Inferno

by Steven Hatch, M. D.

  The doctors in Guinea certainly didn’t have Ebola on their collective radar screen: The one hemorrhagic fever with which they were familiar was Lassa, and while the worst cases of Lassa are every bit as horrific as Ebola, Lassa is transmitted from rodent to human, but not human to human. Thus, health-care workers finding a bad case of Lassa didn’t fear for their own lives unless they were unfortunate enough to suffer a needle-stick injury. Unbeknownst to almost everyone except for a few observant souls working for MSF, by the time the discovery of Ebola in Guinea was announced in late March—more than three full months after baby Emile had so fatefully crept into the tree hollow in Meliandou—several health-care workers already had paid, with their lives, for their confusion of Ebola with other diseases.

  The Guinea Ebola story at the time struck me as a curiosity and not much more. Although I knew nothing of rural Guinea, I knew that Ebola outbreaks usually were contained within a matter of months, and so I kept tuned to NPR or The New York Times for updates, not thinking much about the tiny cluster of cases other than its novelty for that part of Africa.

  However, one story at the beginning of April did catch my attention: It noted about a dozen cases in Guinea’s capital of Conakry, a city of nearly two million people. That seemed worrisome and unprecedented. The Kikwit episode in 1995 had been until then the only Ebola outbreak in a truly urban area, yet Kikwit was a tenth of the size of Conakry, and it had generated world headlines and substantial alarm at the time.

  But the stories only puttered along and so I followed in like manner. April turned into May. Liberia had announced the discovery of two cases up in northwest Lofa County, and since Lofa wasn’t far at all from the Guéckédou region where the Guinean cases were reported, it didn’t seem too surprising. But then, nothing followed. About this time just by chance I gave the same hemorrhagic fever talk to the internal medicine residents at UMass that I had given to the JFK residents. It was simply an odd coincidence, the date having been set months before. When I talked about Ebola, I made an off-the-cuff mention that there was a current outbreak going on in West Africa, but it would be contained soon enough, for that’s how these outbreaks behaved.

  The stories never quite went away, though, and throughout June the news seemed to be getting worse by the week. By mid-June I started scanning the headlines on a daily basis to see what was happening. A BBC news item had shown a picture of workers in gear tending to a patient in “northern Liberia,” which was later noted to be Lofa County. Oh my God, I thought, what happens if this thing gets to Monrovia? Even though the news about Conakry should have gotten my full attention, it wasn’t quite the same as hearing about Ebola tear through a city I had seen and whose streets I had walked. When I linked Ebola to Monrovia, I suddenly understood that if it took hold there, this outbreak was going to be unlike anything anyone had seen before. A few days later, on June 17, my increasing alarm found form in a piece by the Associated Press, which noted that the first reported cases had reached the capital.

  Then I thought of the people I had met.

  *

  What I did not know was that chaos had already engulfed JFK and the rest of Monrovia. “Monrovia was upside down,” Phil Ireland would later say to me. When I had walked around the Sinkor neighborhood in Monrovia, the main thoroughfare of Tubman Boulevard was bustling with people. Parts of Tubman Boulevard were narrow, as were the sidewalks, so during rush hour cars slowly moved by within arm’s length of pedestrians throughout much of the stretch into Monrovia’s city center.

  In early June, that hadn’t changed, although Phil said that paranoia was clearly in the air. “The city didn’t shut down. At the early stages of the epidemic, it was just sinking in,” he said. “Everybody was taking precautions. I would be driving into work, and there would be a taxi ahead of me, and it would just stop, and somebody would just open the door and just vomit, and suddenly there would be a big periphery, a big crowd would clear. This whole area would just clear. The taxi driver would try to kick that person out. It just got crazier and crazier. It was a bad state.”

  As June progressed, however, and the outbreak spread across the city, the panic set in. JFK was seeing the results come in through the Emergency Department. “It was like the Twilight Zone. There were lots and lots of cases,” Phil said. “Our first case was a guy from Lofa County. He passed all the checkpoints. He had all the cardinal signs of Ebola. It wasn’t confirmed. He had fever, injected conjunctiva, scleral redness, very toxic looking. He came in and said he was from Monrovia.” But Phil, who by chance happened to have worked on a cocoa plantation in Lofa County years before, recognized the man. “I looked at him and said, ‘I know you, you’re from Lofa County.’ I asked the taxi driver, and he said they had come from Lofa, so I went to Dr. Brisbane and I said to him, ‘These guys are coming from Lofa County.’ After that I went and washed myself.”

