salia was one of only 5 or 6 surgeons in the entire country of Sierra Leone. His wife and 2 children are US citizens, but instead of pursuing a lucrative private surgical career, Dr Salia returned to Sierra Leone to help his country. He worked long hours as surgeon and chief medical officer at Kissy Hospital in Freetown. He spent his free time putting in additional surgical time at the Connaught Hospital and Davidson Nicol Hospital in Freetown and lecturing at the University of Sierra Leone medical school. He only saw his family in Maryland a few times a year.

 
Had Dr Salia successfully pursued US citizenship instead of returning to his native country to assist people there, he would not have been exposed to Ebola.  Had he stopped treating patients, as many of his compatriots have, he might not have contracted Ebola.  Had Dr Salia been a US clinician volunteering with an international NGO, he might not have detected his own infection earlier, but he would have had a clearer medevac path, and his widow would not be left with a $200,000 medevac bill.

Here's to the surgeon who stayed, in the face of a disease that tears apart families and turns communities and nations against those who should be loved and remembered as heroes.

Pre-Deployment Training at the CDC

Our first group of volunteer clinicians completes pre-deployment training for Clinicians Responding to West Africa, at the CDC.

Sending Clinicians to Treat Ebola Patients: Risks and Benefits

In an October 24th analysis, the New York Times reports that MSF has sent 700 doctors and aid workers from around the world to Ebola-stricken countries.  Of these 700, 3 have been infected with Ebola.  This means that each of those 700 volunteers had a chance of infection of 0.4%.  All three infected MSF expat clinicians recovered.  In fact, the death rate amongst EVD patients who have received Early, comprehensive supportive care in the developed world is near zero.  MSF has not been prompted by the risks involved to abandon their patients in West Africa, and we feel that this is the right decision.  Per the example of MSF, IMA will be seeking to better understand how transmission is occurring, and will be taking every possible measure to insure the safety of our clinic workers.

Allowing Ebola to become a permanent endemic disease in West Africa would create a much greater risk and expense than sending expat clinicians over to work in ETUs does.  If Ebola becomes endemic, hospitals in each affected country will have to consider every patient presenting with general illness will be a potential Ebola case- forever.  Initial triage/treatment of each of these cases would expose a number of unprotected clinicians to potential infection.  In West African settings, where many clinicians cannot even afford to use Basic Precautions PPE, this would make providing basic healthcare either horribly dangerous, or impossibly expensive.  In the US, any patient traveling from West Africa, with general illness symptoms, would have to be treated as an EVD patient until proven otherwise- forever.  To give some insight into the costs this would create: 1 MSF-style suit of PPE costs ~$80 and can only be used once.  This $80 does not include the PAPR recommended by the American Nurses Association.  Every ambulance, clinic, and hospital with potential for coming in contact with an EVD patient would have to keep unexpired stocks of this equipment on hand, and donning this PPE is only the first step in the isolation/treatment process. Imagine all the funding that would be pulled away from other medical programs, just by this PPE requirement.

If the current EVD wildfire in West Africa is not extinguished, but instead is only banked down to a slow endemic smolder, there will always be a threat of a spark traveling to a transit center in a large developing country.  Imagine Ebola in the slums of Rio, Mumbai, Lagos, or Jakarta.   Airport detection measures are notoriously unreliable, and there will not always be a clever Dr Adadevoh to provide an early, correct interpretation of the vague symptoms of Ebola.

The West African Ebola Epidemic is the first great epidemic of the Age of Globalization.  It is safe to assume it will not be the last, nor the most frightening.  It is safe to assume that not every epidemic will occur so far away from America.  The International Community's response to this public health emergency will set the precedent for future responses.  In the history book of the future, will our children read that we acted with courage and compassion, and sent in teams to treat patients?  Or will they read that we stood back, full of fear and indifference, and watched as a country collapsed and a new deadly disease became endemic?

Ebola: The Multiplier Disease: Taking Out Healthcare Systems

Ebola is a disease of poverty, but it is different from other diseases of poverty such as cholera and lassa fever for one important reason: Ebola takes out healthcare systems.  Millions of deaths occur every year from various diseases of poverty, but these do not make the news the way EVD does.  This is because a single cholera patient does not have the potential to shut down an entire clinic.  5000 people die per year of Lassa fever in the same area that is now affected by Ebola.  However, those 5000 Lassa deaths do not shut down an entire nations' schools and hospitals; 5000 Ebola deaths did.  
Ebola deaths have a multiplier effect.  Every Ebola death indirectly leads to dozens of deaths from unrelated conditions that go untreated due to hospital closures.  As vaccination programs are suspended, each Ebola death leads to dozens of deaths from vaccine-preventable illnesses.  As markets, schools, and developmental programs are closed, each Ebola death leads to lost opportunities, general weakening of systems,an increase in the potential for political instability, and food shortages.

Why Should the United States Feel a Duty to Help West Africa Fight Ebola?

Most people think of America as the antithesis of a colonial power.  But in fact we did have a sort of colony in Africa.  During the mid-19th century, the American Colonization Society moved ~13,000 American settlers to a colony on the  Liberian coast.  This effort was publicly supported by American political giants such as Abraham Lincoln, James Monroe, and Henry Clay, and it received public federal funding.  The colony site was scouted out by a US Naval Vessel, the colony organized itself under US Laws, and it adopted a Constitution based on that of the US.  Today an estimated 5% of the Liberian population is descended from settlers that came from America.  This is why you hear place names in Liberia such as Monrovia (named after President Monroe), Maryland County, Buchanan, and the JFK Medical Center.  If any independent country in the world has strong enough ties with the US to hope for assistance during an emergency, that country is Liberia.

Ebola has historically occurred in very rare, self-limiting outbreaks, mostly in rural villages  in Central Africa.  A key difference in the currrent Ebola epidemic is that it is spreading in crowded, poor, urban areas.  The conditions that are present in Liberia are mirrored in many, many other poor urban areas in Africa, Asia, South and Central America.  At the current caseload of 18,000 - 40,000, Ebola has already spilled out of Guinea, to Sierra Leone and Liberia, and thence in limited quantities to Nigeria, Senegal, Spain, the US, and Mali.  During the early phase of the epidemic, unimpeded by effective international intervention, the disease spread exponentially.  In Sept WHO reported that since May 2014, the number of new cases of Ebola has been doubling every 20-30 days.  In September the CDC put out a worst-case scenario projection of 1.4 million cases by January. 

IMA Fundraising Campaign on Indiegogo

Help Send IMA's Medical Team to West Africa - our Indiegogo Fundraising Campaign is Live!

