“Wait. I’m not getting something,” I said to Garmai. “Why does she think he’s responsible? Do we know how he got infected?”
“Yeah—Alex took his nephews to the clinic in Hinde,” she said. “They both had Ebola and died.” Which meant that Matta had not only lost her son, she lost two grandchildren on top of that. So I could see that Matta had gone through some horrible psychological trauma, but I still didn’t understand why she was targeting Elijah as the cause of Alex’s death.
“What happened to the parents of those children?” I asked.
“Oh, they were the children of Alex’s brother, and he got infected too,” she replied. And then, almost offhandedly: “You know, he was treated in our ETU.”
“Really? When?”
“He came in the end of September.”
“What was his name?”
“Aaron Singbeh.”
Oh good Lord, I thought. Aaron Singbeh was the man I encountered lying in the hallway of the suspect ward during my first few moments in the high-risk area.
We were told to be up and ready to go at 7:00 a.m., but Liberian time has a way of seeing deadlines come and then watching them drift by, so we didn’t leave the Kakata ETU until just before eight. During the lull, I sat in front of the entrance to the living quarters, watching the activity as the night shift finished its work and the day shift came on, eating a breakfast of hard-boiled egg whites, which I used to scoop up some sausages in Liberian red sauce. I also saw a few alumni from the Bong ETU and was glad to hear their greetings.
The ride to Mawah took a little more than an hour. The road to the village goes from Kakata through Bong Mines. You take a right in the town center and proceed on a dirt road until you reach Hinde, where a large holding center had been constructed for isolating contacts of Ebola patients. By February, Ebola had nearly vanished, but that didn’t stop local politicians from rounding up anyone who could be remotely considered at risk. As patients were turned away from the international aid organization ETUs because they did not meet the strict definition of suspected cases, the holding centers maintained a steady business, for the funding to keep such centers open proved irresistible to local politicians, the strangest form of governmental pork project ever known. The ongoing detention of Liberians in holding centers like the one in Hinde once again indicated that Ebola could spread its horrors beyond those who were merely unlucky enough to become infected.
The road to Mawah is found by taking a left off the main road just past the holding center. Almost instantly the jungle embraces you, as the road narrows to one lane surrounded by high palm trees. We were in the height of the dry season when we drove, but the ruts in the dirt road suggested that the village was isolated from nearly all forms of motorized travel when the rains came. Just to get to Hinde must have been an all-day affair during the rainy season, making transporting bulk supplies a logistical nightmare. In all likelihood, the village had to be self-sufficient for months at a stretch.
We finally arrived and, unsurprisingly, were greeted like illustrious dignitaries. The PSS team had been coming to Mawah weekly for more than a month at that point, and the villagers had appeared enthusiastic, not only because the IMC staff were offering a chance to formally process some of the horrible events that had befallen them, but also I suspected because of reasons why villagers everywhere, in every age, enjoy receiving visitors: It breaks up the tedium. That and the eight or so cases of Coca-Cola we brought.
After an hour of milling about, perhaps a hundred or more villagers gathered in the main meeting area for lunch and a brief program before splitting off into discussion groups, each led by a member of the staff. As part of the program, the assembly had begun singing various songs. Just as I had reacted in Grace Baptist Church in Gbarnga months before, I was thunderstruck by the magnificence of the tonality as well as the joy and urgency spurred on by a simple rattle composed of beads surrounding a hollow gourd. As much as I loved hearing the morning devotional at the ETU, that was Western music, hymns written by some German or Briton one hundred years ago and had since become adapted to the cadences of Liberia. But the singing I was hearing in Mawah was entirely different. This time I pulled out my phone without any shame whatsoever and started to record the proceedings.
