Inferno

by Steven Hatch, M. D.

  I like being a doctor: I like the complex reasoning of differential diagnosis, the blending of physiology and molecular biology, the dovetailing of cold, hard science with warm, soft pastoral care. I like it when I make good decisions and think through a difficult case, emerging on the other side with some ideas that make a difference for the better in the real world. This was just as true of my time at the Bong ETU as it was in all the years that preceded it.

  That being said, I think one of my proudest accomplishments in my career thus far was the night I held a child who needed an IV line, cleaned up the shit of a confused man at the end of his life, handed out medications, and just tried to comfort my patients as best I could. One of my finest moments as a doctor was the night I was Kelly Suter’s nurse’s aide.

  *

  The night also brought one unexpected boon: The Internet access was flawless. By late October, the ETU information technology people had succeeded in installing a satellite dish. It looked quite impressive, though during the daytime the huge amount of data traffic streaming out of Liberia to the rest of the world made checking even the most low-bandwidth websites, such as those without graphics or streaming video, an exercise in tedium waiting for the page to load. But at night, as the electronic squawking of the nation settled into a dull hum and the airwave congestion dissipated, my laptop again became a window on the world. I caught up on all my work e-mail, wrote friends, was able to peruse Facebook. I devoured the online New York Times, finally reading about something other than Ebola, which was a delight and relief but was balanced by the annoyance that much of what I read was about the impending tidal wave of Republican know-nothings sweeping into power based in part on stoking the nativist hysteria that the West African outbreak had induced.

  One night just past midnight I even had such a good connection that I managed to catch some face time with my children on Skype. A few hours before I did this, I had been sitting around with members of the national staff in the main workplace, a structure little more than twice the size of the medical staff offices that were about ten meters away. One of the pharmacists had started a discussion about salaries and ranks of pharmacists—and, by extension she argued, all professionals with advanced training. She complained that Liberian academic degrees, like those offered by Cuttington University, were considered inferior to those acquired abroad, especially degrees obtained in the United States. Why, she wondered, would the Ministry of Health treat people who had shown faith in the Liberian system of education with less respect than those who had fled? She was tired of Liberians being treated as second-class citizens, and it was high time that the government institute some policies designed to encourage and promote home-grown higher education.

  The counterpoint was offered up by one or two members of the staff whom I did not know. They pointed out that the reason why education abroad was treated as something superior was because it was something superior, and would be for the foreseeable future. Only after a generation of Liberian professionals obtained their training at some of the better systems of higher education in the world would they have enough intellectual capital to reinvigorate Liberian colleges with highly skilled professors and deans. In the meantime, they argued, a Liberian degree wasn’t up to snuff, and those going to a school like Cuttington or Dogliotti (Liberia’s sole medical school) were just not coming out as thoroughly prepared for their jobs.

  I watched the conversation proceed as it morphed from conjecture to discussion to argument, voices becoming raised with each response, the cadence of the language more emphatic, the gestures more assertive. I did something rather out of character; rather than insert myself directly in the conversation and offer up various ideas both for and against, instead I just sat and listened, trying to absorb not only the worldview of those involved but also how they interacted so that I understood at least a little of the culture of Liberian political discourse. My role was to be the pupil, and I stayed on the periphery, trying to remain as unobtrusive as possible—a feat that for me requires heroic levels of self-control—and quietly exited after I’d learned a little but before I was perceived as being something akin to a white spy.

  I was there perhaps fifteen minutes and then I made my way across the compound to the medical staff quarters where I sat down with my laptop and got on Skype. It was the first time I had seen my family since coming to Liberia. I had mostly remained in radio silence save for a few one-way e-mails. I remained out of touch for the simple reason that I didn’t want the distraction. Here I was treating kids and watching them die, and I wasn’t sure how I would handle talking to my own kids or how such a conversation might affect the difficult work I was performing in the unit. I feared that my emotions would get the best of me, and above all else I was determined to remain as focused as possible during my deployment. But as I neared the end of five weeks, with little more than one week to go before jumping on a plane headed back Stateside, I figured a quick hello wouldn’t compromise me.

  The connection was so good it even allowed, at least for a few minutes, a video feed, and I swung the laptop around in my hands so that my daughter, Ariella, could go on a virtual tour of one small corner of the ETU. I spoke with my son, Erez, about what had been going on in school. The conversation proceeded over the next several minutes as we caught up on the events of the past month. They asked me a few questions about my work, and I asked them what the talk was like among their classmates about Ebola.

  When I had left the national staff, the conversation had become fairly animated as each person tried to deliver the final, irrefutable argument that would bring the discussion to a QED close. As I made the call home, I thought I heard a lull but wasn’t sure if I was just tuning it out. At any rate, as my conversation with my kids continued, it felt like the volume and the intensity of the other discussion suddenly made a quantum leap, and disagreement turned into outright yelling. I made a distracted face for a moment, briefly raised my head from the laptop to survey the noise, and then sighed as I went back to my electronic world.