  Samuel Brisbane, a member of the hospital’s senior staff, was skeptical that the Ebola outbreak was really happening, or at least to the extent that was being reported. “Not everybody is an Ebola patient,” he would once say to Phil. “We still have to treat patients like we’ve always treated patients. We have cases of malaria, and we have other diseases.” Brisbane was a colleague of Borbor’s whom I hadn’t met the previous November, though everyone spoke of him in equally glowing terms. When I learned that he doubted Ebola was afoot, I reacted with pure slack-jawed astonishment. Yet when Phil explained how he had arrived at this seemingly preposterous conclusion, I was more muted in my criticism.

  Brisbane was suspicious of any pronouncement by the Liberian Ministry of Health. Like Borbor, he had given much of his career to JFK, toiling in a difficult working environment, all the while watching several government officials do very little for the institution, all while enriching themselves through various grifts, often involving donations from wealthier nations, especially the United States and Europe. Brisbane’s anger and distrust had been fermenting for years such that Ebola seemed like just another scheme, a ministry shakedown of the international community for more aid with which officials could line their pockets. They had hastily arranged for an Ebola Treatment Unit to be set up on JFK’s campus, but one not run by MSF, which was the main group in Liberia with any practical experience in Ebola management. My guess is that to Brisbane, the JFK ETU probably looked like a Potemkin village designed to bilk more dollars out of the World Bank, the International Monetary Fund, or the UN. If his cynicism led him to the ultimate mistake of his career—and indeed, of his life—it certainly was not based on a total departure from careful reasoning and observation.

  However, neither Borbor nor Phil shared his views. Indeed, Borbor was furious if the infection control procedures that JFK did have in place, inadequate for Ebola though they were, weren’t rigorously followed. “You should know better,” he scolded Phil when told of how the staff was handling a suspected case. “If you make one mistake, you guys are going to kill all of us!”

  Phil had worked closely with a physician assistant named Vincent. Colleagues and friends, they spent June watching Monrovia slowly come undone. Nevertheless, they both showed up for work without fail. One day in early July, Vincent was working in an area off the Emergency Department informally known as the “Blue Room,” so named because of its painted interior. The Blue Room was where patients from the ED were kept while waiting for a bed to open up on the floors. Not originally intended to house patients, it had no ventilation and was therefore unusually hot, even by Monrovia standards—and thus not the best place for patients dehydrated by any infection associated with a fever, whether that was malaria, typhoid, or Ebola. That day, a woman had been sent to the Blue Room by the ED with a fever and malaise. She staggered as she tried to walk to her bed, and Vincent, who had known the woman, reached out to grab her and help her to the bed. She died that night, and the Ministry of Health sent workers clad in personal protective equipment (PPE) to draw her blood, which subsequently confirmed Ebola.

  Phil is convinced t
hat this was when Vincent became infected. Several days later the fever hit, and Vincent called Phil to tell him that he couldn’t come to work. When Brisbane heard the news, he told Phil to make sure he came to JFK. He would need to be isolated, he said. The intervening weeks, which had seen JFK overrun with critically ill patients far out of proportion to the usual routine, had convinced Brisbane that what was happening was real. But by then it was too late. In mid-July, Dr. Brisbane started to appear fatigued. He walked slowly, weaving down the hallway, leaning up against the wall for support. Nurses avoided him. Soon he, too, would be unable to come to work.

  *

  I knew none of this at the time; there was hardly any news being reported, and I hadn’t heard anything on e-mail from my contacts. On July 1, an especially ominous headline appeared from Reuters: “Ebola Outbreak Is the Largest Ever.” There were at that point 759 official cases. That was more than double the size of all the Ebola outbreaks in history, with only one exception: the Gulu outbreak in Uganda in 2000 and 2001. The Gulu outbreak tallied 425 total cases, and it was clear from reading the Reuters piece that, whatever the final number, the West African outbreak would soon be more than twice the number of Ebola cases from the Gulu episode as well.