A circle formed, and various leaders went to the middle and started to dance, progressing in what I assumed was some form of hierarchy, starting with the most important villager and proceeding down through those who possessed some kind of rank. Maybe a half-dozen people in all had performed for the group. Eventually the IMC staff started to take their turns, each performing their own idiosyncratic moves—some of which, to be as charitable as possible, were not especially consistent with traditional African dancing. I supposed the juxtaposition of odd Western moves to the ambient music might have been taken for normal behavior at the Burning Man festival, but it might not have been what the villagers were accustomed to witnessing on a daily basis. I could see where this was headed, so when all eyes fell upon me I immediately moved to the center and decided to inject my own bit of ethnic background into this fast-agglomerating cultural goulash, improvising some Mayim steps from Israeli folk dancing into a rural Liberian Flying Hora. It may not have been pretty, but it seemed to earn goodwill, which was my only goal at that moment.
We adjourned to a series of classrooms a few hundred meters away in a school that hadn’t seen any capital improvements in many years. They were rooms with floors and walls and a roof over the entire structure, but not much else except some old and very tight desks. As we were at the height of the dry season, the interiors were baking, even hotter than the ETU on a bad day, although this time I wasn’t wearing PPE. When the heat of the place combined with the lunch now digesting itself in my stomach, I found I had to fight myself from sliding into a postprandial coma, especially as the meeting was being conducted almost exclusively in Kpelleh.
But fireworks soon ensued. Matta, the mother of Alex Singbeh, who had died of Ebola in Mawah, had declined to come to the meeting. I was partly relieved and partly disappointed, since she was also the mother of Aaron Singbeh, my first patient in the ETU, and I both sought and dreaded some form of closure by encountering her. In her absence she had sent her daughter to do the talking to Elijah, Alex’s best friend. And talk she did. Whatever drowsiness I had experienced as the meeting began and the pleasantries were still being exchanged quickly evaporated as Matta’s daughter, perhaps fifteen minutes into the meeting, launched into a verbal explosion that lasted no less than a half hour and was interrupted by nobody at all, including the village elders, who clearly believed they had the right to interrupt whenever they pleased. Not one word of it was in English, and while I cannot describe the content as a consequence, there was no missing the urgency.
She finished. Then, silence.
Elijah then spoke, mostly quietly, and again I was plunged back into a state of cultural and linguistic illiteracy. All I could do was try to read the body language of those around me, which wasn’t much of a guide. Finally, and mercifully, the IMC staff began to explain to me that Elijah was explaining his side of the story.
Elijah had seen Alex take his ailing niece and nephew to the clinic in Hinde. They would not return. When Alex took to fever, enough had transpired in the village for Elijah to know what had happened, as did Alex himself. At that point, Alex made the fateful decision to transport himself by boat across the river that ran alongside Mawah, to an island that had some temporary structures used for fishing but was not fully inhabited, in effect creating a self-imposed isolation zone. The shores of the island were far enough away that Alex could communicate, perhaps fifty yards or so.
But the virus began to tear Alex apart as it did most, and soon his visits to the shore to reassure his family and friends became smaller in number and shorter in duration. After several days, he simply didn’t come. At which point, Elijah faced the decision of whether he should help his friend or just leave him to his fate.
It was just as t
his heartbreaking account was being relayed to me that I realized everyone was looking at me, for while I was listening to the translation, another member of the staff was telling everyone that the doctor would speak. Given that my moment in church four months before had been a dry run for this moment, I at least had an idea of what I would say on the spot. And unlike my moment in Gbarnga, I had a firmer sense of what needed to be said, even if I had missed the vast majority of the nuances of why there was so much discord.
I first apologized for having to speak in English, and American English at that, so that even those who were fairly conversant in what they thought was English were going to have a hard time with my accent. I went slowly and asked one of the IMC staff to translate into Kpelleh, and I halted every few sentences.
“This virus is transmitted by touch,” I said. “People who touch those with the disease can become infected, but not everyone who touches the sick becomes infected.
“When people become more sick, they are more likely to pass along the infection. When Alex got sick on the island, anyone who touched him and tried to care for him was at the highest risk of becoming infected.”
