At a moment when world leaders were all running for political cover, Power was using her soapbox at the UN to urge the international community to step up its response, saying that they weren’t just losing the race to Ebola but were getting lapped. At the time, such frank pronouncements showed real courage—especially by someone working for an administration that had had some difficulties convincing a shockingly substantial portion of the electorate that the president was not a practicing Muslim and citizen of Kenya. I hardly knew Power’s name before the outbreak, but after watching a few interviews and reading a few articles on her work on forcing the UN to respond to the Ebola crisis, I had become a fan.
And now she was really putting her money where her mouth was: She had hopped a plane and flown right into the jaws of the beast, setting out on a breakneck four-day, three-country tour. From where I stood, one couldn’t learn much in that stretch of time, given that it almost takes a full day just to recover from the jet lag. Then again, just seeing the place improves one’s understanding by an order of magnitude, so perhaps her already keen insight became even better informed.
But the real value of having someone of Power’s caliber on the ground was the media entourage, and especially its television cameras, for which I felt skepticism or even outright hostility. The truth was that cameras would follow a person of this stature and would become part of the larger Ebola story, serving as a counterweight to the stories of fear and death. And for that, I was more than pleased that she had come.
The next day was back to work, but during the late morning lull a few people had checked their laptops to see how the Power visit was playing back home. Not everyone from the ETU had been pleased by her presence. She had come to the unit, that much was true. But she and her staff had made the decision not to enter the work area proper—I don’t mean the Hot Zone, which was obviously out, but rather the low-risk area that was no more or less dangerous than standing where she stood at the outer wooden fence. Among other things, it meant that she could not get anywhere close to the patients to find out how they were doing and ask them directly what was being done for them, how they regarded their experience, and generally hear whatever thoughts they cared to offer. By not entering the work area, the closest she could get to the Hot Zone was about half the length of a basketball court; had she entered, she could have casually conversed with actual patients at a distance of her choosing, as close as about four feet.
To at least a few of the staff who were present, Power’s decision to stand at the outer fence seemed more than faintly ridiculous, since it increased her risk of Ebola infection by approximately zero, but just the perception back home that she was being cavalier about her travel was enough to keep her at an unfortunate remove from the action and created the idea that this substantive visit was a bit of a farce. Politicians of the Republican persuasion back home had been sharpening their knives for weeks, and any misstep by Power during such a bold move could add to the president’s woes as the Democrats tried to hold on to the Senate and contain what were sure to be losses to the Republican majority in the House. They did lose control of the Senate a few weeks later, a reversal that allowed me to write one of my finest status updates ever on Facebook: “The realization that you are happier to be in the midst of an Ebola outbreak in West Africa than in the U.S. the day after midterm elections.”
From where I stood, her hypocrisy seemed a very small price to pay for the big benefit of changing the tone of the news coverage, but it rankled some. One nurse quipped with more than a touch of bitterness about what appeared at first glance to be a touching moment. Power had seen one of our young boys in the confirmed ward saluting this important American who had come to visit, and delighted, she returned the salute. Only it wasn’t a salute. “He was squinting and shading his eyes to see what all the commotion was,” the nurse said. “He was just keeping the sun out of his eyes.” And there, I thought, was a metaphor for our self-perception of our good intentions, and I wondered what signals I had similarly misconstrued over the course of my time here.
*
The ETU had opened for business right around September 15, and the first two physicians to staff the place were Pranav and an ER doc who worked at Brown University named Adam Levine. They had not only overseen the medical operations during the first two weeks but had been around throughout September overseeing the construction, the staff training, and all the other details that would go into running our little hospital on the hill. Colin came at the end of Adam’s stint, and Steve and I arrived just after his departure. Since the day we arrived, we had informally agreed to a schedule where Steve took the nights and Colin and I staggered the time we arrived during the days, usually with Colin working a swing shift that overlapped the two. To the best of my knowledge, everyone was content with that plan, and we never had any long discussions about changing things around. The nurses, by contrast, staggered their shifts into morning/afternoon–evening/night blocks. They would rotate with one another, working three or four days at one time, taking a well-earned day off to recharge, and then advancing to the next shift. Though theirs was a different system, it seemed like a happy arrangement.
Sean, however, wanted to make sure that everyone got the full experience and announced that we would be swinging our shifts so that we could observe the ETU operations at all hours. It is also possible that Pranav had a hand in this policy. By late October, he had returned from his R & R to resume his work, which in addition to running the medical staff at the Bong ETU was increasingly consumed with setting up IMC’s second ETU about three hours away in the town of Kakata, in Margibi County. As with our enforced day off, we protested to little avail. But we didn’t care that much because we trusted the judgment of these guys with our lives.
