Yet some of the newly confirmed patients looked at that short distance, especially the one-meter zone that divided the two areas, as a chasm into which their bodies and souls would fall and never be seen or heard from again. It took some gentle encouragement to have these patients assent to the move.
And this day, with these eight patients, more than a little encouragement was needed. The patients spanned a wide age range. A woman in her sixties, wobbly on her feet, who needed special help walking over—that meant one person would be unable to assist further after accompanying her to the other side. A few of the patients were adults who were able to tend to themselves as we organized the caravan. One or two were in their late teens, and they were scared. We held their hands and stroked their foreheads and assured them that nothing was different on the confirmed side. With great reluctance, they gathered their belongings.
And then there was Josephine. She was six.
That was grim news, but what was worse was that her mother’s test had returned as negative. There is a unique cruelty in separating a mother from her child, especially when the mother has been handed a new lease on life while being forced to watch her daughter be carried away to the confirmed ward, helpless to hold fast to her as the undertow of molecular biology pulled them further and further apart.
I knew we were going to need to be exquisitely sensitive to the fears of this child. After we had organized our game plan upon entering, I walked over to the boundary and got the attention of Siatta, who had by then recovered and had become something like a den mother of the confirmed ward. I asked her to gather the healthy women so that they could come out and receive Josephine with open arms.
My goal was not only to have Josephine feel assured that there would be people to look out for her but also to calm her mother, who would soon be discharged to her home and leave her child behind to heaven only knew what fate. As I explained my plan to Siatta, I could see the look of understanding come over her face. Josephine was sitting on her mother’s lap only a few paces from me, and so I tried to convey this plan without explicitly stating my reasons for organizing a welcoming committee. After a few clarifications that were required to overcome the difficulties of understanding my American accent, and doing it through the muffling quality of the mask, Siatta stared at me for a moment. I couldn’t believe my good fortune that without my having to explain my intentions, despite all the barriers to communication both physical and cultural, I was, if not perfectly understood, then at least understood well enough, on something this sensitive at a critically important moment.
By the time that I had spoken with Siatta, the staff had begun to escort the first wave of patients to the boundary. We made the decision to move in two successive groups, picking the most physically able for the first pass since they could walk themselves into the confirmed ward without further assistance, while three of us that remained would escort the weaker few, including Josephine, carrying their belongings. I turned and slowly came over to Josephine and her mother to break the news to them, as neither Josephine nor her mother understood what was to happen, and put in motion what was probably going to be the hardest thing I would ever do in the ETU.
As I walked over I reviewed all of the lessons I have ever taught my students about how to make a connection with patients. Make your patients feel as comfortable as possible, I tell them. Think about every movement you make in terms of sending nonverbal signals. Speak to them at eye level, getting down on your knees if you have to. Hold their hands. Speak gently and slowly. For Josephine, to say nothing of her mother, I was going to need to succeed at every single gesture.
I crouched down and held on to the arm of the chair for balance, and immediately I could see Josephine recoil into her mother’s arms as she moved away from me. Her eyes stared right into mine and I could tell that she thought she was looking at a monster, a faceless creature in yellow whose eyes were the only part visible, and barely so, hidden behind the mist of the goggles. Then I shifted my gaze to her mother, where I was met with much the same look. “Josephine, I’m Doctor Steve,” I said. I slowly explained to both of them what had taken place and that we would need to take Josephine over to the confirmed ward. It was then that I gestured to Siatta, who saw what was happening and, as if she had read my mind, was standing at the boundary with one arm outstretched, ready for Josephine’s hand if she could just get up and walk the few meters to greet her.
Josephine, however, was having none of it. Her eyes conveyed undiluted terror. I tried to put my hand on her arm and she pulled away. I did the same for her mother, and although she did not react with the same level of fear, it was impossible to miss the dread on her face. By now the others had already been escorted to the confirmed ward, and I wanted to be over there to make sure that everyone had been situated and settled. Siatta stood there and spoke to both of them, telling them that there would be several women to take good care of her. A few of the other women had come out to join Siatta, and her lone voice grew to a small chorus. As I saw the scene unfold, I thought that we couldn’t have orchestrated this move any better.
But Josephine and her mother had other notions. After perhaps ten minutes of encouragement, I finally managed to coax Josephine, and along with her the deadly virus to which her mother was being exposed by the second, to take my hand and make that short walk to the confirmed side. During this time, I mulled over the precise nature of her fear. It would be arrogance in the extreme to think I could articulate her viewpoint, but it did not stop me from wondering. Maybe she wasn’t scared in some nonspecific and wordless way of going over to the “sicker” part of the hospital as other patients might have viewed such a sentence, but perhaps she feared the boundary as if it were the event horizon, a line that once crossed would never allow her to return and reunite with her mother. I sensed that her mother, who was nearly equally reluctant to let go of her child, harbored a similar notion, that this would be the last she would see of her baby girl.
