Inferno

by Steven Hatch, M. D.

  But if I had to describe the experience of PPE in one word, it would simply be sweat. The sweat began to flow—and I do mean flow, as opposed to bead—even before I had finished donning every item, and it didn’t stop until I emerged from the decontamination chamber. I sweat so much that I could see it drip above the edge of the gloves and pool in between each layer.

  It wasn’t just that I was soaked in sweat, as if I had gone for a run on a hot and humid day. I pooled in sweat. The sweat from my head and face would come into the mask, which became so saturated that I would suck in a fair amount of sweat with each breath. My socks didn’t just become wet; I could feel the sweat accumulate over the course of my rounds so that the liquid sloshed back and forth in my boots, usually about three-quarters to the top. When I emerged from decontamination, I would sit down, remove the boots, and just pour them out as if they were pitchers.

  With all of that sweat went a lot of electrolytes, and the first few days I didn’t properly appreciate the need to hydrate before a spin through the high-risk area. The staff, like the patients, tried to stay hydrated by means of drinking oral rehydration solution. It was only a small improvement over seawater. On my second day, I spent just under two hours in PPE and I hadn’t had any oral rehydration solution before going in. I emerged dazed, and it took me nearly as long as the time that I spent inside until my body began to feel normal again.

  *

  A major priority for me was to make as many inroads as possible with the national staff. I used whatever gimmicks I could to get to know the Liberians on a personal level. It was not always easy. At first, I relied on some of the goofier tricks in my arsenal, like showing a tendency to pantomime my basketball jump shot as I walked between buildings. That proved a big hit in the opening days, and some of the Liberians would want to engage in a momentary one-on-one in the midst of the various tasks that needed to be done. It lightened the mood but didn’t prove especially useful to meeting people. I was going to need to overcome a fair amount of my own social anxiety and start talking to people if I was going to integrate even remotely with the locals.

  Many of the national staff lived in nearby Gbarnga, a city of thirty thousand, and a bus ferried the IMC workers living in and around the city. It was a risky decision in September 2014 to apply for a job at the ETU. I became friendly with one of the members of the psychosocial support staff, a woman named Garmai Cyrus. She was tall and had her hair braided close to her head, with tiny shells laced in between the various braids, which made her hard to miss in a crowd. Garmai said that many of her neighbors had stopped talking to her once she got the position, and she was avoided on the street. She said this was not exceptional treatment. Everyone from the national staff working at the ETU had to make a calculation about their financial needs from a job that paid very well versus whether they would be considered a member in good standing in their communities ever again.

  I also started to talk to Sam Siakor, one of the senior people working in the water, sanitation, and hygiene, or WASH, group. Take away the scrubs that Sam changed into when he came to work each day, and you could envision him as a rural African prince, for he stood taller than me, easily six three and perhaps taller, with a bald and noble crown, dark brown skin, dark eyes to match, and a magnificent smile. Sam was about thirty years old, which meant that he must have had to endure some dicey situations while growing up during the Civil War. I quickly came to discover how much I admired and liked him. He had grown up in Bong County and attended college, no small accomplishment in this environment. Just before the outbreak started he was working as a teacher in a local high school. His was truly a Liberian success story—which, for someone his age, was a rarity given Liberia’s recent history.

  I eagerly soaked up what I could about his life and his culture. Sam was a devoted member of his local church, and eventually our talk turned to matters of faith. For me, faith is a tricky subject when I speak to those who possess it, since I have none myself. I do not, however, take any pleasure in debating the matter, finding the argumentative tenor in the atheism of a Hitchens or a Dawkins to be off-putting. Instead of a bunch of theological discussions, we settled on a common language that gave both of us pleasure, for we both reveled in song. Sam had surreptitiously photocopied one of the pieces from his hymnal that he carried with him to work each day. The photocopy machine, a piece of equipment that didn’t find the damp of the jungle air to its liking, barely functioned. Despite this, he managed to eke out two perfect images from his book one afternoon: A great miracle happened there. I went home at night with my assignment to learn it within two days.

  When I first set about to learn the song in my flat that night, I had been so wrapped up in the idea of using the music as an opportunity to make a connection that I hadn’t really considered its meaning. Sam, however, was wryly trying to teach me a particular lesson about his faith and perhaps how he thought the divine presence manifested itself in the Blue World.

  You are the Lord, that healéd me,

  You are the Lord, my healer,

  You send your word, and you heal my disease,

  You are the Lord, my healer.

  I am the Lord, that healéd thee,

  I am the Lord, your healer,

  I send my word, and I heal your disease

  I am the Lord, your healer.

  During those first few days, I got to know many of the patients who had been admitted prior to my arrival, but there were of course still patients coming in, and these I met from the beginning of their time at the ETU. One of the first of these new-admit patients was Pastor John from Margibi County. Margibi County lies to the east of Monrovia and is south of Bong, a drive of several hours to the ETU. Our ambulance service had been dispatched to retrieve him. One of his congregants had been very sick and died, and he had ministered to the person, gathering the family in prayer. I don’t think that we knew for certain whether that person had ever been tested for Ebola, since many patients who became ill and died at that time couldn’t or didn’t want to get to an ETU. Regardless, now, several days later, it was his turn. He was lying in bed in his suspect-ward room, awaiting the results of his blood test, sweating from fever nearly as much as I was from PPE.