  But then, moments after returning to my family, I realized that the ever-rising volume had indeed turned to yelling. At first I was irritated, thinking, Is it really that important to settle the question of Liberian postgraduate education once and for all while the worst Ebola outbreak in history is still on, guys? But then I listened more, and I realized it wasn’t angry yelling but frightened yelling. A second later Perris came rushing in and said, “Johnson! He’s on the road!” and ran right back out.

  Johnson was one of the younger patients on the confirmed ward. All of eleven years, the wet symptoms had hit him hard. Usually the kids on the confirmed side, sometimes despite being quite ill, nevertheless managed to rouse themselves each day to come out and sit in the plastic lawn chairs and watch the activity of the ETU. If they weren’t seen outside, it was usually a predictor of their course, and many of them would die. When Johnson’s test had first come back as positive, he was healthy enough to join his playmates, but as the days passed, his energy flagged, and he was seen less and less often, retreating to his bed for ever-increasing amounts of the day.

  Bleeding may be the manifestation that has earned Ebola its fearsome reputation, but after working in the ETU for weeks, we noticed two different signs that were more likely to occur in patients and held great predictive power. Just to see a patient with either of these symptoms was enough to know their chances for survival were slim. The first was hiccups. We had long conversations about what this meant and why it was happening, but most patients who showed up hiccupping were not going to walk out the ETU front door.

  The second sign was delirium. This happened usually right before the end. I saw maybe ten patients with delirium, and they all died. If you came in to round and asked a patient how they were feeling and received a nonsensical reply, it probably meant they had less than twenty-four hours to live. The most unnerving case of delirium I witnessed happened during my second week, when we admitted a man named Ballah. He was in his mid-th
irties and had one of the most rapid deteriorations of all the patients we cared for, dying four days after his admission.

  But the four days were eventful. After being sent to the confirmed ward, he began to behave erratically. He would wander around the hallway in a daze, telling the staff that he was going to kill himself, something no other patient did while I worked there. The disturbing quality of his behavior, however, morphed into alarm two days later when I walked in to find him dead. His body was at the end of the bed, legs planted on the ground, as if he was about to get up and walk around. While I was examining him, I noticed an object lodged in between the mattress and the frame. I reached for it and a moment later found myself holding the handle of a twelve-inch blade. We later concluded that the knife had accompanied him on admission to help him pare the rinds of the fruit his family had given him for sustenance. Tucked away in his plastic bag, nobody noticed it at the triage area. Had Ballah been cognizant that he possessed this weapon in his final days, he might have attacked any of the patients and staff. It was a sober reminder of the ways in which we could not anticipate the complications that might kill our patients or us.

  By the time Perris came running in, Johnson had become equally delirious. I had seen him on rounds just before the Liberians’ debate, and he was unable to respond when I talked to him, just staring back at me with wide eyes. As I headed back out to the low-risk area, I figured that I would find his body when I performed my early-morning rounds just before the day shift arrived.

  Now Perris was informing me in the most urgent tones possible that Johnson in his delirium had summoned the energy to get up and go wandering through the compound. His path followed the precise opposite order by which we moved through the high-risk area, drifting his way back through the one-meter boundary and into the suspect ward area, turning to the triage hut instead of weaving into the suspect ward’s hallway, Jesus be praised. From there he opened the swinging door to the fenced-in road where the ambulances brought patients, and was stumbling toward the beginning of the road where the one fuzzy boundary between Hot and Not existed at the ETU. He was within about three meters of being completely out in the open, within five meters of several of the staff, who until then had been hanging out in various shanties at the ETU’s entrance used for guard duty.

  I hastily finished my Skype conversation (“Sorry, guys, something’s up, gotta go!”), slammed the laptop shut, and headed outside. The only advantage we had over Johnson was that he was barely strong enough to stand up by that point, much less walk, the physical act of having journeyed that far consuming most of his reserves of energy. I ran out to the end of the road, ordered everyone inside the main work building except for one or two staff who were to stand at the entrance and await further instructions, and told Perris to go suit up and walk through to the access road so that she could retrieve him from the inside. Johnson lurched forward another step, enough to convince everyone remaining that my instructions made a whole lotta sense, and I asked the lone remaining person to get me some gloves and goggles. “Before you go, do you guys have any kind of object that I could use to keep him away if I had to?” I asked. “Like a stick or something? Anything like that?” I kept my eye on Johnson, who had been looking at me the whole time. He took one more step. He was now a little more than a tall person’s body length from being completely out of the Hot Zone.

  “Johnson! Don’t you walk out now!” I said to him like a mother scolding her naughty son. A second later, I finally had my object: a square wooden shaft that seemed the length of a pole vault. There would be no problem keeping Johnson at bay, as long as I could hold the unwieldy object properly. I started to plant myself in a stance that would force him backward with the pole, but he never moved a step further. A few minutes later, Perris emerged from behind him and slowly entreated him to take her hand and allow her to walk him back down the road, through the triage area, across the suspect ward, and back to his bed. Thirty minutes later, he was lying down, the episode seemed to be over, and my pulse fell back below 120.