And they were right. About four days later Josephine died, terrified and alone despite all of the care that Siatta, the other patients, and the rest of us offered. Her mother never did have the opportunity to say good-bye or even see her child at the interment. They had correctly surmised at the moment when I had separated them that separation would be irrevocable.
Josephine was correct: I was a monster—her own personal monster—at the moment I escorted her on what would be her final journey. And I had patted myself on the back at the time, thinking myself so swell for being such a sensitive and caring physician, even as I facilitated a horror from which Josephine’s mother will never fully recover. My smugness gnawed at me for weeks after she died, then months. It gnaws at me still.
Other moments were painful not because of my own inadequacies but because of the sheer misery the place was capable of producing.
There was a two-or three-day span when a crew from 60 Minutes came to do a story. Like the other television crews, they didn’t have the opportunity to absorb the ETU at its deepest levels. It was get in, do some interviews, set up some facility shots showing people moving about doing their work, and get out. The reporter was a woman named Lara Logan. I knew nothing of her at the time, only to learn a few days after she left that she had done extensive reporting on the volatile Egyptian protests at Tahrir Square, which had gotten out of control, leading to her being brutally assaulted and raped. It would have been understandable if she took a desk job for the rest of her career, but she had come with her crew to Liberia to report on the outbreak, which when I heard about her past had dumbfounded me. And she had been incredibly kind, bringing some chocolates for the staff as a gesture of thanks. But television was television, and no matter what experiences she and her crew had lived through and reported on, I was skeptical they’d relate a story that went beyond the superficial.1
Just as the 60 Minutes team had arrived and was setting up its cameras, we admitted a woman whose husband was already in the confirmed ward, having come the week before.
By the time she spent her first night he was in the crisis phase. The following afternoon he died, and Fredericka Feuchte, the German expat in charge of the psychosocial team, had suited up to relay the news to the wife, who was still waiting to hear whether she was infected.
One of the qualities that had always surprised me about when we delivered these messages was the almost emotionally flat manner in which the news was accepted. There was very little gnashing of teeth and rending of garments. Whether this was the cultural norm or distrust of showing intense emotions to outsiders or the extraordinary circumstances of the outbreak, I still do not know. But on the occasions when we did have to relay news like this, the silence could be deafening.
This woman, however, did not take Fredericka’s condolences quietly. While I was sitting in the staff quarters tending to some paperwork, a sharp scream pierced the ETU, and everyone instantly stopped and looked up from whatever they were doing. Then the scream continued. And continued. She wailed for nearly fifteen minutes, during which time the 60 Minutes cameraman panned the compound while the noise halted virtually every activity.
That moment would feature prominently when the story aired weeks later. Yet during my time there, it was a singular moment. I thought that it would be good for viewers to be shown such footage back in the States, since listening to this woman’s agony certainly humanized the Ebola story, forcing viewers to think about an actual individual’s suffering instead of scary space suits and bleeding. But I also couldn’t help but feel that these particular journalists were in part given a gift that they hadn’t quite earned, especially when their brief tours of our facility were stacked against the work that Sheri, Daniel, and Ben had been doing over several weeks, gritting it out on a daily basis as they churned out lengthy and complex stories for The New York Times, spending hours on end talking to dozens of people on the staff, developing a deep sense of what was going on beyond the chlorine, the Tychem, and the morgue.
*
Death was part of the daily routine, but some deaths affected us more than others. Each of us grew attached to certain patients as we would have done in any hospital, but one loss hit us all with equal force. We had cared for George Beyan, a quiet man in his mid-thirties who had acquired the virus by tending to a sick friend. George had made the slow recovery after emerging from the abyss in mid-October and waited around for the virus to clear, hardly making a noise as he sat outside listening to Radio Gbarnga in the hot sun.
Daniel Berehulak had featured George in a photo essay in the Times that ran at the end of October. He had created an ersatz studio in the lone unused office of the compound taking portraits of the patients and the staff. He used sheets as a white background and the portraits shared a highly formal quality; they reminded me of the work of Robert Mapplethorpe. Say what you will about the potential for cross-cultural misunderstandings, as well as the risks of projecting oneself onto another’s inner mental state by looking at their facial expressions, but there is simply no mistaking the absolute, unadulterated joyous state of George Beyan in Daniel’s portrait. “I got up in the morning, I prayed. In the evening, I prayed. At dinner, I prayed. Prayed to get well,” the caption quotes him as saying. “Yesterday, they said, ‘You, you’re free.’ I danced, I jumped.” The picture attests to the veracity of his statement.