International Mutual Aid is a Maryland nonprofit, founded in response to the Ebola epidemic in West Africa (EIN # 47-2251946).
 
Please help us publicize our organization and fundraise by visiting our kickoff campaign on Indiegogo at http://igg.me/at/ima    There, you can view our video, read about our organization, donate funds, and share our campaign using Share Tools for Facebook, Twitter, and Email.

So far, we have raised 27% of our goal of $20,000 during the first 24 hrs after launch.  Please act as an Ambassador for IMA - share our campaign and help us reach our goal!

IMA's website is http://www.im-aid.org

Help us stop Ebola!

International Mutual Aid, founded to provide direct patient care in West Africa

Hi all, haven't been here in a few years, I'm surprised how much the page views have jumped.  Glad you all enjoyed this blog/found it useful.

My travels in the south have been put on home and I am here in the US again, becoming inextricably caught up in the crisis response to West Africa. 


On to the next:


As many visitors here know from first-hand experience, the world has become increasingly integrated and globalized.  Some of you may have been affected in your work and travels by trans-border issues from piracy and conflict to diseases such as Swine Flu and MERS.

Now we are in the midst of the first great epidemic of the Age of Globalization.  As of 29 Oct 2014, the World Health Organization has a reported Ebola case total of 13,567.  WHO estimates that if unreported cases are taken into account, the total cases may be closer to 25,000.  Ebola has an average 70% death rate during the current epidemic.

The Ebola epidemic has caused nearly all medical NGOs to pull out of the three affected countries of Guinea, Sierra Leone, and Liberia.  In Liberia, even the local health care system that used to handle routine illnesses has collapsed.  For the first time in its history, the US very nearly saw a legal precedent set for forcible quarantine of a healthy individual.  Proponents of forcible quarantine openly admitted this measure was based not on science, but on public fear.  For those of you who are away from home, the popular response in the US is well summarized in the decision by Maine Judge Charles LaVerdiere, who struck down the forcible quarantine of Kaci Hickox: "The court is fully aware of the misconceptions, misinformation, bad science and bad information being spread from shore to shore in our country with respect to Ebola,” the judge said. “The court is fully aware that people are acting out of fear and that this fear is not entirely rational. However, whether that fear is rational or not, it is present and it is real."

I feel it's safe to assume that this will not be the last, nor the greatest health challenge posed by the Age of Globalization.  At present our response to this epidemic, both emotional and material, does not bode well for future crisis response.  

One primary response component currently lacking, which very few organizations have stepped up to offer, are trained medical personnel willing to treat patients in West Africa.

This is why I have joined with a group of emergency medical professionals to found International Mutual Aid.  IMA is a nonprofit NGO which be sending a group of medical professionals to operate a clinic and provide direct patient care in Liberia.  IMA is coordinating with the Liberian govt, on-the-ground NGOs such as Project Cure and PIH, and WHO to tailer our response to current needs.  Our fundraising campaign begins Nov 4 and we aim to have an advance team on the ground in November.

IMA is a small, flexible organization.  It was founded with the express purpose of advocating for patients and providing a courageous, humane response to this international public health crisis.  Much of the funding that we raise will be matched by larger NGOs who are providing supplies and logistical support.  If you donate to IMA, not only will your dollars make a direct impact on the amount of patient care available in Liberia, they will do so through a multiplier effect.  We will remain in Liberia to assist in rebuilding the local healthcare system after the epidemic peaks and wanes.

Please help us to stop Ebola!  Help us take action in the face of fear.  Every donation is a step closer.

                                                    
                                                              www.im-aid.org


Our fundraising campaign will commence on Nov 4.  To increase visibility, we will kick off with an Indiegogo crowdfunding action, then move to direct individual and corporate donations.

Thank you,
Virginia Price, Board of Directors, International Mutual Aid

Why Should I Care about Ebola?

I live in Maine.  I live in a beautiful, peaceful, orderly place where people pride themselves on their willingness to help their neighbors.  When I'm not putting in a 100-hour work week, I'm off hunting, renovating my old colonial home, or restoring my 1965 Pearson Vanguard.  Why should I care about a disease in West Africa?

Believe me, I would like to be able to ignore the troubled places of the world and just enjoy my life and my family here in America.  After all, that is what my parents got to do.  Unfortunately the technological advances of this century are eroding that privilege.  Whether or not I want it or agree with it, Mainers and Americans are no longer isolated.   Much of the equipment I work with is made from materials produced overseas.  When our ambulance is called to our weekly drug overdose call, it is the result of what's wrong in Mexico and Central America as much as what's wrong in the US.  At the 9/11 ceremony every year I am reminded that when segments of other people's societies become psychologically sick, they are often willing and able to reach out and harm American civilians.  I turn on the news at the station and it's a barrage of images of suffering.  I try to ignore them but they stick in the back of my mind.  We go on a call and the patient is coughing; we have to go through Swine Flu protocol at the hospital, or we have to decon the entire back of the ambulance to prevent spreading Enterovirus.   Now, we are developing special protocols, stocking extra PPE, and asking all our febrile patients if they've traveled to West Africa.  We talk about Ebola, we joke about Ebola, we answer the public's questions.  In the past months Ebola has become our constant companion.

Isn't it all hype?  Won't the epidemic burn out like past Ebola outbreaks?

I certainly hope so.  Our organization does not expect that to happen in the short- and medium-term for the following reasons:  First, past instances of Ebola were outbreaks, not epidemics.  It is a difference of scale.  Before 2014, the largest-ever outbreak of Ebola infected a total of 425 people.  As of 12 Dec, this epidemic has infected over 18,000 people according to WHO's Reported Cases count.   WHO estimates large-scale under-reporting means the real number may actually be closer to 30,000-40,000 cases.  Either of these numbers represents the first great epidemic of an acute, deadly, infectious disease seen during the Age of Globalization.

Second, location.  Past outbreaks generally occurred in villages and rural settings.  This epidemic is raging through cities, through some of the most crowded and impoverished areas of the African continent.  Liberia and Sierra Leone are recovering from long civil wars.  Widespread lack of access to infrastructure, health care, and education, distrust of government, and cultural traditions are all contributing to the spread of the disease. 

 

That's sad.  My country has its own problems.  I don't know anyone from West Africa. Why should I care about West Africa?

I believe that you cannot force change on people.  Whether it is my cousin who is fighting an addiction, my neighbor who is fighting for her civil rights, or my fellow healthcare worker in Mexico who is fighting to keep a hospital funded... the primary motivation and workload needs to come from the affected party, not from an outsider.  I will give my cousin, my neighbor, or my professional ally all the help that I can, but only if they are doing all they can to help themselves.

