Fever in the Jungle: Inside the World of an Epidemic Troubleshooter

By Sebastian Kevany

"This splendid book reminds me of my own experiences, travelling in various places of the world more than sixty years ago. Hopefully, as is suggested herein, things are changing. I wish Bassie the best of fortune in the splendid work he does." – Peter Somerville-Large, author of To the Navel of the World: Yaks and Unheroic Travels in Nepal and Tibet

What is life really like amidst the global battle against epidemics and infectious diseases? In 'Fever in the Jungle', Sebastian Kevany draws on his experiences of over more than one hundred treatment, prevention and outbreak missions, in some of the most remote corners of the world. Amidst the fight against HIV/AIDS, tuberculosis, malaria and Ebola, he takes us out of hotel room bubbles and, not just off the beaten track – but to the places where there are no tracks at all.

'Fever in the Jungle' describes, in vivid detail, the successes and defeats of a field epidemiologist, troubleshooter, liaison, barefoot diplomat and jack-of-all-trades. From rattling convoys and ramshackle malaria clinics in South Sudan, to air-conditioned meetings with government officials in Sierra Leone – with a few full-moon parties along the way – this is a window into the often bizarre challenges, places and adventures that make up an occasionally chaotic, often unpredictable yet, always fulfilling existence.

"Sebastian captures the fine line between success and failure in tackling some of the greatest challenges facing humanity... a book that will inspire involvement in the work of epidemic control in inhospitable places." – Mark Pollock, explorer, speaker and strategist; author of 'Making it Happen'

Sebastian Kevany has worked in the Middle East, the South Pacific, Eastern Europe and Asia, focusing on epidemic and infectious disease control and response, monitoring and evaluation, health security, international relations, human rights, conflict resolution, diplomacy and international relations.

• Language: English
• Publisher: The Manuscript Publisher
• Release date: Oct 28, 2021
• ISBN: 9781005087913

Book preview

About the Author

Sebastian ‘Bassie’ Kevany has worked in the Middle East, the South Pacific, Eastern Europe and Asia, focusing on epidemic control and response, monitoring and evaluation, health security, international relations, human rights, conflict resolution, diplomacy and international governance. He has completed over one hundred epidemic response missions and is the author of over fifty peer-reviewed papers on infectious disease control, security, diplomacy, and international relations. He is a former adjunct assistant professor at Trinity College Dublin; a visiting lecturer at the University of Westminster; and lives in Ireland and the USA.

Other Books by Sebastian Kevany

Barefoot Global Health Diplomacy: Field Experiences in International Relations, Security, and Public Health Epidemics

Between the Moon and the Fire: Life in Surfing Moments

Dedication

To Shandy (the dog, the drink – and of course, the human).

In memory of John Kevany and Yonas Bekele.

Acknowledgements

Thanks to Elizabeth Cope for the cover and author picture artwork (including her subtle representation of viruses in the top-left corner of the former); to Oscar Duggan for bringing it all together; to Meliza and Lillian, the infinitely patient travel agents; and to all who read and commented on earlier drafts: Andrew ‘Hollywood’ Fitzgerald; Kevin Boden; Marta Romani; Helena King; Alfred Alcorn.

Charitable Contributions

Beyond production costs, proceeds from this book will be donated to the Global Fund to Fight AIDS, Tuberculosis and Malaria and to Alone – supporting older people in Ireland to age at home.

Table of Contents

About the Author

Dedication

Acknowledgements

Foreword by Sir Henry Grattan Bellew

Introduction (and Prologue)