  “Pastor John,” I said to him as I walked in, “I’m Doctor Steven. I’m going to be one of the doctors taking care of you while you’re here, okay?” That was okay with Pastor John, who, after politely answering a battery of questions about when his illness started and what his specific symptoms were, took over the encounter and told me that it was time to pray. “You believe in Jesus, yes?” he asked me.

  It seemed not the right time for me to get into an involved discussion about being both Jewish and mostly atheist, so I glossed over the question and suggested that we indeed pray. I was already on the pads of my feet in a catcher’s stance, and I knelt.

  “Good Lord, we ask that you protect us,” he started. “We ask that you guide Doctor Steven and give him the knowledge and wisdom to help us fight this curse of Ebola. Protect him while he does your work here. We ask that you guide the nurses and the other workers that are here today.” And on he went, with a great deal of energy, gaining strength as he warmed to his subject. I was moved, not only because of the gesture, but by the eloquence with which he prayed. It was clear that he excelled at his calling. I also couldn’t believe that this man, who was almost certainly infected with Ebola, was praying for me and my soul.

  I contemplated all of this for some time, as the prayer continued beyond five minutes while I sat there dripping sweat all over his bed. Realizing I had more than a dozen other patients to see and that every second in PPE was a race against the clock, I tried as gently as possible to encourage him to reach a conclusion (Um, Pastor John? Just so that you’re aware, I should be moving along…), taking a moment of high drama and watching it quickly morph into screwball comedy.

  Late in the afternoon the day after Pastor John had prayed at length for me, the Ebola test returned as positive. I acco
mpanied him from the suspect ward to the confirmed ward, finding him a room toward the back. He walked slowly and gingerly. I showed him his bed, and he said he wanted to pray for me again. Very pleased with this, I knelt. This prayer lasted no more than a minute, and he was noticeably weaker, although beyond his weakness and fever, there was nothing about his condition that would have made you realize he was infected with Ebola. I finished up my rounds and wished him a good night. When I returned the next day, his weakness had accelerated. He barely noticed me when I came to see him, and I had to ask him to pray for me. The prayer lasted only a few moments. The following day, there was no prayer.

  He was among the first patients I watched this virus claim for its own. That was only the beginning, however.

  4

  INFERNO

  Traditionally, the spirit world is made manifest in Liberia by various means including the use of carved wooden masks, a notable feature of cultural life in many Liberian rural communities. The use for religious purposes of masks, behind which a person becomes unrecognizable and in which a spirit is deemed to take visible form, says much about traditional Liberian attitudes concerning both the spirit world and the hidden nature of reality.

  —Stephen Ellis, The Mask of Anarchy

  Back in the United States, the Ebola scare moved to an entirely new level. The man I had seen on the news as I was leaving the States was identified as Thomas Eric Duncan. He was a Liberian national who had returned to Dallas from Liberia on September 20, at that time feeling healthy. On September 24, however, he became ill with symptoms consistent with Ebola and decided to go to the ED of Dallas Presbyterian Hospital the following day.

  There, a series of questions should have identified him as a person at risk for Ebola so that appropriate isolation precautions should take place. There is a sizable African expat population in Dallas, so the presence of a man with a Liberian accent and a fever should have been a major trigger to more than just the triage nurse, but for whatever reasons, the alarm was not raised. This means that Duncan had sat in the waiting room for about ninety minutes before being ushered into the treatment area. According to an article appearing in the October 25 edition of the Dallas Morning News, Duncan presented to the ED at 10:37 p.m. on September 25, was seen by the triage nurse at 11:36 p.m., and brought into a treatment room at 12:05 a.m. That’s actually pretty fast for that time of night.

  For those who have never been to an ED in an urban area on a Friday night, there are usually a lot of people sitting around or milling about waiting to be seen, so surely Duncan must have exposed a large number of people by doing nothing other than sitting there. He then went for evaluation and was seen by the ER doctor, the nurse, and other staff. He was referred for a CT, which meant that he exposed the people who transferred him onto a stretcher and the radiology techs working the shift that night. He got discharged almost exactly five hours after he had arrived with a working diagnosis of sinusitis and was given a prescription for antibiotics.

  I don’t like second-guessing physicians or nurses through the retrospectoscope unless I know all the details of a case and there is a clear and unambiguous error that can be identified. I’ve seen too many cases where something appears obviously wrong in the rearview mirror until you speak with the provider at the time, and when you hear their logic, you discover how reasonable their actions really were. We know now that Duncan had Ebola, but how many cases of vague abdominal pain does an ER doc typically see over the course of the week? Or sinusitis? The answer is a whole lot more than cases of Ebola.