I want to help West Africans because I admire them.  Over 600 health care workers have been infected in the epidemic, largely due to lack of safety equipment.  Yet nurses, doctors, ambulance workers, and body recovery teams continue to do their jobs.  Liberian nurses receive just $500/month in compensation.   Contact tracing and public information teams head into affected areas, often with little protection.  They risk becoming fatally infected and leaving their families with no means of support.  Many of them have not been paid in months.  They are often stigmatized by neighbors and family due to their work.  Yet they continue to make their vital contribution; often inspired to do so because they have lost someone they love to Ebola. 

The news is full of truly inspiring tales of heroism in West Africa.  Gordon Kamara, a Monrovia ambulance driver, has isolated himself from his wife and children to protect them and has seen them only a few times in the past 5 months.  He drives one of only 15 or so ambulances that cover a city of 1 million.

Foday Gallah, another Monrovia ambulance driver, went back to work soon after being infected with EVD, suffering horrible pain, and watching others die in fear and pain in the ETU. 

In August, a key study on changes in the genome of the 2014 Ebola strain was published in Science.  Unfortunately, 5 of the 50 co-authors of the study died of EVD before the study was published. 

Dr Martin Salia, one of only 5 or 6 surgeons in the entire nation of Sierra Leone, dedicated nearly all his waking hours to treating patients and teaching in Freetown.  Dr Salia was married to a US citizen, who lived with his children in Maryland.  He had every chance to pursue US citizenship and a lucrative career in America.  Instead Dr Salia dedicated himself to bettering his home country, continuing to perform general surgery in Sierra Leone in the midst of a public health emergency.  In Nov 2014 he contracted Ebola, was medevaced late in the course of his illness, and died in isolation in Nebraska.

Nigeria is a country of 170 million, 3/4 of whom live on less than $2/day.  Poverty, crowded, impoverished urban areas, and political instability make Nigeria extremely vulnerable to epidemic EVD.  In July an EVD patient flew to Nigeria and presented with nonspecific symptoms at a local hospital.  After evaluating the patient, Dr Stella Adadevoh ordered an EVD test, which was positive.  Dr Adadevoh and several of her staff contracted Ebola and succumbed to the disease, but Ebola in Nigeria was halted at 20 total cases, due to Adadevoh's crucial recognition of the disease.

Local healthcare systems received a terrible blow, starting early in the epidemic.  Several of the country's leading doctors and researchers fell victim to the disease they were trying to stop.  Yet West Africans haven't given up.  They are still taking heroic measures to try to help themselves.  No country can fight a disaster of this scale alone, and I think West Africans have earned our help.  IMA will be focusing on enhancing West Africans' demonstrated ability to help themselves by hiring and training talented locals to assist us as frontline healthcare worker staff.

​

International Mutual Aid's Mission

International Mutual Aid is a nonprofit organization started by a group of medical professionals.  We are coordinating with local government, WHO, and involved Non Government Organizations (NGOs) to provide direct medical care in West Africa.  This is a rapidly evolving situation which demands flexibility and willingness to adapt to realities on the ground.  With that in mind, our provisional treatment model is detailed below.

Due to the magnitude of the epidemic, losses of local clinicians, and collapse of local healthcare infrastructure, there is an acute shortage of trained clinicians in West Africa.  The current Expat Clinician-intensive care model is expensive and difficult to sustain long-term.  Control measures have so far successfully reduced cases only in Liberia; EVD is unlikely to be eradicated from West Africa in the near future.  Our goal is to augment current efforts against EVD in West Africa by mobilizing civilians to assist in patient care.  Properly trained civilian healthcare providers are already used with great success in various sorts of underserved areas: examples include EMS systems worldwide and Last Mile Health in Liberia.  In the US, soldiers are trained to start and maintain IVs and IOs during an 8 hr course.  During a disaster situation, with similar accelerated training, appropriate supervision, and ongoing education, civilians are capable of providing care such as IV maintenance, cleaning, feeding, and moving patients.  In every town in America, EMS technicians - often civilian volunteers - extend the reach of the doctor far beyond the hospital, by implementing standardized treatments under his direction.  While it takes a doctor to diagnose and treat the myriad tropical diseases that are seen in the West African setting under normal conditions, it is IMA's belief that the EMS Model can be used to provide treatment for a single epidemic disease such as EVD during a public health emergency.

IMA is deploying a small team of expat clinicians who will train, equip, and lead a team of local frontline healthcare workers (FHWs), most of them non-clinician civilians.  With careful supervision, working alongside our expat clinicians, our FHWs will assist in providing basic supportive care to patients in a CCC-scale isolation unit.  The team will work under the supervision of a single physician Medical Director and a small number of RNs and/or Paramedics.  IMA will focus on EVD treatment until the epidemic is brought under control.  After this, IMA plans to establish an expanded training and support program, to allow FHWs to provide access to basic medical care in their villages.  

IMA will use a standard EVD treatment protocol: MUST. For IMA’s purposes MUST- Maximum Use of Supportive Therapy- consists chiefly of oral and IV rehydration, treatment of secondary infections (antimalarials/antibiotics), and transfer to a higher care facility when possible.

Though the Ebola response is accelerating, many areas of Sierra Leone remain underserved.  CCCs are designed to promote local access to EVD care, but they can become foci of transmission if not properly managed.  IMA will ensure that our CCC not only limits EVD transmission, but also improves patient survival, through the following:

1) Engineering controls: Promoting effective isolation of non-confirmed EVD cases through facility layout and regulating movement of patients, visitors, and health workers.  Ensure supply and correct use of PPE.

2) Leadership: Our expat clinicians will provide careful training, supervision, and ongoing re-inforcement of proper PPE use and correct technique for basic patient care skills.

3) Treatment Protocol: Define a simple MUST Protocol that can be carried out safely and uniformly, using minimal imported personnel.

It is our hope that our treatment model will offer a realistic way of getting as many patients as possible into Ebola treatment centers early.  We believe this is the best way to slow the spread of Ebola - a disease which has shut down the healthcare systems of several nations, and may become a permanent endemic issue in West Africa.  Getting patients into treatment centers improves their survival chances, frees them and their loved ones from the fear of spreading the infection, and insures them compassionate, non-judgemental care.

Availability of treatment for health needs other than Ebola has plummeted.  One of our primary aims is to reduce the burden on multi-purpose hospitals and clinics, allowing them to resume their normal mission of treating complications of pregnancy, trauma, heart attacks, malaria, typhoid, and much more.  As the epidemic is brought under control, IMA will shift our focus to supporting efforts to rebuild local healthcare systems and reduce susceptibility to future outbreaks of Ebola and other epidemic diseases.