A Note on Timelines, Events, People and Chronology

Part One

South Africa, Zimbabwe, Thailand, Tanzania

2006

Night Flight to Harare

Lightning Bolts in Kwa-Zulu Natal

Fevers in the Jungle

Enlightenment in Kisarawe

Moon Rivers in Thailand

Beyond Dar es Salaam

Zimbabwe on the Edge

Kenya, Uganda, Ethiopia

2008

Over the Wall

Kampala and Beyond

Life in the Sarova

Addis Underground

The Wheels Fall Off in Kisumu

Gondar and Bahir Dar

Jordan, Egypt, Iraq, Afghanistan, North Sudan

2010

Never Arrive at Night

Arab Spring

On the Road in North Sudan

Tuberculosis in Iraq

Malaria in Afghanistan

Journeys Beyond Erbil

Southern (and South) Sudan

2012

Juba International

Deep in Equatoria

Friends in Strange Places

The Djebel

Green Ape in Aweil

Post-Secession Dynamics

Touching the Edge in Izo

Vanuatu, Samoa, Papua New Guinea

2014

Life in the Coconut Palms

Circling Samoa

Port Moresby

With the Braddas in Mount Hagen

Mozambique, Lesotho, South Africa (Switzerland, Bulgaria, United States)

2015

Ambassadors in Mozambique

Flying Doctors in Lesotho

South Africa Redux

Grounding in Switzerland

The Bulgarian Romani

The State Department

Part Two

Sierra Leone

2017

Arrival

First Night

First Day

Mister Cool

Handshakes

State House

Freetown by Night (1)

Freetown by Night (2)

Surfing at Bureh

Last Night

Departure

The Solomon Islands

2018

Delayed in Hong Kong

Distressed in Moresby

The King Solomon

Epidemic Investigations in Honiara

A Distant Passing

Body Clocks

Western Province Paradise

In Munda

King Solomon 2

Life in Honiara

King Solomon 3

Cruising with Alo

Waiting to Go

Central Province Arrival

Epidemics in Paradise

Malaita

Forgotten Shoes

Journey to Choiseul

Differences of Opinion

King Solomon 4

Departure

Foreword by Sir Henry Grattan Bellew

Lifelong friendships can happen in strange circumstances. Mine with the Kevany family started while waiting for the boat on the North Wall, Dublin, as John Kevany and I were departing for Ampleforth College in Yorkshire. It was 1945, and we were part of the Irish schoolboy contingent setting off for five years of public schooling.

Some years later, I took off for Africa in the early 1950s to farm — whilst John chose North and South America to further his medical studies. After that, we used to meet up back in Dublin, over the years, when our love for trout fishing brought us together on summer evenings in County Wicklow. We would bring each other up to date on the comings and goings of our respective sons and daughters - Sebastian was off surfing the shores of California, whilst dipping his fingers in things medical. Perhaps he might, we speculated, follow in his father’s footsteps….

Bassie, as he is widely known, chose Africa and epidemiology — coupled with public health — as his platform. He would be working along parallel lines with his father — but perhaps out on the occasional tangent, as well. His laid back but steely personality (not to mention his footloose style) soon attracted the powers that be in the World Health Organisation and elsewhere.

They needed a troubleshooter to confront the Everest-style challenges of HIV/AIDS, malaria, tuberculosis and Ebola that were peaking above the dust clouds and pollution of Africa: Bassie was their man, and in this superbly chronicled memoir tells of the many hardships encountered on his way — along with comical and outlandish adventures, and the occasional party as well. It is an eye opener, and something his late father, a man who was my best friend, would be immensely proud of.

Sir Henry Grattan Bellew, Bart

November 2020

Lean brown men from the ends of the earth may be seen on the London pavements, now and then, in creased clothes and walking with the light outland step – slinking into clubs as if they could not remember whether or not they belonged to them. From them, you may get news of Sandy.

John Buchan, Greenmantle (1916)

Introduction (and Prologue)

I always skip introductions (often prologues as well), and I encourage the reader to skip this one. Maybe, if I have liked a book and am lost for a next step, I will go back and read the back story after I have been through the rest. But, for more civilised readers, some kind of structure can occasionally help: in attempting to describe a life amidst epidemics, an American surf writer flatteringly advised that the arc they followed suited a literary template called the Hero’s Journey.

In it, I discovered, the protagonist follows a noble and circular path of being cast into the unknown, and faced with challenges and temptations. But receiving assistance from natural or supernatural guardians he or she meets along the way, a brush with an undefined abyss is overcome and the homeward leg begins: via further trials, moments of enlightenment and redemption now propel the so-called hero back into familiar realms realm, triumphant and transformed by revelation and atonement.

