Since this is a doctor’s story, but also a story by a white American doctor in the midst of African patients, I have tried to be acutely aware of the need not only to bear witness to their stories but to note the special circumstances in which I am obligated to bear witness to them. A century ago, Joseph Conrad, who was not a doctor, did a good deal of bearing witness to the shocking cruelty taking place in the Belgian Congo, and he turned that experience into the classic work of fiction Heart of Darkness. Marlow’s travels up the Congo would become required reading for generations of students in the West, and in some sense set the standard by which we measured this kind of literature. If Inferno shares Paul Fussell’s notions of literary tragedy, it follows Conrad’s form.
Yet in a lecture given in 1975, the great author Chinua Achebe reappraised Conrad’s work, and the critique that resulted is scathing. Achebe alleges that Heart of Darkness represents a “desire—one might indeed say the need—in Western psychology to set Africa up as a foil of Europe, as a place of negotiations at once remote and vaguely familiar, in comparison with which Europe’s own state of spiritual grace will be manifest.” He charges that Conrad’s novel projects the image of Africa as “other,” a savage place where “man’s vaunted intelligence and refinement are finally mocked by triumphant bestiality.” That is, Achebe alleges Heart of Darkness is just idealized claptrap about Africa; what makes it supposedly great literature is that Conrad happened to be a remarkable English prose stylist.
Achebe wrote those words while living in Massachusetts, the place I now call home, and I suspect that by “Europe” he meant not just the physical place where Europeans live but a mental space where a good many people of European descent locate themselves no matter where they find themselves on a map. The problem with Heart of Darkness, he argues, is that whatever its earnest contempt for human enslavement, it nevertheless manages to hold fast to this duality of civilization/primitiveness and doesn’t appear to be especially interested in doing the hard work required to move beyond it. The actual Africans are just window dressing.
He ponders all of this as he completes his analysis of Conrad, saying that the West’s goal should be “to look at Africa not through a haze of distortions and cheap mystifications but quite simply as a continent of people—not angels, but not rudimentary souls either—just people, often highly gifted people and often strikingly successful in their enterprise with life and society.” It’s a relentlessly downbeat evisceration of a work that even Achebe agrees is deserving of attention. By the end, the reader might dare to hope for a silver lining, but his dissection of Conrad doesn’t end on a buoyant note. He concludes by writing, “I realized that no easy optimism was possible. And there was, in any case, something totally wrong in offering bribes to the West in return for its good opinion of Africa. Ultimately the abandonment of unwholesome thoughts must be its own and only reward.”
If we, as Americans, or Europeans, or even Africans, are to find a way past the degrading binary of civilized-versus-savage—a binary that was subtly reinforced in the vast amount of news coverage devoted to the West African Ebola outbreak, even though it took place one hundred years after Joseph Conrad’s tale and nearly forty after Chinua Achebe’s prescient diagnosis of its shortcomings—then it’s high time we made some effort at demystifying our larger narratives about events in Africa that have a major impact on the West. The Hot Zone, for all of its spine-tingling excitement, not only fails to take part in this demystifying process but largely perpetuates the dualities that so incensed Achebe in the first place.
What I have tried to do here, in telling my Ebola story, is to remove the haze of distortions and cheap mystifications as best I can. I cannot say whether the effort is clumsy, nor whether it is any less racist than Conrad’s well-meaning and lyrical work. I send this work out into the world mindful, even perhaps fearful, of a sharp reprimand from the spirit of Achebe as well as his intellectual descendants that I have repeated Conrad’s mistakes, substituting my own distortions for his, having gotten no further in understanding the place a century later. I can only note that I have tried to do something different in writing about Ebola, which is to be conscious of the virus as a metaphor and the power that metaphor holds in so many people’s thinking. I have done what I can to meet Africa on its own terms.
The patients my colleagues and I treated weren’t Ebola victims: They were farmers, miners, and nurses; they were husbands, wives, and children; they were the aged who had lived through so much suffering in the lives of their countries and still were there. The words of Haley Newman, the med student I listened to that day, are right: Patients are unique people with powerful stories, and their identities should not be erased by their illnesses. No more, no less. If their identities, their stories, become part of the larger Ebola narrative as understood in the West, then the virus won’t simply serve as a standin for all that is “savage” or “primitive” or all the other nonsensical things ever written or thought about Africa by a Westerner. Ebola is just a virus. That fact should not by any means distract from just how deadly that virus could be, however.