IMA will be conducting all of our emergent-phase operations with an eye to laying the groundwork for long-term solutions. The final shape of the outbreak curve remains a mystery, and prolonged low-level transmission may result in ongoing shortage of general medical care in affected countries. West African healthcare systems, already weak, have been dealt a heavy blow by Ebola.  Even before the epidemic, Western-level access to healthcare was many years away.  While the long-term goal is a physician-/hospital-intensive, developed-world level of care, right now West Africa needs healthcare models that are functional in current conditions.  Last Mile Health in Liberia is setting an excellent example of such a system.  IMA’s long term goal is to train and organize existing talents, and to partner with existing healthcare providers, to build a similar frontline healthcare organization in underserved communities of Sierra Leone.  Specialized Ebola training is only the first step.  Frontline health care workers, fully trained to practice in their own villages, can do an enormous amount to link villages to regional clinics, and to prevent, diagnose, and treat myriad health issues.  Potential village-level care includes healthy pregnancy support, childhood immunizations, ensuring compliance with treatment regimens, identification of patients in need of higher care, initiation of patient transport, and frontline control measures against malaria, pneumonia, meningitis and much more.  Additionally, frontline healthcare workers will be in an excellent position to identify and help control any future Ebola outbreaks at an early stage.  Community-sourced FHWs, familiar with traditional practices and fully integrated into local social and power networks, are perfectly placed to provide a bridge between the village and regional clinics.

While our FHW selection process will be primarly merit-based, IMA has a special interest in EVD survivors.  In the case of Ebola survivors who are able to work, paid FHW employment has several potential benefits:

1) Access to good nutrition, psychological support, and treatment for residual effects, necessary for full recovery

2) The extra safety margin of apparent immunity to Ebola Zaire

3) Enhanced community acceptance due to status as a wage-earner and source of help for those who are ill

4) Any measure that increases acceptance of EVD survivors will indirectly promote the best possible solution for EVD orphans: adoption into Sierra Leone families.

In the face of potential exponential disease growth and a rapidly evolving public health crisis, we have five  priorities: 1) Courageous Patient Advocacy and Compassion 2) Safety 3) Speed 4) Simplicity 5) Sustainability.  We will be streamlining and expediting our operation by simplifying care guidelines, seeking the help of civilian organizations and local leaders, and when possible using existing structures and supply chains put in place by other NGOs, including Project Cure.  Our safety plan includes formal ETU training for our expat volunteers, formal, ongoing on-site education for our local staff, religious use of appropriate PPE, and adherence to WHO-recommended safety measures currently employed by MSF, PIH, and IMC.  

This is a unique situation that demands adaptability and flexibility.  We have no doubt that our current treatment model will have to be adjusted to fit realities on the ground.  Medical and moral decisions will be based on expert advice and consultation with our healthcare partners operating in West Africa.  The only thing that is not negotiable is our commitment to the safety of our personnel and the well-being of our patients, their families, and their communities.

Why Paramedics and not just MDs and RNs?

After spending 1-2 years in school, US Paramedics make field diagnoses and treat patients with only remote supervision of a doctor, providing advanced interventions such as IOs, intubation, nasogastric tubes, chest decompression, emergency tracheostomies, cardioversion, and cardiac pacing.  They also give several dozen medications in the US, including adenosine, diltiazem, metoprolol, morphine, versed, RSI cocktails, and much more.  Paramedics are accustomed to working in hazardous, high-stress environments, with minimal support, and are often faced with the need to improvise.  They are trained in the use of HazMat PPE.  They are committed to the safety of their crews, but also to rapid, effective response using the materials immediately available.  Paramedics often treat patients for hours or, in the case of rescues, days, before they reach a hospital         

On the use of survivors as patient care technicians:

Working in an Ebola treatment facility is a hot, physically tiring, and emotionally exhausting job.  Western-style infrastructure is lacking and in many current facilities proper PPE is not always guaranteed.  Even in facilities where the most stringent of safety precautions are used, mistakes inevitably occur and lead to exposures of staff.

When a staff member is infected, it has a negative emotional impact on other staff members, as well as potential recruits for the organization.  It prompts NGOs to pull out of Ebola-affected areas, and dissuades new NGOs from taking their place.  It creates expensive medevacs and fosters unease in the countries and communities to which infected staff return.

Several pieces of scientific literature (see Links) suggest that those who have recover from Ebola achieve persistent immunity against the strain with which they were infected  (The West African epidemic is caused by the Zaire strain).  There is even evidence that some individuals may be exposed and acquire immunity without ever becoming symptomatic.  More than one expat health worker has been very public about their belief that they are now at least relatively immune to the disease. 

According to WHO, Ebola has infected 10,000 - 20,000 people, and killed 70% of them.  That means that there are 3,000 - 6,000 Ebola survivors.  It is reasonable to assume that most of them continue to inhabit the homes and villages in which they were exposed.  After recovering, many provide care for family and neighbors infected with Ebola.  Not a single survivor has reported being re-infected with Ebola.

As IMA understands it, the current recommendation is that survivors work in the same level of PPE as regular providers.  Any change in this standard should properly be the result of very serious consideration by medical experts and an interagency ethics committee.  In the course of the West African epidemic, several measures have been approved emergently, measures which have not gone through the usual period of pre-approval testing.  As with ZMapp and Ebola vaccines, the decision of whether to change survivor PPE standards would be the result of a risk-benefit analysis.  It is possible that the natural epidemiological course of the epidemic has already created a far more thorough study of survivor immunity than could ever be achieved artificially.

At present, IMA feels that there is enough evidence of immunity to justify preferentially employing survivors as medical technicians.  So long as only those who have demonstrably survived Ebola and have recovered sufficiently to withstand the rigours of working in fully encapsulating equipment are used, we feel this adds an extra layer of protection to our operation.  For a high-profile example of an Ebola survivor who has returned to medical work, see British nurse William Pooley. 

In the hypothetical event that WHO and the Ministry of Health determined that survivors could safely work in Basic Precautions (in this instance gloves, boots, an apron, face shield, and a surgeon's mask would be an example), the game plan would be drastically changed.  Survivors have weakened immune systems and need to be protected from diseases such as respiratory infections, but PPE for this purpose is far simpler and less expensive than that currently used against Ebola.  Funds now spent on vast quantities of specialty PPE could be used on more medications and more medical facilities.  Time spent with patients would increase and physical stress on technicians would be reduced.  Interventions such as IV rehydration which are now often withheld due to safety concerns could be given with much less risk to both patient and caregiver, resulting in better outcomes.  Seeing human faces rather than plastic hoods would make clinics less frightening places for patients and families.  Less fear and higher survival rates would hopefully attract more patients earlier to treatment facilities, thereby reducing transmission in the community.