A diagrammatic path to redemption, through trial and discomfort: it would have been clean and convenient had life followed the orderly cycle presented by the diagrams. Yet was there ever anything, in anyone’s experience, that matched the map? Rather, in the realm of infectious disease control, revelation and transformation had usually felt distant and unattainable, just as the heroic and starry-eyed qualities required of a Hollywood protagonist often feel beyond our reach.

But epidemic control isn’t glamorous, or clean, or neat: it is, instead, training locals in poor countries to look after their health; it is the testing, treatment and prevention of HIV/AIDS, tuberculosis and malaria in huts and bare rooms – grandiosely called health clinics – in far-out places, where there is no doctor. It is dealing with the threat of the spread of infectious diseases from poor countries to rich ones – it is both work and adventure, Quixotic quest and raison d’être, for those who – voluntary, or by circumstance – travel to those places, to do those things.

***

As it turned out, a lifelong style of deep analysis of choices and paths – the trade-offs and careful decisions over next steps, from what to wear to where to live – was all totally unnecessary: circumstances now dictated evolution. The future had been determined, the moment I heard of the sudden death of my father in Ireland – after only six months of a new life in America.

On a phone call in a lighthouse near Santa Cruz in California, it was the morning after a seismic surfing beach party the night before: I had last seen him on the steps of the Irish house waving goodbye in the rain; now, seven months later, I was taking the Greyhound bus from sunlit Santa Cruz to rainy Ireland (via foggy San Francisco) to see him for the last time. I sat there: hungover, disembodied and dazed and beside a jarringly loud and garrulous lady on the hot and overcrowded Hound, the first leg of a long journey ahead.

Thus, reality intruded into surfing paradise. From a surf trip, that had evolved into a working holiday in a San Francisco financial district bank, to Ireland, without time to process what had happened in my absence: off the plane, and into a bizarre energy and attention and rush; into the old house to the wake upstairs; into the artificial whirlwind of distraction. I found myself, incongruously, still sun tanned and in shorts amongst half-remembered faces in sober suits; I felt both absurdly futuristic and slightly out of place amidst the two-hundred-year-old red brick walls, and the creaking floorboards.

And so I stood, discombobulated, bronzed, amidst my Mum and sisters. Looking out the South Dublin window along the April-yet-still-wintery beach, towards the Wicklow mountains, I realised I had become the one called back from a proverbial holiday – that I was the one, this time, whose fun had been cut short. The one who looked as if he had, very reluctantly, just stepped off a sunlit distant beach and into the cold Irish light of day; the one disrupted. And yet I knew I looked as if I was the one – on the surface, at least – least affected by the loss.

But even at twenty-six years old, it was still too much too soon: immediately, I tried to avoid the sadness of the occasion – though a low profile, immediately began to try to avoid every consequence. But one could run, but not hide: unexpectedly, I felt the full impact beside his coffin, lying open in his former bedroom – in the same instant, I silently mourned what I feared was the beginning of the end of the high times and surf and youthful excess of California.

There in the bay window, beneath the high ceilings, amidst sudden gravitas I told the man from the government standing beside me that the old boy had been a good man. More than good, I continued eloquently, ruffling slightly my protagonist’s statesmanlike and ambassadorial composure: he had been a Bond-esque adventurer, whose lifelong pursuit of medicine and epidemics among those who had nothing in developing countries had ended inexplicably and ironically early.

In those moments there was, briefly, deep emotion and confusion. Yet I stayed long enough only to scratch the surface; the whirl wind trip home did little to help regain perspective; little to calm or reassure. Epitaphs and speeches, wake and burial, airport and plane; a funereal return to Ireland from America had been far from the dreamy riposte envisioned when leaving months before – far from the dreamt-of laurel-wreathed triumph. Yet something had changed: six months later, restless in California and driven by ides of legacy and adventure, I was on my way to Cape Town.

