The plane arrived in Atlanta, and a small group of the early attendees waited at an assigned location to be picked up and taken to Fort McClellan in Anniston, Alabama, for the four-day course. A half dozen of us were there milling about, and we would form the first cohort to make the ninety-mile drive west from Atlanta to wait for the people coming in on later flights. As we stood around, I recognized the voice of a woman talking on her cell phone but didn’t know why I would know someone here. I then realized that I had listened to this woman, whose name was Emily Veltus, in an interview on NPR only a few days before about her work with MSF in Sierra Leone. She must have practically gotten off the plane from Africa and come straight here. Some of the course leaders, I would later learn, did exactly that.
Eventually I started a conversation with a woman in uniform. Initially I took her for being in the military, as uniforms equal military to my civilian eyes, but she was a lieutenant commander in the U.S. Public Health Service whose name was Elizabeth Lybarger.5 The USPHS was a group that President Obama was preparing to deploy to Liberia in an effort to build a state-of-the-art ETU to care for the health-care workers at such high risk, not only those working in existing ETUs but those like Zoeban Kparteh, who were continuing to see patients at hospitals like JFK without any serious protective gear. Elizabeth was in charge of making sure her USPHS troops were trained, and as such she was attending this CDC pilot course as something of a reconnaissance mission. As we started out making small talk, I observed two salient features about her: First, she felt a deep responsibility for those working for her, and second, she swore like a sailor. Which is to say I liked her tremendously right from the start.
We rapped the entire way from the airport to Alabama swapping our life stories. In the mid-1990s we had both read The Hot Zone, and we both had developed a passion for the virus as a consequence. Unlike me, however, whose career ambitions to do work in Ebola or Marburg got sidetracked by family priorities, Elizabeth really did go into this line of work. Her life had become, in some sense, exactly like the kind of people that Preston wrote about. She had worked at USAMRIID—the United States Army Medical Research Institute of Infectious Diseases, a place that filovirus aficionados regard as a sort of mecca. She had worked at CDC as well, in both places working on Biosafety Level 4 agents. And now she was working for the U.S. Public Health Service facing potential deployment to a Hot Zone of unprecedented proportions, a fact that was creating some unpleasant scheduling conflicts with her upcoming wedding.
For the course, the CDC had commandeered a small corner of the vast army base at the southern tip of the Blue Ridge Mountains in eastern Alabama, sharing that part of the campus with a bunch of firefighters undergoing hazmat training, which was part of the base’s permanent educational activities. We were assigned dorm rooms that were Spartan but clean, and given time to relax while we waited for the rest of the participants to arrive. Elizabeth and I made our way to the mess hall and ran into some other uniformed personnel, this time actual military in the form of Lieutenant Colonel Tom Wilson and Major William Thoms of the U.S. Air Force, who were there to think through the logistics of flying infected soldiers back to the States if worst-case scenarios took place. “The grub here is pretty good,” one of them said, and after the initial sampling of down-home Alabama fare, with menu items like glazed ham and scalloped potatoes or country fried steak with gravy and green beans, I thought, Yes, but it’s missing eighty milligrams of Lipitor for dessert.
The next morning the class of “Camp Ebola,” about fifty people in all, was in one of the classrooms in a huge concrete office building about a mile and a half from the dorms. It must have been sixty degrees in the nondescript classroom. I ended up sitting in the back with the military people, who by that point had expanded to include Major Matthew Chambers of USAMRIID and Commander James Lawler of the Naval Medical Research Center in addition to Elizabeth and the USAF guys. One of these things is not like the others, my mind would sing to itself from time to time during the course, as my uniformed colleagues may not have been fully aware that they had something approaching a more well-behaved version of Abbie Hoffman sitting beside them.