Visions of a seemingly vast pool of potential survivor technicians must be tempered by the realization that the bulk of current survivors are newly recovered.   Ebola is often a devastating disease with a long convalescent period, during which survivors tend to have weakened immune systems, are prone to infections such as pneumonia, and thus staff would need to be supported with antibiotics, etc. if they took ill.   Additionally, evidence is emerging of "Post-Ebola Syndrome" - a cluster of symptoms that includes visual impairment, aches, and fatigue.  Survivors have also just been through a frightening ordeal.  They may have lost loved ones and livelihoods, and be shunned in their communities.  Personal disaster affects different people in different ways.  To some it becomes a source of inspiration.  It is only a minority of survivors who are physically strong enough and psychologically willing and able to work as patient care technicians.  These are the people we will seek to employ.  As the epidemic goes on, the number of such people is one of the few resources that will increase.

Indonesia Books

The Airmen and the Headhunters - by Judith M Heimann.  Excellent true account of two Allied aircrews who are shot down over central Borneo during WWII.  Based on extensive interviews and research, author describes their long months in the jungle and Bornean towns, hiding from the Japanese and helping touch off a  native resistance movement.

Amidst the Archipelago of the Spice Islands Sails the Woden Borne - by Allan Spencer.  A fictional tale of adventure and romance amongst foreign adventurers/entrepreneurs on the seas of modern Indonesia.  Goes on way too long and is way too mushy.
Bali: Sekala and Niskala- by Fred B Eiseman 2009.  All about Balinese religious beliefs, ceremonies, and ritual.  The author goes into a lot of detail.

Captain Cook’s Journal During the First Voyage Round the World - by James Cook.  Cook’s journal recounts, among many other things, Cook’s passage through the Torres Straight, weather difficulties, sickness, and refitting in Java, and departure for the Indian Ocean.  Fascinating.

Diansinkan the Exiled - by Martin Kerr.  Fictional novel about a Dutch expatriat who is arrested, then forced out of Sentani, West Papua by the Indonesian occupation.  He subsequently becomes involved with the rebel movement.

Eat, Pray, Love - by Elizabeth Gilbert.  This is the super-popular travel narrative.  Everybody else seems to love it, but I thought it was mostly awful.  The actual travel narration - maybe 1/3 of the book- is OK, but the other 2/3s is the author endlessness ly whining about her petty personal issues- and she comes off as a real nutter as far as I’m concerned!

The Expedition to Borneo of HMS Dido for Suppression of Piracy - by Cpt Henry Keppel.  Free kindle book by an English captain who spends several years charting the coast of Borneo, chasing pirates, and having interesting encounters with locals- from headhunters to rulers of local kingdoms.  Well written, down-to-earth with some humor, a good read.

The Fifth Season - by Kerry B Collison 2009.  The fictional stories of 3 women caught up in the post-Suharto violence in Indonesia.

A History of Modern Indonesia - by Adrian Vickers 2005.  Social and political history of Indonesia from colonial times to the Bali bombing.

The History of Sumatra Containing An Account of the Government, Laws, …  - by William Marsden

The Island of Bali is Littered with Prayers - by Jeremy Grimshaw 2009.  A music professor studies traditional music in Bali and brings back a gamelan set to teach Western students on.

The Indonesia Reader - by Tineke Hellwig et al.  Excellent collection of dozens historical essays, documents, and interviews that works its way through Indonesian history, from ancient times to the present.

In the Time of Madness - by Richard Lloyd Parry 2007.  Foreign correspondent Parry relates his coverage of the social troubles in Indonesia at the end of Suharto’s reign, and his resulting emotional turmoil.  He travels to Papua, meets headhunters in Borneo, and treks into the hills of East Timor to meet with the rebel front.

The Indian Ocean Tsunami - by Pradyumna P Karan et al 2010.  Analysis of the response and recovery efforts of government and NGOs after the 2004 tsunami.

The Invisible Palace - by Jose Manuel Tesoro 2004.  True account of events surrounding a famous Java murder of journalist Fuad Mohammad Syafruddin in 1996.

Javanese Lives - by Walter L Williams 1991.  Interviews tell the life stories of dozens of (now elderly) regular Javanese men and women from all walks of life.  Excellent book; it really gives one perspective into life in Indo.

The Killing Sea - by Richard Lewis 2008.  A very readable fictional story of two teenagers- an American and an Indonesian- who struggle to survive and find their families after the 2004 tsunami.

The Long Oppression - by G.L. Simons.  History of government repression in Indonesia.  A grim reality check that covers the more unpleasant aspects of Indonesian history from colonial times to Habibie’s tenure. 

Love and Death in Bali - by Vicki Baum.  A classic tale of the violent colonial takeover of Bali and the changes in the lives of ordinary Balinese.  Very readable; one of the best Indonesia books in my opinion.

The Malay Archipelago - by Alfred Russel Wallace 1854.  Wallace bumbles his way around almost all the major islands of Indonesia, enraptured with the wildlife.  This is a wonderful book to read as you travel along in Indo.  Free online.

Oil Patch: Living in Oil Company Compounds from Desert to Jungle - by Gary Gentry.  A fun, short, irreverent book that gives good insight into life as an expat oil worker in Libya in the 80’s.  Also includes some short stories on Indonesia.

Playing the Poor Man - by Thor Kerr 2010.  Fictional tale of a foreign freelance journalist and an NGO volunteer who encounter corruption, poverty, social unrest, and danger in post-Suharto Jakarta.

The Spice Garden - by Michael Vatikiotis 2003.  The villagers of a small fictional Maluku island turn against each other in post-Suharto religious violence.

A Taste for Green Tangerines - by Barbara Bisco.  Awkwardly/abruptly written in a couple spots, but not a bad story if you stick with it.  A London-bred anthropologist goes to work with the Dayaks at a ‘green resort’ project in Borneo.  Deadly snakebites, corruption, ethnic clashes, wildfires, romance, and personal growth ensue…

Throwin Way Leg - by Tim Flannery.  A humorous account of a modern-day scientist’s search for new mammals and new experiences in PNG.

Through Central Borneo; an Account of Two Years Travel in the Land of the Headhunters between 1913 and 1917 - by Carl Lumholtz.  I found this to be the most readable and engaging of the old Borneo river-and-jungle traveler’s tales that are available free online.

The Timor Man - by Kerry B Collison 1999.  Fictional tale of army officers, coup plotters, and spies during East Timor’s last half-century or so of history.  From an author with very in-depth knowledge of Indonesian politics.