I then looked straight at Elijah and stopped talking for a moment. I did not understand anything of the social rules in this village, knew nothing of their worldview, and could only remotely grasp the kind of trauma they had survived. But I was willing to risk all the potential misunderstandings in making a simple declaration out of the belief that some motivations, and regrets, are universal. I have no idea whether this is true now, but I said it then, with the hope that I was bridging the divides that separated me from this community.
“Elijah,” I said, “it isn’t your fault that Alex died. He was going to die no matter what you did. And all you would have done by going over to be with him is that you probably would have gotten sick yourself, and died as well. I’m sorry to say all of this. I am a doctor, and I can tell you that anyone who cared for Alex probably would have gotten sick. This is why Alex isolated himself. He knew. None of this is your fault.”
*
At roughly the same time as I was ambling around Mawah doing what I could to support the psychosocial team, in the United States an outbreak of a different sort was under way. In California, a minor sensation occurred when a few dozen cases of measles came to medical attention. The spread was mainly due to unvaccinated children roaming around Disneyland. Although it is not clear which child was Patient Zero, the parents of that child probably brought the family to the park, either unaware or unconcerned about their child’s sniffles and sneezes. That child would expose other children, spreading the disease predominantly to those who had also not been vaccinated. By the time the outbreak was over, public health authorities in a half-dozen states were involved, and nearly 150 cases had been diagnosed.
The fact that none had died might have led parents who refuse to vaccinate their children to raise their fists in mighty triumph against the Medical Machine of Moloch that would jab their offspring into autism or God knows what other fate in their insatiable greed for profits. All of the warnings of public health officials about measles had proven, unsurprisingly they would contend, to be wild exaggeration. Not only had nobody died, no child suffered any serious complications at all. Given the reaction by the medical establishment, the anti-vaccination parents could wag their fingers at the authorities with a righteous air of I-told-you-so.
Indeed, there was almost a poetic irony in the fact that the epicenter of the measles outbreak was Disneyland. Measles might even be described by the anti-vaccine advocates as a Mickey Mouse virus: cuddly, warm, and inviting. By eschewing vaccination, they believe they are allowing children to come and introduce themselves to the world in a safe and comforting manner, surrounded by people whose principal concern was their development, an event that would take place by exposing them to nature. The executives at Disneyland, however, were not amused by the whole affair. They offered testing and vaccination to their employees and publicly declared that parents whose children were vaccinated were perfectly safe to come—an indirect but unmistakable rebuke to the parents whose children weren’t.
The California measles outbreak served as a curious counterpoint to the horrors that were finally abating in West Africa. The self-righteous, and largely willfully ignorant, parents of the children who came down with measles may have derived a measure of emotional satisfaction from having demonstrated that measles wasn’t deadly at all. Their children had gotten the rash and felt lousy but were now the better for it, with “heightened” immunity, more ready and able to face the world. Instead, what they had unwittingly demonstrated was that when one plays Russian roulette with a one-thousand-chamber gun, odds are pretty good that you can pull the trigger once without consequence. The problem with measles is that it forces the gun into the next person’s hand—quickly—and makes them play the same game as well, and so on.
For measles is, in critical ways, almost a perfect mirror image of Ebola. Measles spreads like wildfire; the epidemiologic estimate is that one unvaccinated person can spread the virus on average to eighteen other unvaccinated people. Ebola, by contrast, is relatively hard to spread, as one sick person has been estimated to spread infection on average to only two people—so that if you institute the proper infection-control precautions, including isolating sick patients, you could stop the virus in its tracks.
But those transmission dynamics carry a hidden truth about just how lethal these diseases are. Ebola is deadly to you if you have the misfortune of contracting the disease, but within populations it isn’t especially deadly. It lumbers along, and while the daily business of more than twenty million people in West Africa had ground to a standstill because of this killer, it had become clear that the 1.4 million infected worst-case scenario envisioned months before was not going to take place. By contrast, measles appears at first glance to be laughably un-lethal, with a mortality rate of about one in one thousand or so. But because it spreads so much more efficiently than Ebola, it is no less dangerous in an unvaccinated population. Measles isn’t deadly to a child, but it is certainly deadly to children.