  That said, the only issue to which I confess some puzzlement is how Duncan evaded proper identification as someone at risk that first visit. Liberians have an obvious accent, and Presby has a patient base that includes a fair number of West Africans. Surely not only the doctors but a number of the staff must have been on the alert for West Africans presenting with fever—the whole country was increasingly anxious about this—and yet his presentation didn’t trigger any follow-up questions by anyone caring for him. I worked in a hospital in the Chinatown neighborhood in Boston during my residency in April 2003 when SARS, a virus even more scary than Ebola, was being reported not just in the Far East but among Chinese nationals in Toronto. You can be assured that everyone working in the ED at New England Medical Center at that time was on the lookout for any person recently returned from China with acute respiratory symptoms, which then was a not insignificant number of people.

  At any rate, Duncan returned to his home, a small apartment with one bathroom that he shared with his partner and their five children. There he continued to deteriorate for another two days until he called 911 and the EMTs arrived, transporting him back to Presby and exposing themselves in the process. Finally, in the ED he was identified as being at risk for Ebola and was properly isolated.

  One would have hoped that after his appropriate identification and isolation as a possible Ebola patient, Duncan posed a much smaller threat to everyone and our list of exposures would stop there. Unfortunately, almost every aspect of his care over the next week was botched. The initial protective gear worn by the health-care workers was inadequate, leaving critical parts of their bodies exposed. Moreover, the decontamination process, which in many ways is even more important than the protective gear itself, was neither well understood nor standardized.

  As his symptoms worsened and he became progressively more infectious, he was moved deeper inside the hospital to a different unit. The transfer itself increased the chance of depositing virus in fluids on floors, walls, and anything else that came within contact of him. Instead of assigning a small number of health-care personnel to his care and thus minimizing the number of further exposures, the administration tried to distribute the risk among a bigger pool, and he was seen by a rotating cast of doctors and nurses as he became more ill. It was about as close to maximizing the chances that the contagion would spread to as many people as one could envision. The entire Dallas metropolitan area would be on edge for weeks.

  Nobody knew it at the time, but it would later be revealed that Duncan had escorted his neighbor’s daughter into a taxi for transfer to an ETU in Monrovia and accompanied her during the taxi ride, obviously at close quarters for a prolonged trip, on September 15. She would die in the ETU.

  Duncan died on October 8, at the beginning of my second week of work in Bong County.

  *

  In Monrovia, Phil Ireland began the slow process of convalescing as he tried to resume his life. Though he was not yet ready to return to work, his strength began to increase. It was not, however, the end of his troubles. “After I got sick and I went back home, I saw some of the guys where I used to live,” he said. “They said to me, ‘We know you work for the government, we know what you guys planned, you weren’t sick.’ Some of my relatives said this.” Even by that point in Liberia, some people were still inclined to view Ebola as an outright hoax.

  To counter this, the Liberian government began a campaign, elegant in its simplicity. “Ebola Is Real” was the slogan. A huge mural painted onto a wall on Tubman Boulevard proclaimed this. It was situated only a few blocks from President Sirleaf’s residence. Adjacent to the slogan were rudimentary life-size paintings of people exhibiting the most common manifestations of the disease: a child squatting with diarrhea exiting his body, a person vomiting, a face showing the sclera—the whites of one’s eyes—a pinkish red. And so on.

  Yet the fact that the Ministry of Health needed to launch an “Ebola Is Real” campaign served only to underscore many people’s skepticism that a biological disaster was actually in motion. The level of trust in official government pronouncements was dismal, created in part by a system in which the powerful and wealthy lived in gated compounds and drove around in SUVs expensive even by American standards, while the vast majority of Liberians toiled for appallingly low wages, which forced them to live in domiciles that only rarely possessed plumbing or electricity. The lack of plumbing, in particular, was critically important, for the inabil
ity to wash one’s hands meant that Ebola could spread more easily, as the uninfected would touch the infected yet have no easy manner by which they could literally wash the virus away.

  The lives of so many Monrovians were, from a structural standpoint, almost indistinguishable from that of a Londoner in 1750, except for the cell phones. And they didn’t have to travel to Europe or North America to see the developed world and understand that they were not a part of it, for the developed world drove by them on Tubman Boulevard as they made their way on foot or on the back of a motorcycle from home to work or the market. At a population level, the kind of middle-class life that someone like Phil was living was almost nonexistent, providing no societal ballast in a crisis like this.

  That chasm between wealthy few and impoverished many fed true cynicism, so even perfectly sensible advice given out by the Ministry of Health could produce the entirely unintended opposite effect. And there were other, older frames of reference to make sense of the events taking place in Monrovia. Tribal animistic beliefs were still alive and well in West Africa. They did not vie with Christianity and Islam for primacy as a coherent view of the world, but rather complemented those religions. It wasn’t at all a contradiction for a Liberian to go to church and praise Jesus Christ on Wednesday and on the following day proclaim that evil ancestral spirits had infested their house because a jealous person had cast a spell on them. This way of understanding natural phenomena was seen by many as perfectly legitimate. When ETUs started to spring up around the city with their rigid boundaries, strange rules of engagement, and faceless PPE, tens of thousands of frightened Monrovians reacted in bewilderment, without any frame of reference to make sense of these events.