So the three of us sat down to figure out how to spell one another while we made the switch without having to work a twenty-four-hour shift. I happen to like working twenty-four-hour shifts or even longer ones, at least once in a while, and always have since my medical school days. At the end of such a period, there’s a euphoric feeling that I assume is not altogether different from a runner’s high. It’s one of the reasons I kept moonlighting well beyond my residency years, as it provides an odd feeling of accomplishment after having become symbiotic with a hospital for one full cycle. But working twenty-four consecutive hours here was out of the question. Walking into the Hot Zone even a little groggy could quickly prove to be a lethal mistake, and so we performed some complicated scheduling algebra to switch ourselves around, and with a little more than a week to go in my deployment, I was about to show up for work after the sun had already gone down.
7
NIGHT
An ancient English law made it a crime to witness a murder or discover a corpse and not raise a “hue and cry.” But we live in a world of corpses, and only about some of them is there a hue and cry.
—Adam Hochschild, King Leopold’s Ghost
When I had returned from my little Gbarnga adventure, I was not quite refreshed, but I did feel as if a small weight had been lifted from my soul. I tend to assume the worst is going to happen, but by the end of the day, I realized that, at least with respect to one aspect of the West African Ebola outbreak, the worst wasn’t going to happen. The worst would have been a Womey-style massacre in every major city across the region by the end of 2014. But I had gone to Gbarnga and sat through an orderly and sedate church service, in which a discussion about the End of Days was received with about as much anxiety as one devoted to Tupperware, yet no machetes were produced. I had concluded back in September that the fast track to a million deaths would much more likely involve the collapse of society, as the countries lost their collective faith in their institutions and one another, than from actual infections. However limited, there was evidence right in front of me that Liberia wasn’t going to descend into that kind of anarchy.
As I began my night shifts a few days later, some news was filtering in that suggested optimism on other fronts might no
t be completely ridiculous either. Sheri Fink had returned to Monrovia to continue her reporting there, and she wrote a story noting a phenomenon that seemed too good to be true: There were fewer cases of Ebola being reported throughout Liberia. The Liberian Ministry of Health, the World Health Organization, and the Centers for Disease Control—each of which had by now imported small armies of personnel to engage in detailed surveillance of the outbreak—could see ETU beds only opening up, without replacements waiting in the wings to fill them. The article reflected the tense balance of cautious optimism and skepticism, noting that this downturn was either a very good sign, or, mindful of what had taken place earlier in March, a very bad one. In Bong County, our slightly smaller census appeared to be due to the ambulance fleet requiring a one-day sabbatical for maintenance rather than want of patients, and so I assumed this was some kind of epidemiologic optical illusion. The opinion among the rest of the staff was divided.
That was the mood of the place when I began work the night shift. Similar to the hospitals back in the States, the ETU at night had an entirely different personality. The frenetic pace disappeared. The ancillary staff, performing all their essential but nonmedical duties, were almost completely absent, though a few members of the sanitation staff continued to work, mainly doing all of the laundering of the scrubs that the staff wore during the day. The patients, most of whom had struggled to maintain some form of normalcy in their daytime existence, drifted off to sleep. Nearly everything fell into a lull.
Only the jungle’s insects asserted themselves, as the night lit up with chirps and clicks and clacks of dozens of species of African arthropods. The electric lighting of the ETU proved an irresistible lure for the winged insects. We tended to walk around the periphery of the light to avoid having our heads assaulted by the various creatures, ranging in size from that of a common gnat to a small bird. There was a moth so large it could easily have been mistaken for a bat, and indeed the first night I spent some time watching the creature, finally ruling that it was not actually a bat, although Pranav had given me a preparatory course with one very emphatic roll of his eyes and the following quip when I told him that I’d soon be on nights: “Yeah. Watch out for those moths.”
The moth, however, was small fry compared to the real nighttime terror, the flying rhinoceros beetle. Picture an insect with the subtlety of a Sherman tank and the mobility of a B-29, and you’ve got an idea of it. It was at least twice the size of the stag beetles that I encountered in my youth, with a third horn emerging from its head in addition to the two pincers that came from its jaws, making it look a little like a miniature triceratops. With wings, because it, you know, like, flew. Its spindly legs along its length had small claws that allowed it to hold onto trees in a vertical position despite its significant weight, which meant that it could also find a perch on just about anything—say, the scrubs on a human’s leg. The discovery of one of these creatures attached to me proved an event sufficiently traumatic that I would gladly have run into the arms of a patient infected with Ebola to avoid it. Everyone found my little-girl screeches amusing when these bugs flew around the staff quarters. One of the expat nurses, a Kenyan named Perris Tabby, grabbed one of them one evening and placed it on top of the paperwork I was doing, with a sheet underneath it bearing the message, “Hi Steve! I missed you.” A smiley face accompanied it. Mirth ensued.
Rounds lasted longer and had an easier pace to them, for dehydration was not a concern in the cooler nighttime temperatures. That meant I had more time to assess patients with greater care, to observe their bodies and pay attention to their diarrhea and their vomit. I had more time to talk to the patients, and I had more time to think about them. Which meant almost by definition that I had more time to brood.