George got the news of his impending freedom from the Navy lab one late afternoon. As much as patients understandably wanted to get the hell out of such confinement upon hearing the news, almost nobody left the day they received it. Coordinating the discharge paperwork and setting up a plan for them to return by alerting family of their departure all took time. Moreover, this was the same time that some of the staff were busying themselves with the patients in the suspect ward whose tests returned as negative, as they were prioritized to leave the high-risk area as soon as possible to avoid further risk of exposure. Others were working on taking the patients whose tests returned positive to the confirmed ward. Patients like George, who had lingered for weeks, were not going to suffer any ill effects from hanging out in the ETU another night. For all their understandable jubilation, in terms of the tasks to be performed at that hour, they were not the top priority.
George savored his triumph over death, dancing and jumping, but bad news was about to arrive in the form of his wife and two sons, one aged five, the other a toddler. They all had some form of symptoms. That night he stood at the boundary talking to his wife across the one-meter divide that separated the suspect from the confirmed ward, the boys in tow. The following day would be a waiting game for the blood tests.
That next morning we sent George through the decontamination shower as he returned to freedom after nearly three weeks in isolation. I assumed he would have regarded this as a pyrrhic victory since his entire family now awaited word as to whether they would have to endure a similar experience, but I was surprised by the serenity of his appearance as he sat outside the main staff quarters. There is always the chance that given the cultural barriers I was misinterpreting his reaction, but I had seen anxiety, dread, and fear on enough Liberian faces to sense that this was different. Having lived through what he had just lived through, however, it was certainly not for me to judge him. Daniel took him into his studio, and his reaction was captured for posterity.
The question arose as to whether he should return home in the morning or spend the afternoon waiting for his family’s test results. George chose to wait. He was going home with his family, you could almost hear him think. Only fate had a crueler plan in store for him. We again got the call from the Navy guys in the late afternoon. His wife and younger son tested negative, but his elder son, Williams, was positive, and shortly we would need to escort him over to the confirmed side. He was obviously ill and was too young to fend for himself. He was going to need help or he would surely die. The women on the confirmed side could not be expected to provide essentially twenty-four-hour nursing support to this child, busy as they were with other children, to say nothing of their own illnesses. And we would not allow his mother to take him to the confirmed side, even if she wanted to.
That left only one obvious choice: We would have to ask George to return to the confirmed ward to nurse Williams. We knew that this was asking an enormous amount of him. Yet we also knew that this would not endanger him and that it was Williams’s best chance for survival. After a brief team conference where we all agreed this was the best course to pursue, I walked over to hand George the news and our singular and extremely unpleasant request.
Although he did not explicitly say so when I first explained the situation, I had the distinct impression that he thought I was utterly out of my mind. He gave a little shake of his head at first and said quietly that he wasn’t going back in there. I told him his wife couldn’t care for Williams and that I couldn’t ask anyone in the confirmed ward—people whom he knew well by this point—to take on such a responsibility. And Williams needed help. After a brief exchange I realized that he was more than simply dreading returning inside, as if the posttraumatic stress of moving back into the nightmarish prison from which he was so recently set free was only the beginning of his vexations. I saw that same fear in his eyes that I saw every day with patients in the suspect ward.
But what was he concerned about? He was, after all, cured, possessing Ebola-specific antibodies and lymphocytes, which now made him immune to a repeat infection. But … did he know that? As I spoke with him, I sat there puzzling this over. Surely he knew at some intuitive level that he was not at risk of getting sick again while he spent day after day convalescing, although maybe he had thought a reset button had been pressed when he emerged from the decontamination shower. But how to explain a concept like acquired immunity to someone who probably had no formal education beyond grade school?
“Look, George,” I said. “You’re like Superman.” It crossed my mind that he might not be familiar with Superman, but I plowed ahead. “You have … special blood now. The virus cannot hurt you. You can go back in th
ere and you won’t be sick. And your son needs you right now.” Some more give-and-take took place, and along with heaping spoonfuls of reassurance, we convinced him to perform the nearly unthinkable act of walking back into the high-risk area and receiving his sick son from his uninfected wife.
In the coming days everyone on the staff, Liberian and expat, followed Williams’s progress carefully. Nobody said anything, but it was easy to see when we discussed everyone’s status as we ran the boards that we were monitoring Williams with heightened vigilance and had attached special emotional importance to his prospects for survival. We also carefully observed Williams because he had taken a less typical clinical course. Most patients were on a clear trajectory: either up, or down. We could usually tell within about a twenty-four-hour window whether they were getting worse and would likely die, or had weathered the storm and would likely survive.
However, Williams behaved differently: He plateaued, then bounced around. His wet symptoms were not as profound as they were in so many other patients. We would see him on morning rounds inside the ward, lying in bed listless, unable even to sit up and take fluids while his fever raged out of control, the heat draining his small body of the water and electrolytes that would be critical to his survival. Then only hours later George would be seen escorting him by the hand outside to sit on the plastic chairs while he idly munched on some cookies, and the afternoon rounds would include chattering among the staff about how he had turned the corner.
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