  And then … almost nothing about Monrovia for three weeks, during which time I thought that perhaps my colleagues were going to be spared the worst. The disease seemed to be spreading in the countryside, but if Monrovia was being overrun, it wasn’t making the reports. I started to contemplate an upcoming vacation to Canada with less foreboding than I had been feeling in June.

  On July 27, however, the Associated Press reported my worst fears. “Ebola Kills Liberian Doctor, 2 Americans Infected,” read the headline. Dr. Brisbane was dead. The two Americans were Kent Brantly and Nancy Writebol, a doctor and nurse working for the Protestant missionary group Samaritan’s Purse, which, along with a second missionary group, staffed a hospital on the outskirts of the city. The hospital was called ELWA, the acronym standing for Eternal Love Winning Africa. Like the staff at JFK, Brantly and Writebol and the other ELWA staff kept providing care throughout June and July while the epidemic raged on the streets of the capital. Brantly and Writebol were airlifted to Emory University Hospital’s Biosafety Level 4 unit, since Emory was equipped for such care owing to its proximity to the CDC headquarters and its laboratories in the Special Pathogens Branch. The news in the States was virtually nonstop from there on out.

  In terms of my acquaintances, the situation was worse than I knew. Borbor had tested positive, and Phil Ireland had become symptomatic as well. Phil believes he became infected by caring for Vincent, who by then had been taken to an ETU that had been set up on the margins of ELWA’s large campus. He was critically ill, though how ill no one could say, as the ELWA ETU was deluged with cases by that point. There was no easy way to get an update from the inside.

  Four days before the AP story broke on July 27, Phil knew it was his turn. “I was having headaches that I had never experienced before, so bad that it felt like flashes of lightning,” Phil said. He was in the outpatient clinic at JFK, where he used an oximeter to check his pulse. “I was running 118. I’ve had malaria a thousand times and it had never done this. I checked my temperature and it was 38.1, and I thought, This is Ebola. So I went to the pharmacy, bought paracetamol, antimalarials, and ciprofloxacin. I went home and told everyone, ‘I’m isolating myself in this room. Nobody come to me. Just stay away.’ The next morning, I felt a little better. I drove myself to work, but I was feeling weak, so I went to the hospital kitchen to get a bun and some tea.”

  Despite the hope that some nutrition would revive him, the sight of food and drink proved too much for Phil. His abhorrence of food and especially drink reminded him of the characteristic presentation of a different disease that he had seen at JFK, rabies, but he knew he wasn’t suffering from rabies. He got into his truck and drove straight to ELWA. Amazingly, they turned him away, saying that they knew he had been careful and tried to reassure him that he was just anxious. Shocked, he returned home.

  Phil was too weak to return to work and would need to remain in his house, so he sent his wife and children out to stay with other family members. The thinning ranks of his colleagues from JFK, as well as physicians from the Ministry of Health, continued to check in on him. Several days later, when his symptoms had worsened, the ministry sent an ambulance to his house to take him back, dazed and confused by then, to the ELWA ETU for testing. At the entrance to the ETU, an argument ensued between the drivers and the staff as to who would assist him out of the ambulance. The unprotected drivers wanted no part of this, but the ETU staff insisted that until he got out of the ambulance, he was their responsibility. “I came to a little bit, and heard the argument going on, and whatever strength I had, I went to the ambulance door, kicked it open, and two guys in PPE came over and took me straight into the ETU,” he said. After the test would return positive, he was given a cot. He would turn out to be only a few feet away from Vincent, who did not have much longer to live.

  *

  Until I learned that Borbor was infected, the Ebola outbreak had remained mostly an abstraction. Although I had been on Monrovia’s streets and knew something of the place, the news of the ever-increasing bedlam still seemed far off. But when a phone call came from Trish McQuilkin and the news about Borbor was conveyed to me, a switch flipped, and I realized it was time to find my way over there. I knew this man, and although I can’t claim to have known him well, I understood enough to know how much a country like Liberia needed a man of Abraham Borbor’s stature. He wasn’t just another doctor who happened to be working in Liberia; he practically was internal medicine in Liberia. Because the Civil War hit the pause button on an entire generation of physicians (or health-care workers of any kind, for that matter), those few who were still standing by the tail end of their careers were the only ones left to train a new generation of physicians. Dr. Borbor was very nearly the sole Liberian internist who hadn’t fled but had seen it through and was now around to help Liberian medicine get back on its feet.