Since I mean to keep the focus of this story on my experience as a physician working through the outbreak, I have largely kept my personal and family life out of the narrative. Readers may wonder at various points about how my departure or return affected my family and find it a bit of a shock when they finally are mentioned more than two hundred pages into the book, thinking that I have removed a critical piece of a narrative puzzle, or perhaps have revealed myself to be a disembodied or heartless professional with no personal attachments in the world.
For better or worse, I deliberately chose not to include extensive passages about my family or personal life, for I mean to keep the spotlight on Africa, since I believe this is the story that needs telling. Already much is known about the personal experience of Ebola volunteers through the experiences of such brave and remarkable people as Craig Spencer, Kent Brantly, and Kaci Hickox, so writing about my own life would describe already-covered ground. The major exception is the chapter “Purgatory,” which covers the period immediately following my return home. In that instance, I thought it important to explain what it felt like to be a returning volunteer, so that people could have some understanding of the effect of the many policies being implemented by various states at the time and how those policies played an important role in national politics during that stretch.
A word as to the title. Dante’s masterpiece serves as the starting point for many reasons: Africa is hot, working in protective gear is hotter still, and inferno aptly describes the almost unending raging fever of Ebola, a phenomenon that I have only rarely seen in an acute viral illness. But other parallels justify borrowing his title as well. Inferno calls attention to the time during which the work made its appearance in the 1320s, for Dante finished it a little more than a generation before one of the greatest plagues, the Black Death, decimated Europe. There were definitely moments when even the most seasoned epidemiologists wondered whether the West African outbreak might reach similar proportions.
The title Inferno also underscores that the Ebola outbreak was experienced by the vast majority of people living in the affected countries, to varying degrees, as a religious experience in which God’s judgment was unleashed on the world and people were being asked to journey through a literal hell on earth. In Liberia, where I worked, this spiritual dimension was broadly understood through a Christian frame of reference, as Christians constitute nearly 90 percent of the population. I meditate on the relationship between Ebola and Christianity in Liberia at greater length in the chapter “Behold, a Pale Horse.”
When I began writing Inferno, I had a more concrete notion of how the book would pay homage to the original by incorporating nine circles, each one descending further toward some final, unspeakable horror that encapsulated the entire episode. After a few attempts at drafting an outline like this, I realized I was being too literal. However, the nine chapters of the Inferno you find b
efore you are, I hope, not entirely unlike Dante’s poem: stops on an unplanned pilgrimage that consumed nearly two years of my life and altered me in ways with which I am still coming to terms.
Along this journey I have encountered not only patients but hundreds of professionals from all walks of life and dozens of countries. They, too, were in the midst of their own journeys, and I have tried to capture a shared quality of the collective experience.
I pray that I have done right by all of them.
1
THE VESTIBULE
A screaming comes across the sky. It has happened before, but there is nothing to compare it to now.
—Thomas Pynchon, Gravity’s Rainbow
This is a horror story. And as if someone from central casting were pulling the strings, this horror story begins with a small child happily playing right outside his home.
Meliandou is a small village of a few hundred inhabitants living in approximately thirty rustic dwellings in the hinterlands of Guinea, a satellite of the city of Guéckédou, a place to which the villagers, mostly farmers, come to sell their produce in the Nzérékoré Region, the easternmost province of a country shaped almost like an apostrophe that lost its footing in the middle of a sentence and was falling forward. Meliandou’s North American equivalent would be described as “sleepy” and perhaps “idyllic.” Although it would be naïve to think that Meliandou’s people have lived a content, pastoral existence for centuries or even decades, as of the early twenty-first century, a quiet kind of peacefulness could be found there.