***

Soon after arriving in South Africa, I found myself counting how many months until I was finished – how long until I could escape from the blue skies that were traditionally meant to bleach anomie, but instead seemed to be accentuating it by contrast. Yet despite such misgivings, Cape Town was where it all began: the discomfort and hardship, ideas and thrills. The start of life amidst epidemics with all its adventure, romance, redemption: a search for a more meaningful path was starting via a degree in epidemiology and public health at the University of Cape Town.

My girlfriend and I had arrived reluctantly, and everything overwhelmed at once: the medical school was, we found, located in a brutalist set of building blocks away from the lively parts of the uni. We were plunged, also, into strange accommodation, with far-out roommates, and neighbourhoods; we lived in Observatory, with ethnic musicians who often forgot to lock the door on the crime-ridden streets without. Thus, amidst the excitement of being there, the more challenging parts – adjusting to a security mentality, as much as to poverty, arrogance, and antipodean attitudes – were taking some of the idealism and bohemianism out of it: there wasn’t much time for playfulness when in at the deep end in Africa.

Yet slowly, glimmers of light emerged. Cape Town was far from the Rainbow Nation, but still showcased the New South Africa asserting itself racially and socially – economically and stylistically. No matter how bad things got, one couldn’t escape that thrill: the elements of social justice and altruism and responsibility that were woven into daily life and popular consciousness, from newspaper articles still unearthing apartheid crimes, to the world’s focus on halting the spread of Africa’s HIV epidemic.

Sometimes, there was even a hint of idealism – though the locals, rich or poor, didn’t really seem to like that style: too dreamy; almost an indulgence. The environment, the sensibility, the situation didn’t groove with western visions of utopia – rather, made them look faintly ridiculous. Instead, Cape Town seemed in those early days to be more a place where everyone accepted the realpolitik of modern but also imperfect societies, for better or for worse.

No one, local surfers told me between my early African waves in Kommetjie and Noordhoek, was lionised or regarded as some kind of saviour for working towards better global health or epidemic control. The realities instead made infectious disease responses look like a luxury and an indulgence – at worst, a romantic self-image. Pursuing it, I found, was regarded as something that was counter-intuitive, as one stepped off the ladder, and out of the rat race.

So a kaleidoscope of contradictions in the Rainbow Nation – and we were, after all, mere arrivistes who didn’t know, or who couldn’t understand, the big picture, or the mechanics of developing countries and their health problems. Yet that dismissiveness sometimes felt like a deep, primal challenge – and, even in the baptism year in the world of infectious diseases, there were silver linings.

By April, we were learning local etiquette – the Capetonian styles, not least the attention to order and cleanliness and timeliness that the proximity of poverty produced and that belied the city’s laidback image. A temperamental powder blue Peugeot 504 (a 1983 sedan model, old school) was bought for three thousand rand, or around five hundred dollars, opened new horizons: the Africans loved it; its high clearance on wash boarded, corrugated roads made it, they said, the Lion of Africa.

***

In the Peugeot, we travelled on more and more frequent surf trips to Jeffrey’s Bay – eight hours hard drive with no radio, to the best wave in the world. From that – and other long drives to desert waves north of Cape Town, or to shimmering blue-green point breaks under the desert sun – we also seemed to gradually internalise a soupçon of local style and awareness. A reductionism, and a type of Afro-cool, combined with an extensive ad hoc education in bush mechanics – from desert fixes of exhaust pipes, to cracked engine blocks on the veldt.

For my thesis, I drove to the townships around Manenberg and Khayletsha each day in the Peugeot, and naively tried to write about the positive downstream effects – the ripples – of antiretroviral treatment for HIV; how the locals might also plan for, optimise, and leverage them. How drugs for epidemics might bring more nebulous global attention and infrastructure and cooperation in their wake: how they might somehow thus improve international relations and security as well.

In the townships, as well – for the first of many times to come – I was reluctantly exposed to the very poor and the very sick. In a precursor of such gut-freezing exposures that would (though I wasn’t to know it, then) happen around the world at the least welcome times, I came face to face with HIV and tuberculosis and malaria patients in ultra-hot and ultra-crowded inpatient wards: there, for the first time, I felt the odd combination of personal good fortune and distress that resounded whenever I looked into the eye of a man or woman, boy or girl, propped up on pillows in an iron-framed, developing country public hospital bed.