  After the sun had come up and the day shift began, I made a passing reference to the incident in the morning meeting but downplayed its importance because I wanted to have a chance to give Pranav the full rundown, as Johnson’s little jaunt had clearly exposed some structural flaws that needed to be addressed as soon as possible. The knife incident with Ballah might have been a weird one-off that wasn’t likely to happen again, but not only was there a decent chance that another delirious patient might have a wandering episode, there could just as easily be someone who was pissed off, perhaps by the tedium of waiting around for a positive test, who would march out of their own accord. The ETU operated on an entirely voluntary basis: No patient was ever held against their will, and confirmed patients were free to leave against our medical advice, though none did.1 But I wanted to point out to Pranav that it might be worth considering where the soft spots were so that we could make alterations that would physically discourage such patients from getting on the loose.

  We talked in the open part of the compound, the geographic center of all the action, because it was the noisiest place with all the post-meeting commotion, and therefore paradoxically the most private. The conversation quickly turned to identifying these soft spots and what would be the most useful changes—mainly to be implemented by Jean-Francois Baptiste, a Frenchman who had some formal title but I basically thought of as the Everything Fix-It Man. As Pranav and I were having this conversation, we turned to see something at our feet. To drive the point home, there was Johnson, who instead of walking toward the suspect ward as he had done the night before, had walked straight out through the decontamination chambers and into the middle of the compound, and was maybe two feet away from us. The effort to travel that far had depleted him, and he rocked back and forth on his hands and knees. Somehow in all the commotion, we were the first to notice, but within a few seconds all the staff had scattered to the periphery, like a drop of dishwashing liquid in a greasy water-filled frying pan.

  When we looked at how Johnson had once again managed to leave the confirmed ward, the lack of a door to the decon chamber seemed like such an obvious oversight. It wasn’t, really; it was simply that the circumstances were producing contingencies that required improvisation. The events of the past eight hours suggested, however, that it was high time to improvise. We repeated our strategy of trying to contain his movements while someone suited up, and he was led back in to his room. Now thoroughly exhausted, I went home for some sleep. When I returned, there were now swinging doors to the decon chambers that needed to be unlatched, something a delirious person would be hard pressed to accomplish. The presence of these barriers solved one problem but created another, as the hooks to the latches were simply large nails sticking out and could easily tear the PPE of someone who wasn’t careful while they unhooked the contraption. That could not only lead to an Ebola infection if the outside of the PPE was coated in virus but could just as easily lead to tetanus from a scratch of the rusty nail.

  Johnson died that afternoon.

  *

  The night brought other features of the daily rhythm of the unit. While I was still working days, Sambhavi had been on a mini-warpath to make the Bong County facility “the happiest ETU in Liberia.” At first I made some snarky asides about this to Colin, but as usual, the joke was on me, as several of her improvements really did keep morale high, not only among the staff, but even more importantly, among the patients as well. The most important of these tweaks was to have movie night. Somehow she managed to procure a digital projector from Monrovia, and staff people provided copies of movies that they had kept on their memory sticks, allowing for a small Ebola Cineplex to be operated for several days. It took some time to work out the logistics of showing the movies since the projector could not move into the Hot Zone behind the audience and project forward onto a screen, but instead had to be rigged so that it was presenting an image in reverse so that when it hit the screen it would appear correct
ly. The screen itself was a sheet that had been strung up in one of the no-man’s-land boundaries between the high-and low-risk areas, which technically made it Hot, so any adjustments had to be done from the inside in full PPE.

  The first of these movies, screened when I was still working the day shift, was The Lion King. After some false starts, we finally got the picture set up and the movie started; we all stood next to the exit area of the decontamination chambers and watched almost every member of the confirmed ward watch the movie. Those on the suspect ward who were interested brought their lawn chairs to the edge of the boundary and craned their necks to see what part of the screen they could.

  Virtually everyone stopped to participate in the same activity, like we were all a family sitting around a very large dinner table at a special holiday gathering. You could touch the joy in the ETU that night. I did marvel at the choice of movie: Here we were, in real Africa, watching real Africans watching a movie about a most unreal Africa dreamed up by people who were on the whole very un-African.

  Postcolonial critiques of Disney be damned, the audience was rapt from start to finish, and demanded a rescreening as soon as possible. Watching this whole bizarre event take place, I felt the same sensation I had at church, when the words of Revelation had started to cascade down from the pulpit: You really can’t make this stuff up—or if you did, you’d be accused of importing the most transparent and shallow of metaphors. But there we were.

  By the time I had taken up my work on the night shift, however, we had cycled through the popular movies. I had stopped paying attention to them while I was working days, especially as the movies often started to play only as we were headed home. But now I was rounding between nine o’clock and midnight, and so I basically couldn’t avoid movie night. The popularity of the activity had diminished, and it was mainly the children whom I would find sitting outside, spellbound. By that point, the cache of movies owned by the expats had been exhausted, and so some members of the national staff working for the WASH team had brought their movies in. But like the adult patients, I paid little attention to them and stayed inside the building, able to actually spend some quality time with my patients.