Emile Ouamouno was the beneficiary of this relative prosperity. The child of Etienne and Sia, Emile was growing up as children do in a relatively sheltered environment, exploring the natural world around him, which in the depths of the West African rain forest provided no end of wonders for a curious two-year-old. A picture of the three of them can be found on the Internet. Although they aren’t smiling, one gets the sense that they are satisfied with their lives. They’re an unmistakably beautiful family. Sia is on the right, her left hand on her hip, wearing an abstract-patterned light dress, with long white earrings and a yellow bead necklace. Her hair is close cropped. Etienne occupies the center, wearing a red-and-black soccer jersey. And Emile sits upright, staring into the camera, held in the crook of his father’s right arm, eyes wide, the chubby cheeks of toddlerhood not yet dissipated. The graininess of the picture makes it look like it could have been taken in the 1960s, but it is from 2013.
Along with other children, Emile used to frequent a large tree at the periphery of the village. The tree was a natural jungle gym, with a hollow at its center large enough for a grown man to walk inside and even climb up into. By the news reports, the kids used to love playing around the tree. Again, you can find pictures of this tree in a few seconds with a Google search. It provided a natural setting for children to spend their afternoons doing what kids should do, especially a child of Emile’s age.
It wasn’t only children who utilized the tree for its size and the protection it offered. Farther up in the hollow, a nest of Angolan free-tailed bats had quietly taken up residence. The bats belong to the insect-feeding species Mops condylurus, and they are extremely common throughout much of sub-Saharan Africa. Their droppings would fall to the ground and mingle with the soil. With the heat of the jungle in the dry season, you would hardly have noticed the guano at all. And nobody did. Certainly the children didn’t, focused as they were on the joys of playing. But it was this interface of child-bat-guano that may have led to Emile Ouamouno becoming Patient Zero of the West African Ebola outbreak in December 2013, the first spark in a fire that would rage for months and then years, a child who became the nexus of a tragedy in which thousands would die, thousands more would be maimed, and tens of thousands of others would feel its shockwaves without ever coming near the agent that transmitted such suffering.
*
The screaming first came across the sky in 1976. Quite remarkably, two simultaneous outbreaks took place hundreds of miles apart, one in the southern part of Sudan, the other in Zaire, the country we now call the Democratic Republic of the Congo, or DRC. The Sudan outbreak led to nearly three hundred infections, and half of the patients died. The Zaire epidemic led to about the same number of infections, but in this outbreak nine of every ten patients died. The identification of this strange and very deadly new virus would take place in state-of-the-art facilities designed to deal with the most lethal pathogens on the planet—so-called Biosafety Level 4 laboratories. In short order Ebola would develop a reputation among the scientists who studied it as the most fearsome of a small group of truly terrifying infectious agents.
Ebola became one of a number of viruses that would earn the moniker of “emerging infectious diseases,” although the term itself indicates the hubris by which Homo sapiens sometimes regard our world. The virus had hardly “emerged”; it’s just that we finally happened to stumble upon it and identify it for what it was. What we now call Ebola has without any doubt been around for thousands of years, probably tens of thousands. Although much of what we know about Ebola is provisional and therefore subject to wide ranges of interpretation, we’re reasonably sure that the virus has circulated among fruit bats for millennia in much the same way that cold viruses circulate among humans—that is, it might make them sick, but not ever sick enough to do any real harm. A virus has an interest in not making its host too sick, because then it can survive in a happy equilibrium by making copies of itself and continuing to survive as long as it has plenty of hosts to which it can spread. It has no interest in killing its primary host—or at least killing it quickly—since then it can’t spread and will ensure its own demise. But when a virus jumps a species, and it happens to be deadly to that other animal, all bets are off.