I supposed, at the time, that maybe with more experience I would be better able to do and say the right thing when listening to faint voices saying occasionally inaudible things to me about their treatment experiences; supposed that, some day, I would come away from the bed having helped. I wasn’t to know then that over the coming years that I was neither to find such encounters getting any easier, either. I wondered – not for the last time – if leaving the Wall Street of the West back in San Francisco had been such a good idea.

Yet new ideas emerged in those overwhelming moments, just as much from living in South Africa at a time when activists were trying to get more and more HIV patients treated: the drama and the controversy of the Treatment Action Campaign and its charismatic leader, Zakie Achmat, was in 2004 ranged against a counter-movement that said the government had to choose the most cost-effective programmes – the ones that gave the most bang for the buck (which antiretroviral drugs didn’t, because they were so expensive).

Yet in the GF Jooste Hospital in Manenberg, deep in the Cape Flats, I saw first-hand that disconnect between science and reality: felt it, often viscerally, as I learned about everything from the costs of the complications of untreated HIV requiring more complex and esoteric and risky drug regimens, to societal and local cultural ostracisation of epidemic control programmes. It was clear, even to an amateur, that if what donors were doing didn’t jive with realities or day to day environments or local lives – if epidemic response efforts lacked artistry and artfulness – they would invariably fail.

I thought I could see, then, that if politicians and doctors, locals and internationals hadn’t thought about the domino effects of each epidemic control decision they made – not just in terms of the economic, but also in terms of the streetwise, the holistic; in terms of communities rejecting programmes because of something as superficial as bad branding – then no matter how good infectious disease control plans appeared on paper, no one would turn up.

After a year or more, my erstwhile lady friend returned to America; I wasn’t ready to leave. Reluctantly, and not without reservations – amidst the sweat and dust and clamour and crowds of the townships – I found myself drawn in.

***

After two years in South Africa, I moved back to San Francisco and, for over a decade, travelled from Addis Ababa to Zimbabwe (and the alphabet in between) working on epidemic response and control programmes for international agencies, universities, and others in a variety of roles – analyst, specialist, consultant, programme manager; evaluator, trouble-shooter, fly-in, fixer. Usually, this required weeks in obscure clinics in far-out parts of the world, finding out what was working and what was going wrong: checking that protocols were adhered to; or that funds spent matched results reported; or that the drugs on the wooden planks nailed to the back wall were not long expired.

There were high-profile tasks – rolling out drugs for HIV/AIDS epidemics – and obscure, forgotten jobs: restructuring clinics; decoding kinks in the provision of supplies; switchovers to electronic medical record-keeping. There was the checking of nocturnal bed-net use to prevent malaria in remote villages outside Khartoum, or the reviewing of tuberculosis testing equipment in revolutionary Egypt: in bizarre places, there was, also, the work of listening to the problems of impoverished nurses, as much as of the patients waiting in long queues outside.

All of this involved the investments that many in the western world might consider useless. In mosquito-infested rondavels or smashed by jetlag in expensive hotel rooms, I sometimes wondered if they were right. Over the years, I encountered many such sceptical opinions, at times believing them – yet I also discovered that the right infectious disease control effort, in the right place and at the right time, solves other problems as well.

Not all projects, and not every programme, works that way: just the occasional ones – the gems in the dust. Just the programmes that helped South Sudan to secede from the North – or the ones that could exist alongside the powder keg of the Arab Spring: the ones that looked beyond the mechanics of results, and costs. Those epidemic control efforts that – as well as improving health – eased anti-western antipathy in Iraq or Afghanistan, or sidestepped the Zanu-PF hard-men in rural Zimbabwe.

And so, along the way, I realised that – for better or for worse – this story had instead been something less common: a chaotic and unexpected Anti-Hero’s Journey amidst the world’s epidemics, straying far from fairy-tale stories of knights slaying dragons. One that had been characterised less by smooth arcs and circles than by the jagged scrawls of irregular events, unexpected outcomes, and untimely crescendos – experiences to be personified less by Luke Skywalker than Han Solo, less by Beau Sabreur than Flashman.