And because the entire medical infrastructure had been shut down for the better part of a year in Guinea, Sierra Leone, and Liberia, with hospitals shuttered and clinics closed, the practice of routine vaccination had vanished. While I wandered around the Liberian countryside contemplating the aftermath of this transformative epidemic, a number-crunching doctoral candidate from Princeton named Saki Takahashi, along with colleagues from other universities in the United States and Europe, wrote a paper that was published in Science magazine trying to make some estimates about the effect of the vaccination hiatus. Estimating a 75 percent reduction in the overall vaccination rate in West Africa due to the shutdown of the medical system, Takahashi and her colleagues took into account published data about both the mortality rate of measles and the efficiency by which it spreads. Although their work accounted for a wide range of possibilities, the upper range of their estimates was that as many as sixteen thousand children could die from measles as a direct consequence of Ebola’s effect on health infrastructure. At that point in time, the official tally of people dead from Ebola infection was just over ten thousand.
While that latter number was almost certainly an undercount by some unknown quantity, possibly in the thousands, the fact that the estimated measles mortality was even in the same range served as an object lesson in what constitutes a virus’s lethality. It would turn out that the terror a given virus induces in people is but one factor among many, and may not even be the most important. The measles data also showed that Ebola created ripples well beyond those in whom the virus took up residence. The case fatalities in the WHO situation reports included only those dead from Ebola, but the actual death toll would need to account not only for unvaccinated measles victims but those who could not be treated for, and ultimately succumbed to, typhoid fever, malaria, tuberculosis, pneumococcal pneumonia, and all the other maladies that went untre
ated while millions were left to fend for themselves.
*
After Mawah, I went back to Cuttington to finish training two more cohorts and then returned home. The landing in Massachusetts was easier, and I was no longer of major interest to anyone. Many people from UMass had gone back and forth by this point, and I had started to ease myself back into my clinical and teaching duties. But one more opportunity opened up, and I returned to Liberia in late June of 2015. This time I was going to stay in Monrovia and resume the work I had started when I first set foot here in 2013: help the residency program get back on its feet. Over the four months I had been away, the medical system in West Africa had slowly started to reboot itself, like a decade-old desktop computer that you should probably scrap, but you hang on to because it remains functional even though it is slow and has only the most basic programs. This meant that residency training would officially resume on July 1, and the Liberian College of Physicians would get back to the business of certifying specialists. Once again, by sheer dumb luck, I managed to return at a critical moment, and also at a time when my own academic and clinical responsibilities back in Massachusetts could be paused.
I would be back at JFK Hospital doing what I love to do, which is teach residents. I would be staying in the Congo Town neighborhood, where most of the embassies were located, as well as a good number of offices of the international aid groups. I was, in fact, a two-block stroll away from the IMC headquarters, and I drifted there from time to time over the next month to socialize.
Compared to my housing in Bong County, I was living in almost obscenely luxurious accommodations. The apartment, which could house up to five or six doctors, nurses, and other professionals from around the globe, had been rented by a consortium known as ACCEL (the Academic Consortium for Combating Ebola in Liberia), one of the many aid groups now flush with cash and putting it to use by sending personnel and equipment to Monrovia for the purpose of getting Liberia back on its feet. Its interiors were clean, and each room had its own air conditioner, the showers had hot water, and there was a fully equipped communal kitchen with a gas stove. It was what anyone would expect from a rudimentary apartment in the West, or even in Monrovia for that matter, if they were living there to work. Indeed, it wasn’t especially fancy. But after the cabin-like conditions that I had experienced in February at Cuttington, this was a big step up.
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