Wanderings Among South Sea Savages  -by H Wilfrid Walker.  The author’s 1910 journey through Fiji, the Philippines Sulu Islands, and Borneo.  Available free online.

Where the Strange Trails Go Down - by E Alexander Powell.  Author’s 1879 travels through Indonesia and Southeast Asia.

With Pythons and HeadHunters in Borneo- by Brian Row McNamee.  A young travel writer’s 1983 quest into the jungles of Borneo.  A bit whiny.

Wyvern - by A A Attanasio.  Epic novel follows the fortunes of a half-Dayak, half-Dutch boy who is raised as a jungle shaman and goes on to worldwide piratical adventures and high society.

South Pacific Books - Fiji, Vanuatu, Solomons, PNG

General

Lonely Planet’s South Pacific Guide

A History of the Pacific Islands - by Steven Robert Fischer 2002.  Good, highly readable account of Polynesia, Melanesia, and Micronesia that spans pre-history right up to modern times.

The South Pacific - by Ron Crocombe 2008.  Goes into a lot of detail and is up to date. Topics include history, culture, health, education, corruption, economics, security, international relations, and more. However, the book is organized by topic rather than country or timeline, and the sections go by ambiguous titles such as ‘parameters’ ‘patterns’ and ‘perceptions’.  I’ve gleaned a lot of interesting tidbits by scanning the index for entries on our next destination.

The Fatal Impact - by Alan Moorehead.  Talks about the havoc wreaked by European explorers, but it really wasn’t worth buying.  It’s written in the 60’s and is dated.  It’s pretty much a basic history of Tahiti, Australia, and the Antarctic, and doesn’t offer any exciting new facts, figures, or ideas.



Fiji  -
The best book sources I found were the arrivals area at the Nadi airport and the University of the South Pacific bookstore in Suva.  My favorites were Daryl Tarte’s Fiji, Getting Stoned with Savages and Fiji - A Natural History

Stalker on the Beach - by Daryl Tarte - a nice little fiction piece based in an imaginary Fiji-like country.  A local business woman fights against an international tycoon’s attempts at exploitation.

Fiji - by Daryl Tarte - really good historical fiction read set against a backdrop of Fiji events from ‘discovery’ up through the eve of independence.

Deuba - can’t remember the full name of this piece, but it was a good, short study of traditional village life written by a future anthropologist who lived in the south Viti Levu village of Deuba, training local recruits during WWII.  Details on clothing, menus, spirituality, and more.

They Came for Sandalwood - can’t remember who this was by, but it was not the detailed study I meant to buy, which was by Marjorie Crocombe.  The book I did buy was a short tone which described the discovery of Rarotonga in a clumsy way.  I got it at USP.  Not recommended if you’re older than a fifth-grader.

Getting Stoned with Savages - by J Marten Troost - fun book about an expat who goes to work in modern-day Vanuatu and Fiji and describes the life and people there in an often comical way. 

Fiji - A Natural History - by Paddy Ryan.  Beautifully illustrated descriptions of Fiji’s common marine and land plants and animals.







Vanuatu -
Hard to find good books on Vanuatu; Happy Isles, Tales of the South Pacific, and the Shark God were probably the best reads. 
I didn’t find any good book stores here ( ex: the most comprehensive was the Vanuatu Cultural Center bookshelf, which had two history/culture books: To Kill a Bird with Two Stones in English and Les Melanesians in French) and the only book available on kindle was South Seas Hitchhiker .  Most of my books came via ABE books via Aus, NZ, and Britain at some expense.  (I ordered them 6 weeks in advance and went to the post office to check for them every day during the 10 days we spend in Vila.  On our last day, just when I had given up hope, there was a new mail clerk at the counter and she miraculously produced the entire stack of 7 books.  An owner of a Vila bookstore described similar experiences receiving books by mail here).
Here’s my list of Vanuatu reads:

To Kill a Bird with Two Stones - by Jeremy MacClancy.  The only full history of Vanuatu.  A small book, 1980’s, not that well written, races through some events, ends at the end of the condominium.

Beyond Pandemonium by Father Walter Lini and New Hebrides: the Road to Independence - both books written in the 80’s by local politicians, both delve a lot into party politics and were a bit boring for me.  Interesting to read something by a local leader though.

The Shark God - by Charles Montgomery 2006.  A journalist traces his missionary ancestor’s path through Vanuatu and the Solomons in 2002.  Focus on current events and magical and spiritual beliefs of the natives.  I really liked his account of the Melanesian Brotherhood’s involvement in the Solomons Civil War.  Great read.

Coconuts and Coral - by  Gwendoline Page 1993.  Written by a british colonial housewife, gives a good picture of the colonial family experience but contains very little on local culture or life outside of Vila.

South Seas Hitchhiker - by Robert Hein.  Hein, a gregarious, perpetually broke 35 year old backpacker, wanders through Fiji, Vanuatu, NZ, Australia, and beyond, crewing on sailboats and taking odd jobs on shore.  Nice book.

Happy Isles of Oceania, Paddling the South Pacific - by Paul Theroux 1992.  Good old grumpy Brit Theroux produces yet another wonderful travel narrative filled with fascinating encounters with locals.

The Natural History of Santo - by the Santo 2006 Global Biodiversity Survey.  This multidisciplinary French-university-based study descended on Santo in 2006.  It was one of the largest scientific expeditions anywhere, ever.  This big glossy 57- pg book is full of beautiful photographs and articles by participating scientists that range from very accessible to somewhat technical.  I found this one at the Beachfront Resort in Luganville for $60 US.

Cataclysm- by David Luders.  Third book in a three-part series based on ancient Vanuatu legends.  This book covers the Krakatoa-like destruction of a large volcanic island that used to be north of Efate.

Tales of the South Pacific - by James Michener 1947.  A great Michener WWII fiction with fine stories and memorable characters.  Basis of the musical ‘South Pacific”.


Solomons -


 Best bookstore in the Pacific so far in the Hyundai Mall in Honiara.  They also bought back some of my old books for a decent price.  Fat Boys, near Gizo is rumored to have a reading library, and Uepi Resort in north Marovo had a good natural reference library and a large fiction section for trade.  We got a lot of $1 books from Honiara and gave away a book in just about every Solomons village, which was very appreciated.


Song of the Solomons - by E Hunt Augustus 2009.  Second in a three-part series of WWII historical fiction based in the Solomons.  A great, fun, funny book, one of my favorites.  Keeping an eye out for the other two in the series.

White Headhunter - by Nigel Randall.  Story of 19th century Jack Renton, who was shipwrecked amongst the headhunter tribes of eastern Malaita and was adopted into local culture.  Anthropologist Randall has some good insights on the tribal world.