The course was a Who’s Who of the international health scene. In addition to all the military folks, several of whom had been doing Biosafety Level 4 work for decades, were the aid organizations: MSF sent a nurse and a social worker, each with Hot Zone experience, to help guide the proceedings; about five members of Paul Farmer’s group Partners In Health were present; a person from Save the Children had come; there were people from various institutions such as Johns Hopkins and Emory; and of course there was a big CDC presence. The lectures were devoted to all topics Ebola: the history of the outbreaks; the dynamics of the current outbreak, which was literally changing by the day; the clinical presentation and course of the disease; the infection-control procedures necessary to contain the virus; and so on. Lectures were held in the icebox in the morning, with the practical exercises of learning to wear (don) and take off (doff) personal protective equipment in the afternoon. I thought that wearing PPE in Alabama in late September was going to be good training for the physical stress of working in Liberia, but it turned out we came during an unseasonably cool stretch, and during our three-day PPE practicum, the temperature hovered in the low seventies without a hint of humidity. I hardly broke a sweat during the exercises. That was about to change.
One evening a group gathered at the campus bar, where we shared the space with the firefighters turning in from their hazmat work, and sat on a porch listening to the workers who had just returned from the outbreak to hear their informal impressions of what would await us. Nahid Bhadelia, an infectious disease doctor from Boston University who had been working at an ETU in Kenema only weeks before and who had seen some of the worst of what this epidemic had to offer, made a comment that seemed both completely unsurprising and simultaneously shocking. “Guys, it’s not like you haven’t seen this stuff before. It’s just sepsis. They’ve got sepsis,” she said, referring to the physiologic process of the body’s severe reaction to bad infections. In saying that, she was trying to communicate that we had all seen sick patients; there wasn’t anything bone-jarringly weird about a health-care worker tending to the ill, so it was best to mentally recalibrate. But then came the counterpunch. “It’s not the sepsis,” she added. “It’s the volume of patients with sepsis that is the challenge. You’re going to see a lot of people die.”
And I thought back to that day at JFK when I witnessed seven young patients expire in one day.
*
The third day of the course, The New York Times ran a story that got everyone’s full attention during one of the morning breaks. “Ebola Cases Could Reach 1.4 Million Within Four Months, CDC Estimates” was the headline, and although the text of the article indicated a more nuanced reality—mainly, that the 1.4 million figure was a worst-case scenario—it was hard not to escape the notion that Liberia, along with its two neighbors, were on the fast track to total collapse.
I thought again about Womey, where Ebola had managed to kill even without direct infection; the terror that the virus had unleashed upon the countryside was causing the social fabric to rip, turning mild-mannered rice farmers and palm oil harvesters into cold-blooded machete-wielding murderers. Womey suggested that as the virus became harder to contain, the violence would expand, hampering the efforts that might stanch the bleeding, and in doing so make the virus harder to contain, in an escalating feedback loop. It could make other humanitarian aid organizations hesitate to join forces with MSF, IMC, IRC (the International Rescue Committee), and the few other groups that had established beachheads to help fight the outbreak. It looked grim.
During that break, everyone was discussing the Times piece. Nobody was really surprised, for we had all thought previous media reports about thousands of victims to be a gross underestimate. But it was a different matter entirely to see one’s worst fears posted on the front page of the Paper of Record. When we started t
he training, in more poetic moments I conceived of what was taking place in that cold little conference room in Alabama as something like being at the first wave of D-Day: a perilous action but also something at which the survivors would someday look back with a certain level of pride in their accomplishment. After I read the Times piece, I thought the more apt allusion could have been the Charge of the Light Brigade.