The fruit bat may be Ebola’s “natural reservoir”—the creature in which the virus finds its primary home—although, again, nobody is completely certain of that. Unlike many other viruses, whose place in nature scientists have been able to deduce from careful field studies, Ebola for all its ferocity has been something of a shy predator, disappearing back into the jungle as quickly as it materializes, making itself seemingly invisible despite decades of animal testing conducted on the creatures who live at the site of the outbreaks. It wasn’t until 2005—after nearly three decades of seriously funded, high-level research—that scientists were able to spot the genetic signature of Ebola in the blood of fruit bats, which provided indirect evidence that the bats were its natural home. Four years later, Ebola’s sibling, the Marburg virus, was isolated in fruit bats. Thus far, three species have been proven to possess the virus: the hammer-head bat, or Hypsignathus monstrosus; the little collared fruit bat, or Myonycteris torquata; and finally, the elaborately named Franquet’s epauletted fruit bat, or Epomops franqueti. Fruit bats are fairly endearing creatures, with humanlike faces and a soft fur on all but their wings. They are commonly called “flying foxes” based on their resemblance. But the bats believed to be nesting in the tree in Meliandou were not fruit bats at all and aren’t especially cute. Yet the close proximity of Mops condylurus to Emile Ouamouno seemed suggestive, although subsequent research on bats captured in the area found no evidence of current or prior infection. The bat-origin hypothesis could not be confirmed, becoming another tantalizing clue in a complex puzzle, and much about how the virus behaves in its natural environment remains completely unknown.
Ebola got its name by a slight bending of the rules of virus nomenclature on the part of the scientists who discovered it. The Zaire outbreak in 1976 began in a Catholic mission hospital in a village known as Yambuku. The hospital saw the first patients of this distinct and novel disease, more than twenty in all. Nearly all of them died, which led the staff doctor to alert the Zairean Ministry of Health, who sent a team to investigate and found the hospital closed because the staff themselves had become sick. The medical staff too nearly all died. This was what prompted the government of Zaire to call for the international response that le
d to the collection of blood samples and eventual isolation of the virus. Traditionally, viruses such as these are named based on the location where the first cases are identified. Marburg’s natural reservoir, for instance, is in Africa, but it is named after the German town where the first known human cases of the disease occurred, in animal workers handling African green monkeys. Similarly, at nearly the same time the patients in Yambuku were dying, a group of teenagers in a small town in Connecticut had become moderately ill with a disease that would eventually be proven to be bacterial in origin, but the scientists applied the same “viral” rule of naming it after the site of its discovery. The town’s name is Lyme.
There were, however, some downsides to following the custom of naming this particular virus Yambuku, especially in a place like rural Africa. Stigmatization was a serious problem. A virus discovered in the late 1960s in a small Nigerian town led to its christening as the Lassa virus, with the consequence that the inhabitants of that place were treated with suspicion and hostility for years afterward. Of the international team, Dr. Karl Johnson, who served as the head of the Centers for Disease Control’s Special Pathogens Branch, had proposed sidestepping this problem by naming the virus after a local river. He had done the same the decade before with a deadly virus that caused a disease known as Bolivian Hemorrhagic Fever, giving it the name of Machupo—a tributary of the Amazon. The team favored this approach. They looked on a map, saw a tributary of the Congo known as Ebola, and the name thus took. The name Ebola is from a local Bantu language, Lingala, and means “black river.” It was hard to come up with a better name for it than that.1
Ebola required another name as well—the class to which it belonged. Viewed under the scanning electron microscope, both Marburg and Ebola had a shape that was completely unlike that of any virus seen before. Most human viruses are roughly spherical in shape, whether HIV, measles, the Hepatitis A, B, and C viruses, and so on. One partial exception is rabies, which if contracted and left untreated is nearly 100 percent lethal, and is thus, along with untreated HIV, technically humankind’s most deadly virus. Rabies has a shape that looks almost exactly like a bullet. But Ebola and Marburg have a long, tube-like structure that folds over on itself in erratic ways, each copy of the virus appearing to be slightly different from the next. Not long after Ebola’s discovery, a group of scientists proposed the family name of tuburnavirus, from the Latin meaning “tubular virus.” Instead, in the early 1980s, a symposium on Ebola and Marburg naming was held by the International Committee on Taxonomy of Viruses, the body in charge of providing names and classifications not only to Ebola and Marburg but to all viruses discovered in the world, so that there is some uniformity of nomenclature in the scientific literature. Shortly thereafter, a new proposal to call the family filovirus (from the Latin for “filamentous virus”) was submitted to the committee. The concept was the same as that of the name tuburnavirus but was less of a mouthful, and the name stuck.
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