Solomon Time - by Will Randall.  Untraveled English schoolteacher travels to an isolated island in the Solomons to help the locals set up a chicken farm.

The Thin Red Line - by James Jones.  A classic world war novel.

Devil-Devil -  by Graham Kent.  A fun fiction read about a detective and a nun combating crime and sorcery in the Solomons.

The Last Wild Island: Tetepare - by Dr John Read.  A good book about two ecologists’ battle to have Tetepare Island in the West Solomons recognized as a protected area.

Solomon - Times and Tales… - by Roger Webber.  An excellent read about a doctor’s time in the Solomons.  He works on several different islands and visits seldom-seen parts of the interior on foot.  Well written.

PNG -

Most of these were books I found at the Hyundai Mall in Honiara.  Check hotels and little tourist shops for used books.  Kindle has a decent selection of ebooks on PNG.

Notes From a Spinning Planet - by Melody Carlson.  A touching fiction novel about a student who visits PNG learns about AIDS and makes some self-discoveries.

Rascal Rain A Year in Papua New Guinea - by Inez Baranay.  A development worker struggles with the local culture and development culture in PNG’s highlands.

Diansinkan the Exiled - by Martin Kerr.  Fiction tale about a businessman tortured and evicted from Indonesian West Papua, who makes a new home in PNG.

Mister Pip - by Lloyd Jones.  A new classic about a village girl who lives through the terrifying Bougainville war.  Great book.

A Solomon Island Society - Kinship and Leadership Among the Siuai of Bougainville - a 1950’s ethnography of a SW Bougainville society.  Pretty well-written overall, alternates between interesting and dry.

Notebooks from New Guinea - by Vojtech Novotny.  Great book, highly recommended.  Humorus, engaging field notes of a Czech biologist, lots of interesting tidbits about the people and animals of PNG.

The High Valley - by Kenneth Read.  Pretty dated ethnography by an odd anthropologist who is driven to mental exhaustion by the experience.

The Lost Tribe - by Edward Marriot.  Easy read from a journalist who breaks the rules and has a not-too-inspiring encounter with a ’lost tribe’ in the PNG highlands.

Not a White Woman Safe - Sexual Anxiety and Politics in Port Moresby 1920-1934.  By Amirah Inglis.  I think this was her college thesis?  Research on the odd views of locals vs. Australians and sexual and social tensions in the 20’s and 30’s.

Papua New Guinea - by Sean Dorney.  A history of PNG by the TV reporter.  Focus on politics and economics 1975- late 90’s.  Gets good reviews. 

Intimate Communications - by Gilbert Herdt and Robert J Stroller.  A series of transcribed interviews with PNG Sambia villagers.  The Sambia live in the highlands and practice ritualized homosexuality from an early age.  Quite interesting.

New Lives for Old - Cultural Transformation in Manus 1928-1953 - by Margeret Mead 2001.  A long term study of cultural change in Manus, which experienced rapid modernization during WWII.  Mead argues that cultural change can come rapidly.

Seagulls Don’t Fly into the Bush - by Alice Pomponio.  Culture and economics of a people in the Siassi Islands.  A little dry, though the traditional trading activity in the Siassi Islands is fascinating.

The Island of Menstruating Men - Religion in Wogeo, NG - by Ian Hogbin 1996.  A study of traditional culture in Waigeo- magic, mythology, social structure and gender relations.

And We the People - by Tim O’Neill 1972.  Entertaining book about daily life and the people in this missionary’s remote PNG life.

Throwin Way Leg - by Tim Flannery 2000.  A humorous travelogue by a biologist who travels to remotest New Guinea in search of undiscovered mammals and adventure.

Wayward Women - by Holly Wardlow 2006.  A really excellent book about gender relations, violence, family, sex, and prostitution in the PNG highlands.  A must read for anyone interested in the staggeringly high level of violence against women in PNG.

The Ghost Mountain Boys - by James Campbell 2008.  Portrayal of the sufferings of the Allied and Japanese troops on the Kokoda Track during WWII.

The White Mary - by Kira Salak.  An excellent work of fiction by a very adventurous female war journalist who traversed PNG.  In the book, a lone woman fights her way far up the Sepik River and beyond in search of a missing friend.

Mangroves

Did you know if not for small mangrove crabs, the fallen-leaf mulch of mangrove forests would be carried away by each tide?  The crabs take these leaves into their burrows, where they eventually provide nutrients to the forest.
Mangrove leaves and hypocotyl  of stilt mangroves (elongated seedlings that grow right on the tree) are edible but not widely used as food.  People mainly use mangroves for wood, but also for charcoal, traditional medicine (boiled bark),  and tannins in the bark and seedlings provide a preservative dye.

Sailing Bali Indonesia - some cruising basics

 BALI CRUISING BASICS 2012

Notes from SV Marquesa
Entered Indonesia at Jayapura, April 2012.  Route: Jayapura-Biak-Sorong-Raja Ampat-Ambon-Flores-Komodo-Sumbawa-Lombok-Bali.  Currently location Serangan Island, Bali.(pic of a small portion of Serangan harbor below, Mt Agung in background).

Here’s a little info we Wish we’d had before arriving in Indonesia/Bali:

CRUISING PERMIT, VISAS, CUSTOMS, THE BOND:

- Kartasa Jaya in Java, who gave us good service, took 2.5 months to process our CAIT application.  Through them, the 3-month CAIT cost US$150, the 3-month CAIT extension cost $150, and a sponsor letter for a Sosbud visa cost $50. 
- Instead of the 1-2 month Visa on Arrival, we got the longer-term Social/Cultural 'Sosbud' visa in advance.  It cost $60 at the Vanimo consulate, one or two-day processing.  It's good for 2 months, then you can renew it monthly for $25/month up to 4 times (for a total stay of 6 months). 
- Clearance was pretty painless and the customs guys were friendly and helpful in Jayapura.  In a few other places we were asked for bribes of $10-$50 dollars, but we always refused successfully.  Sorong customs asked for the bond but gave up after phoning our agent, Kartasa Jaya.  The bond law has been officially revoked, but word hasn't necessarily gotten out to all the local officials.  Customs in Benoa didn't give us any trouble.  
For more info check out Noonsite's Indonesia page

http://www.noonsite.com/Countries/Indonesia/?rc=Formalities#Clearance

BALI

The channel west of Bali is full of obstructions and wicked currents and not easily navigable.  Lombok Channel, west of Bali, has south-flowing currents up to 5knots/+ in the SE monsoon (May-Sept).  Currents flow north during the NW monsoon.
Anchoring in Bali is NOT as easy as it used to be.  We have heard good reviews of Lovina anchorage in north Bali, but we have not yet been there.  As for E/S Bali, here are the choices we are aware of:

1) Port Benoa/Bali Marina - Benoa harbor is a very busy commercial harbor and the boats are pretty packed in places.  Parts of the harbor are very shallow.  Both Benoa and Serangan are as dirty as any other commercial harbors in Indonesia- just something you have to learn to look past, I guess. 
Approach through the s-curved marked channel.  Better to do this in good light, the shallows extend Well south of the marks on the north side of the channel, especially in the outer half of the channel.  After you take a final 90-degree turn into a roughly north-south dredged channel, you will have the Bali marina to port and ~ 20 moorings to starboard.  Bali Marina is small- about 20 slots, most of seem to be filled with resident boats. A berth at the marina will cost you about US $25/day, and a mooring here will cost about US $10/day.  The marina has no moorings; these are run by some random local fellow who will find you if you pick up a mooring.  A few sailboats manage to anchor north of the marina and moorings, but it is very shallow and space is very limited here.  Rumor has it you can also anchor south of the marina and main channel, though we did not see any sailboats doing this.  Benoa Marina charges a US$5/day landing fee to tie up dingies. 
Beware if you're entering Indonesia in Bali; Bali Marina has been known to insist that you use them as an agent when you clear in, for a US$200 fee.  This $200 clearance fee is excessive, since there's no reason you would need an agent, and all relevent offices are located within walking distance south of the marina (unless you needed to go in to town to the main immigration office?  That's an $8 taxi ride).  We know a couple boats that stayed at the marina, but Serangan really seems to have become THE place for cruisers in Bali.

2) Serangan Island - this is where nearly all the cruising boats end up.  There are 30 or 40 moorings here that cater to a mix of cruisers and local boats.  I guess they could conceivably all fill up during the busiest couple weeks of the year, but there would probably still be room for anchoring.
The Serangan passage is about 10m, marked by small unlit buoys, passing through breaking reef, but not anything that made us uncomfortable in good light.  I wouldn't want to enter any unfamiliar harbor at night and Serangan is no exception.It is accessed through a separate 10m wide channel through breaking reef north of Port Benoa.  Multiple masts are visible from the Lombok Channel and the channel into Serangan anchorage is marked by a couple funny little unlit red-and-green floating buoys.  Once inside the buoys, you will see two well-protected anchorages that offer 5 choices:

a) Mande’s moorings: Mustached- Mande and his goons are known to everyone on Serangan as ‘the mafia’.  They operate out of a beachfront shack just east of the dingy dock.  He will probably motor out to you as soon as you enter the anchorage, offer you one of his moorings, and tell you (untruthfully) that it’s hazardous to go any further in.  His moorings are US $8/day or about US $170/month.  THE PRICE OF ALL MOORINGS INCLUDES A ~US $70/MONTH (Rp 600,000) VILLAGE FEE, which is supposed to go to the people of Serangan.  The reason we recommend avoiding Mande if at all possible is that he has a reputation for stealing this village fee, as well as your dingy engine and anything on the boat that’s left vulnerable.  If you take a Mande mooring when you arrive, you are stuck with it; no one else will dare to rent you a mooring.  Make sure the village fee is included on your receipt and lock up your boat.
b) Made’s moorings: I know, it sounds like Mande, but this is Bali and everyone has the same name!  This is the 2nd local fellow who has moorings.  Rates are roughly the same as Mande’s but you won’t have to worry about mischief.  Made’s shop is to the right of the  dingy dock and the conspicuous 3-story old yacht club with the curved blue roof on the waterfront road- ask around. 
c) The Royal Bali Yacht Club - probably the best choice.  Try Ruth on Ch 17 on arrival.  She is honest, friendly, and  helpful.  The yacht club is hidden away; land at the dingy dock, turn left down the little main road/waterfront road and walk about 1 km- the RBYC will be on your left.  RBYC moorings are a couple dollars more expensive than the others, but they come with a shower. 
d) Anchor - You should be able to anchor for free NE of Serangan in the large area between the moorings and the reef.  Holding here is reputedly poor in a mud/plastic bag bottom.  This area and the outer moorings are windy and thus more rough than the inner moorings.  Swell protection is good everywhere at Serangan. You cannot anchor inside of where the moorings start. 
e) If you happen to be a good personal friend of former Indonesian dictator’s son Tommy Suharto, you can anchor in the absolutely beautiful, protected, peaceful, perfect inner anchorage that lies up the southern channel that you will notice to port just after you pass through the reef.  Tommy’s dad was one of the richest men in the world after he stole billions from the Indonesian people in the 60’s-90’s.  Tommy owns a large portion of Serangan, and unless you’re buddies, his goons will show up to chase you off shortly after you drop anchor here.

REPAIRS AND SUPPLIES IN BALI

Good news: Local produce, services, and goods are cheap and imported ones are often reasonable.  Shop at Lottemart (near Serangan), Carrefour in Kuta, or Hardy’s in Sanur.  Public transport from Serangan or Bali Marina is nonexistent, taxis are about US $10 to Denpasar/Kuta/Sanur, but you can rent a motorbike for about US $3/day/  Traffic in Bali is scary.  In Serangan drinking water is US$1.50 for 20L.  Local tapwater (bleach/boil before drinking) can be delivered to the boat for $8/500L.
- In Serangan diesel can be delivered for about US$0.85/L negotiable.  Jerry canning is technically illegal, but we've had no problem filling our jerry cans at a dingy-accessible petrol station for $0.50/L.  If you need laundry done US$0.15/peice) or water find Ibu Lala's shop near the dingy dock for honest service.  Local labor is around $15/day.  Good sail repair can be done by Nusa Dua Boatworks south of Kuta ($$$) or Julie on Serangan.  Local beer is cheap and good.  Telkomsel- near Ramayana on Diponegoro St in Denpasar - can provide a 3G internet plan for US $15/month + plus dongle. 

Bad news: Imported (ie palatable) wine and alcohol are expensive here.  This is a double-whammy for us because we have spent the last month trying to get work done on the boat here, and we really need a stiff drink now!  Quality boat parts and metalworking/mechanic services are really hard to find here, unless you’re fluent in Indonesian and  looking for something very basic.  Propane- The only places we've found that have Indonesian-to-US/Europe propane adaptors are Bali Marina or the Royal Bali yacht club.  Both charge US$50 for a 20lb bottle fill. 

Unfortunately the harbor water in Benoa and Serangan is very dirty and a giant pile of trash does loom on the horizon between Benoa and Serangan :(
On the bright side, Serangan is a lovely, quiet, friendly little traditional village with tons of temples.  Except for the pollution, can't think of a better place to stay on Bali.