  Think about it this way: If I got run over by a car in the United States, it would be a sad moment for my family and my friends, but in terms of my impact on the medical community in central Massachusetts where I work, life would go on in much the same way as it did the day before. There are something like twenty-five infectious disease doctors in Worcester alone, to say nothing of hundreds of other internists. In terms of the impact on patient care, my passing would hardly register. But if Borbor were to die from Ebola, Liberian medicine would suffer an impact that couldn’t be measured. He was irreplaceable in a country that was ill suited to lose any help, but especially the type that mentored a fledgling class of young doctors learning to find their way in a country in full reboot.

  I had more on my mind than Borbor, however. I had barely gotten to know Liberia—the sum total of my knowledge was based on my brief visit, reading a few books about the country and its history upon my return, and some solitary time spent ruminating on what I had seen. To go charging into what increasingly looked to be a highly unstable situation with one of the deadliest viruses on the loose, completely overwhelming the government’s capacity to respond, may seem like an exercise in folly. To do it to help people I hardly knew may seem like a death wish, but I could not shake a sense that I had a responsibility to be there. If you travel to a place like Monrovia, with its desperate poverty, and you are treated with such remarkable kindness and deference as I had been, it is hard not to feel a sense of obligation to these people, even those I hadn’t met and about whose lives I could only guess.

  Indeed, I had made it to Liberia because the institution where I worked, the University of Massachusetts, had fostered a relationship with the country since the end of the Civil War. In 2012, UMass had invited Liberia’s president, Ellen Johnson Sirleaf, to receive an honorary degree at our medical school commencement, an act that couldn’t have been a more public affirmation of our commi
tment to this country. The Web page of our Office of Global Health prominently featured a picture of our faculty standing in front of the main building of the University of Liberia. As an institution, we had proclaimed to the world our assurances that we were there to help them.

  Now, I had become part of that relationship and was bound by that commitment. My feeling was that, even if you have a brief experience like mine in Liberia, and those people suddenly find themselves in a major crisis, and you can help them, you must help them. It wasn’t noblesse oblige; it was keeping your word. If I failed to help when I could, in their hour of need, then what was my moral worth? Our good name as an institution and my good name as a doctor—my good name as a person—would mean nothing at all if I sat on the sidelines.

  And this was no crisis of political instability typical for the region—it was a health-care crisis, and I was a doctor who could make a tangible contribution at the ground level. Trish and some other members of the Liberia group at UMass were making their difference by getting much-needed supplies to JFK and organizing the providers in the United States; I needed to make my difference by getting myself to an ETU and doing what I do for a living, which is take care of patients with infections. Once I saw that my new friends were being overrun by this pestilence, I had decided on doing everything I could to return to Liberia, come what may.

  About the time I was flipping my mental switch into “go” mode, a family physician named Rick Sacra, who by chance also was on the faculty at UMass, had already gotten on a plane to work as a doctor at ELWA—not in an ETU, mind you, but mainly to deliver babies, given how starved the entire medical system was for competent medical help as Liberia’s already tenuous health-care structure imploded. Rick would pay for that decision by becoming infected in short order. But Rick was deeply invested in Liberia, having worked at ELWA off and on for more than two decades. He had friends, colleagues, and patients whom he knew at an intimate level. However dicey a proposition it was to head into Liberia in the summer of 2014 to perform medical work without proper Ebola training and protective gear, for a man like Rick Sacra, there were clearly other matters that factored into the equation based on his long-standing relationship with the place, to say nothing of his permanent relationship with Jesus Christ. By contrast, I had merely been a guest on a quick flyby to a country I was only beginning to understand. I wasn’t about to take that kind of risk, but I was determined to assist in what would surely be a massive international aid effort.