At dinner that evening, I had pulled aside Mary Jo Frawley, a nurse who had done stints with MSF in prior Ebola and Marburg outbreaks. I started to talk about the staff with whom I would be working: By mid-September many articles had highlighted just how risky treating Ebola patients had become for the nursing staff. I knew that IMC’s ETU would be much safer than the local clinics where many of these nurses had become infected, but I also knew that even if the national staff worked at an ETU with the proper equipment and procedures to ensure maximal protection, these people still had to return to cities and villages where the virus was running rampant and could just as easily be infected there. And although I would like to think of myself as being a progressive and egalitarian doctor when it comes to the subject of teamwork, I am still a touch old-fashioned when it comes to the notion that, as the physician, I was responsible for everyone’s life in that ETU. I thought of those nurses dying on my watch, and after three days of preparing for the end of the world, I sat there and held Mary’s hand and wept like a child, the tears flowing down my face and off my cheeks onto a plate of roast beef with gravy and mashed potatoes, which until about a month ago was, at least in the aggregate, much more likely to be deadly to me than Ebola.
The public display of raw and uncensored emotion no doubt must have caused some alarm to my colleagues walking by, who may have concluded that I was emotionally unfit for what was to come, but my frontal lobes have always functioned with just enough oomph to make me aware that my displays of emotional intensity can be jarring to people but not so much that I modulate my behavior unless it’s absolutely called for. And at that moment, I didn’t give a damn.
Later that night we went to the campus bar for pitchers and karaoke. After the third beer, I unwound by singing Gordon Lightfoot’s “Sundown” to mild amusement and playing a game in which Emily Veltus and one of the docs working for the CDC named Rupa Narra would toss popcorn into my mouth from ever greater lengths, and I would bark and clap my hands like a seal if I caught them. Later still, a group of about ten of us caught a taxi into town, or whatever constituted “town” in rural Alabama—which by my definition meant a cluster of buildings, of which one had a perfectly functional bar—and I added a few glasses of bourbon to the beer that had become part of my bloodstream. The next day I left Camp Ebola with enough of a headache to last the bus ride back to Atlanta but not so much that it was still there by the time I arrived in Columbus for a previously scheduled visit to my mother, as the training session had overlapped the first day of the Jewish New Year.
IMC had finally sent me a contract, making everything official. I was to be deployed soon. I began the laborious task of formalizing my temporary leave with UMass, asking colleagues to cover my panel of patients during my absence and letting go of my teaching responsibilities for at least the next few months. I was supposed to be in Columbus for about three days and then make my way from Columbus to Chicago to Brussels and then Monrovia, but a freak incident occurred at O’Hare airport the day of my departure, where a disturbed man tried to set fire to the air traffic control tower, shutting down O’Hare and therefore a huge number of the flights going through the Midwest.
It was a weekend day, so I made frantic calls to the on-call travel agent to try to find an alternate way out of the country, and came within minutes of a flight going to Philly and then Brussels, but too much time was required for someone at IMC to sign off on the plan. So I remained stranded in Columbus for an additional two days, since there were no longer daily flights going to Liberia, as most of the carriers had suspended their service to all three of the affected countries. I decided to stay at the airport hotel rather than return to my mother’s apartment in case I got a call for some crazy new plan that required my returning to the airport immediately, but nothing transpired, and two days later I found myself sitting in the terminal somewhere in the vicinity of 5:00 p.m. glancing at the television, flicking through e-mails on my phone.
Then I saw it.
The TV was tuned to CNN, and the headline ran across the bottom of the screen: “FIRST DIAGNOSED CASE OF EBOLA IN THE U.S.” I blinked a few times, and then picked up my phone and called my best friend. “Mark, you’re not gonna believe this,” I said to him, then relayed the news. “I’ll tell you this. America’s about to lose its mind.” I read the updates as they flashed, which was that a Liberian expat had become symptomatic at a hospital in Dallas and not much else was known. We chatted for a few minutes, but I had to board my plane to make my connection. As I got onto the plane, I thought that Liberia might be a better place in which to find oneself over the next few days. Then I thought about what was actually happening in Liberia, and I realized that was wishful thinking.