I had often displayed, in infectious disease environments, less noble fortitude than bouts of uncertainty; less bravery and valour than opportunism and survival. And yet there were parallels: for each Hero’s Journey phase, there was a suitably outré anti-hero antithesis. For the step into the unknown, read a desperate lurch; for transformation and atonement, read chance encounters; for supernatural guardians, read football-loving taxi drivers and a dreadlocked Zimbabwean lady called Gertrude.

Yet, as with other anti-heroes, maybe the same ends as the Hero’s Journey had been attained: whether infection control efforts had been achieved gracefully or chaotically didn’t seem to matter. At least in part, this is the story of those epidemic experiences, as much as it is a tale how an almost-forgotten HIV/AIDS testing clinic on the edge of the earth can – if handled in the right way – subtly contribute to more abstract holy grails such as conflict resolution: how they can contribute to bigger pictures, to world events, as much as to controlling the epidemics themselves.

Today, such ideas resonate globally. Countries, as much as individuals, are finding it harder and harder to isolate epidemic responses from other concerns. In turn, efforts to control infectious diseases are increasingly recognised, not just by the fringe but by everyone: by the enlightened self-interest of diplomats and politicians and generals and magnates, by the man or woman in the street as much as by (as an Australian nurse once described them to me) the mercenaries, missionaries and misfits who treat the fevers in the jungle.

But first and foremost, this is the real-life story of what it is like to work in the fight against global epidemics – and the startling people, places and experiences that come with it. It is also, to some extent, the narration and description of the backdrop that accompanies any academic journey – the people and places required, at least for me, to catalyse new ideas and attempts at innovation.

I hope that this will inspire others to engage in such work – despite its many and various trials – and cast some light on what happens behind the scenes amidst the fevers in the jungle.

S.K.

November 2020

A Note on Timelines, Events, People and Chronology

The stories that follow are representative of over one hundred epidemic response missions around the world – a lot to try and remember. Unfortunately, I didn’t always keep track of where I was, or when I was there: beyond email archives to travel agents, collections of boarding pass stubs, and other shreds of evidence, most of this is from memory.

As a result, it has sometimes been easier to group the stories together by region or theme: there is a chance, for example, that one of the trips to Bulgaria might have occurred alongside the Zimbabwe era, but to have been chronologically pedantic would, I think, have negatively affected the flow of the stories.

There is also very little said about the duration of the trips, though, in general, each ranged from one to five weeks in the field – along with associated preparation and recovery time. The key, thus, was not perhaps the length of the mission but both their frequency – a hundred missions of a dozen years adds up, believe me – and the way that they would often be stacked on top of and linked to one another: cost-saving piggy backs, involving travel directly from, say, South Sudan to Ethiopia.

The reader may also observe, if they make it that far, a distinct difference in the structure between Parts 1 and 2 of the book. While Part 1 was written pretty much exclusively from memory, by the time Part 2 rolled around I had gotten in to the habit of making notes on people and places. Hence, the stories from Sierra Leone and the Solomon Islands are much more detailed than those of earlier adventures.

On the same note, it is perhaps also worth noting that, compared to many others, I arrived late into the global health and epidemic control game. No doubt, many others have done more, travelled further, and seen stranger things: yet I think it is important to emphasise that I believe such paths to be open to anyone, at any stage of life, if they are willing to take a chance or two on an uncertain and precarious path.

Finally, a note on the patients: those affected and infected by HIV/AIDS, tuberculosis, malaria and other conditions that I met with on my travels. Naturally for reasons of confidentiality, few details beyond broad-brush pictures of conditions are provided here. Nonetheless, I hope that is enough to provide honest and compelling examples of related circumstances and conditions in some of the most remote parts of the world.

And just one other thing: besides the grumbling and description of hardships, I can assure you that these were, without exception, great days and amazing experiences. I was, throughout, privileged to travel to these places in a decent state of health, for which I am very grateful.

S.K.

November 2020

Part One

South Africa, Zimbabwe, Thailand, Tanzania