Nighttime brought special challenges, however. It was dark. The lightbulbs threw little light, and the dark blue tarp seemed to soak up what light there was like a sponge takes up water, so moving about the high-risk area required even more attention and deliberation than it did during the day shift. Finding items in the stockroom could be an exercise in folly. Moreover, although donning PPE didn’t induce the river of sweat that coated my eyeglasses and goggles during daytime hours, it was still warm enough that a hazy mist was produced, so everything appeared as if I was living inside a dark Monet painting. It certainly made hooking and unhooking the IV lines tricky.
We worked a skeleton crew: There were fewer nurse aides, which meant that there was more to be done in the way of basic care for the patients. One of the first nights on, I worked with a lead expat nurse named Kelly Suter. Kelly had come from Michigan with the most impressive health-care résumé imaginable for someone who hadn’t yet turned thirty. She had done disaster response work during the Haiti earthquake as well as the ensuing cholera epidemic, had seen action in war-torn Southern Sudan, aided in the postwar rebuilding efforts in East Timor, and had a job at a tough city hospital in Pontiac, Michigan, all before coming to Bong County. Yet she still worked with as gentle and caring a manner as could be envisioned. You would want Kelly Suter to be your nurse.
Her cholera experience was perhaps the most amazing of these accomplishments. “I was sent to the northwest corner of Haiti with a manual about cholera and instructions to build a team to respond to the crisis,” she told me when we shared our experiences to help pass the night hours. “There wasn’t any training. I had to learn everything about cholera from that manual, and I had to learn everything about running a team just by doing it.” This being asked of a woman in her mid-twenties who had never been to Haiti before the earthquake. It was there that she met Godfrey Oryem, where she supervised him and his WASH team. Now she was in the middle of something even deadlier than cholera.
We entered one night, just the two of us, to work in the suspect ward. There was a family, a mother with two children, one of them a toddler running a temperature of nearly 39 degrees (about 102 degrees Fahrenheit). Kelly was determined to get an IV line placed in this child so that we could hydrate her. A fever means fluid loss, and children lose a greater percentage of fluids than adults when they run a fever, so staying hydrated in such a situation is critical. Since I don’t throw IV lines as part of my work and haven’t done so for many years, there wasn’t any point in me trying to attempt what Kelly could not accomplish, for it would be cruel to the child and dangerous to me and perhaps Kelly as well. So I held the child while she tried to get access, and the girl wailed so loud that I wondered if she could be heard in Monrovia. Because she had so much energy, and because her mother said that she had been holding down some fluids, we decided to leave it be after two attempts and would try again in the morning. Even in failure, given the dangers of trying to find a vein from an apoplectic and confused child bucking about in the dark, when one errant twitch could potentially lead to a needle stick injury with Ebola, it was a remarkable piece of nursing. Moreover, we did at least get enough blood to send off for the test the next day.
Then we were on to the next patient: a man in his forties who was obtunded. That’s doctorspeak for confused and mentally altered. His loose pants were soiled with semisolid excrement, and he had moved about his bed, soiling the mattress as well. I didn’t know what was causing his delirium, but I was reasonably confident that whatever it was, it wasn’t Ebola, for an Ebola patient this sick should have been pouring out watery diarrhea instead of the brown paste that we needed to clean up. He would die the next day, the test negative, of what disease God only knows. At any rate, Kelly and I went about cleaning him, taking time to wash him down with care, soothing him in whatever ways we could as he loosed his grip on life. It took perhaps thirty minutes; during the day, I would never have had the chance to provide this kind of sustained attention to a patient’s body and still make rounds, and the work would have gone to one of the national staff. Here it was a privilege. Strangely, this was among the happiest half hours of my time in the Hot Zone.
Next it was time for distributing medications to the patients. I approached a man
in the adjacent room, about the same age, and this time I was fairly confident that I was looking at someone infected with Ebola and that his test would come back positive the next day. (I was right.) He had already gone into the throes of the wet symptoms, when diarrhea and vomiting come in wave after wave of wretchedness. I handed him his evening medications, a veritable pill bonanza. As he looked at the drugs I held in my hand I could feel his nausea, although he clearly wanted to prove that he would do anything to not be overtaken by this illness. I got into a catcher’s stance to encourage him as best I could to take the meds. I held a large plastic bottle of water in one hand, almost spooning the meds into his mouth while I put the water to his lips to help him wash the pills down. Down they went, where they stayed for all of maybe ten seconds before coming back up in a miserable heave.
After medications, it was time for cleaning the commode buckets. I took them one by one, sloshing liquid filled with filoviral particles, to the latrines, where I would carefully dump them so as to avoid splatter, then slowly wash them in the bleach solution multiple times before returning them to their owners. I took the broom and swept the hallway before moving over to the confirmed ward for the same process. We emerged about three hours later, having not only worked with the patients but also having conversed with one another through the work just as we would have done at any typical hospital. Indeed, much of what I know about Kelly’s life I learned that night.
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