I got to Newark airport with about two hours to spare before catching the red-eye to London. The O’Hare connection to Brussels was full, so I was now going on an even more adventurous pathway through Newark to Heathrow to Casablanca and then finally to Monrovia. About an hour before boarding, they announced that first-class upgrades were available if anyone wanted to inquire at the desk. I am normally not given to even considering flying first class—as pleasant an experience as it is to fly in such manner, it has always seemed an extravagance that can’t be justified, and it rubs hard against that part of my personality that is adamantly socialist. But an upgrade on a red-eye heading into what was going to be a long few days meant that I might get some much-needed rest, which I definitely wasn’t going to do in the upright seating of coach. So I went to the desk to inquire and was cheerily told that upgrades were definitely available and would cost $575.
This seemed a ridiculous amount of money for a six-hour flight.
Ah, to hell with it, I thought. I probably wasn’t coming back anyway, so I might as well enjoy it. And I handed over my credit card.
3
THE BLUE WORLD
The current scientific understanding of Ebolaviruses constitutes pinpricks of light against a dark background.
—David Quammen, Ebola
The Royal Air Maroc Flight 559 from Casablanca landed in Monrovia at two-thirty in the morning. The Roberts airport is more than an hour outside the capital, its lone airstrip not far from the Atlantic Ocean, so that a passenger’s slightly unnerving point of view makes it seem as if a water landing is being attempted. For Americans, airstrip is probably a more helpful description. What one normally envisions when the term airport is used—long concourses, electronic signs indicating flights arriving and departing, so much artificial lighting that it seems perpetual daytime—is nowhere in evidence here. Roberts airport in its entirety consists of one low-slung concrete building about the size of a car dealer’s showroom, a small outpost of partial light gamely fighting back the dark African night. The signs are all either painted or are printed on poster board; there’s nothing electronic here.
Even in the middle of the night, emerging from the air-conditioned plane into the air of Liberia is like entering a sauna. The few of us who were on the plane, mainly a collection of health-care workers, news reporters, and a few Liberians, disembarked by descending a rickety aluminum portable staircase and walked about one hundred feet to the entrance of the building. I had been here before, but this time as we trudged along, there was definitely a sense of transition, of leaving one kind of world and emerging into an entirely new and different one. We were first guided to a series of plastic buckets containing a light bleach solution with a tap at the bottom and were told to wash our hands. Then we stood in line, for the building couldn’t be entered until one passed through a group of workers who stood by to check everyone’s temperatures, holding onto
infrared thermometers shaped like guns that were aimed at one’s temple. As we waited, contemplating our thermal regulation while we perspired in the heat and humidity, we were provided with fliers about Ebola, explaining the signs and symptoms and what to do should we become sick in Liberia. It was no longer a training exercise.
Despite the fact that the plane was mostly empty, it still took more than an hour to get through Immigration and Customs. Afterward, the ride from Roberts airport to the IMC guesthouse in Monrovia took another hour. I shared the ride, which ambled down a one-lane road in utter darkness, with Steve Whiteley, an emergency doctor from California. Steve had extensive experience in disaster situations and had done prior stints with MSF. He had been all over the world and done medicine in some very trying situations. As an infectious disease doctor with no specialty in disaster response, I could not help but find this intimidating. I began to worry about whether I would be seen as a legit player here, and I hadn’t even been on the ground long enough to see daylight.
We were greeted at the guesthouse by a Scotsman named Jimmy Steel, who told us that we would be meeting at just past seven for debriefing. I got to bed a little after five and awoke less than two hours later, bleary-eyed, and headed to the living room to meet.
The debriefing, as best I can recall, was a short meeting in which I was told, “Welcome to Liberia. Ready to go to work?” Shortly thereafter we drove to Monrovia’s heliport, where a chopper waited to take a group of us to Bong County, where we were going to perform various jobs at the Ebola Treatment Unit. Normally transport to Bong County is done by car: a five-hour, 120-mile ride over a tattered highway that was in the process of being reconstructed. But we were needed there with all haste, as we were scheduled to replace some of the staff who had been working weeks without a day off, and were set to depart on their R & R over the next day or two.1 Thus, we were booked for the helicopter ride to maximize overlap between the incoming and outgoing workers.
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