Inferno

by Steven Hatch, M. D.

  On my first morning back, I made the half-hour walk from my flat to JFK in the pouring rain, for the rainy season was well under way and drenching squalls were now part of the daily routine. I wandered the corridors on my way to the Internal Medicine floor, and it looked much the same as it did when I had first arrived. The commotion of the place was unchanged. The first floor, which housed the outpatient clinics, was thick with people crammed onto rickety benches waiting to see doctors with the same kinds of complaints that can be found in the States, ranging from the mundane to the life-threatening. People wandered about the hallways, hand in hand with loved ones. Touching. People in Liberia were touching one another again, and the hospital was back in business.

  But no Dr. Borbor this time.

  The sole remaining internist on staff at JFK was a Nigerian who had long lived in Liberia named Joseph Njoh, but the residency leadership had been temporarily aided by a Rwandan doctor named Ignace Nzayisenga. He was returning to Rwanda for his wedding and a brief honeymoon soon after I arrived, and I was tasked with covering him during his absence. Joining me was a young Ethiopian doctor, Kidist Tarekegn. I take pride in correctly pronouncing the names of those from other cultures and have what is for me a subversively formal streak, in that I like to always refer to my colleagues as Doctor So-and-So. But Kidist’s last name was hopeless, and mastering her first name was difficult enough, for it is harder to get right than it appears on the printed page because of a click in the first syllable. Kidist was new to Liberia, and after a few days I could see the same shock on her face that I had registered on mine when I had first worked here. Experiencing culture shock is predictable whenever you take on a task like this, but going through that in a country that has suffered as Liberia had over the past year could potentially leave scars. I worried about her.

  A huge surprise for me was in store the first day I was back, when I walked into the residents’ lounge and saw Phil Ireland standing there. We embraced one another as if after a long journey, each of us knowing that the other had gone to extreme places and had been altered by the experience. Somehow circumstances had placed us in exactly the same position in which we had found ourselves a year and a half before. It was a teacher-student arrangement: I was the teacher of Internal Medicine and Infectious Disease; I was the pupil of Liberian history and its social structure and, above all else, the experience of living through the epidemic when there was nothing but chaos and then becoming infected. We spent a lot of time talking over the next several weeks.

  During the first days I often spent some time just wandering around the hospital. One morning I was changing corridors at a brisk pace and stopped dead when I saw a woman named Sia Kammara staring back at me. Sia was one of the key faculty at JFK working in the pediatrics division. Although I had only been at JFK for such a short time before, and had met many Liberians since, I immediately recognized Dr. Kammara for the simple fact that—Lord, and Betty Friedan, forgive me for saying this—she is a stunningly beautiful woman. There was simply no forgetting her face. But she did not appear amused to see me despite my glow in her presence.

  Sia had been in the room that day the previous November when I gave the lecture on hemorrhagic fever and had made my little sort-of joke about the Taï Forest Ebolavirus being not too far from Monrovia. It had registered. “Doctor Hatch,” she said an instant after confirming that my presence was not apparently that of an apparition. “The last time I saw you, you were making jokes about Ebola being not too far from Monrovia. A few months later, we have the largest Ebola outbreak ever. Then we get rid of Ebola. Now, you have come back, and there are new cases in the country. I think you should leave our country!” Her eyes were pure Betty Davis. I nervously chuckled but wasn’t sure whether she was teasing.

  She wasn’t kidding about the new Ebola case, however. Almost within hours of my touching down at Roberts airport, a young man in Margibi County, in a village known as Nedowein, about a ninety-minute drive from the center of Monrovia, fell ill. He had a fever and body aches. With the Ebola outbreak over, this would almost surely be malaria. After all, the outbreak had been declared over on May 9, and another forty-six days had passed since. But it wasn’t malaria. It was Ebola. I found out the news after coming home from work that first day. When weeks before I had made arrangements to return to JFK, I assumed that Ebola would finally be starting its long fade into the Liberian memory. Yet when I arrived home that first night, I was stunned to receive a message from a friend linking to a BBC story describing confirmation of the index case in Margibi.

  After reading the story, I was befuddled, since I could not understand how Liberia could suddenly have a new case on its hands. Nearly three months had passed since the last case of Ebola, and the longest known incubation time was twenty-one days. Years ago, the World Health Organization had more or less arbitrarily decided that it would double that number as a hedge against premature decreased vigilance, which was how the forty-two-day countdown to declaring an outbreak over came to be. This case, however, was so far past the incubation period that there was no way it was a statistical outlier. At first blush, it made no sense.

  I also realized that I had signed up to work at a hospital, to evaluate patients in an emergency room, without the protections of PPE, in a country that now had a new Ebola outbreak on its hands. This was how Borbor himself got infected almost exactly a year ago. Now it could be happening again, and I wasn’t working in an ETU but was on the front lines. True, there was now a screening process in place at JFK designed to flag potential cases. Yet when I toured Phebe Hospital in Bong County in February, I had seen firsthand how peoples’ vigilance had flagged as the outbreak abated and there were suddenly no more cases to be found. All the paranoid precautions seemed like overkill, and the screeners at the intake areas slacked. We had watched this happen at the time, and I had several conversations with the IMC training staff, who expressed their frustration. Now, months later, there was at least one case, and who knew whether that meant there were others out there, perhaps sick and on their way to JFK at that very moment—or, indeed, already lying on a bed in the inpatient wards? Without protection, I stood a chance of getting infected, and now I had no way of knowing whether that was a highly unlikely scenario or something about which I should be seriously concerned.

  I also felt something novel for me since this entire odyssey had begun nearly one year before: I felt fear.

  I sat on a couch in the apartment and tried to be a clinician again. How did he get infected? Several possibilities, each one more implausible, presented themselves:

  1. He had become infected as part of a brand-new outbreak totally unrelated to the previous one, and this was just a weird coincidence of timing. At first, this seemed to simply have “bullshit” written all over it. West Africa had one documented case of Ebola prior to the 2014 outbreak—just two spillover events from animal to human since the discovery of Ebola. Now we were to believe that a third one would start so soon on the heels of the other? However, if Ebola spreads through the bat population in epidemics, it could mean that there might be more copies of the virus in them as well, leading to more chances for a bat-human species jump, and this one just happened to take. It was like having more aces in a deck of cards in a game of poker: Sooner or later, someone was going draw one.

  2. There was a nonhuman primate animal that became infected and in turn infected the young man. Chimps and gorillas and other primates become sick from Ebola just like we do; maybe there was such an animal involved here? Biologically, this was plausible. Demographically, I was dubious, because Margibi County isn’t deep into the jungle where such animals could be found. If a case had popped up in, say, Maryland County, on the border of Ivory Coast, I might buy the theory. Just south of the town of Harbel in Margibi County, there is an island on which a chimpanzee colony lives, but there hadn’t been any talk of a chimpanzee outbreak, and he would still have to have gone there, so I doubted this explanation.

  3. There had been a “qu
iet” chain of transmission that had escaped the notice of health authorities. This seemed to me to be exceedingly unlikely. By June 2015, you couldn’t walk into the remotest village in Liberia without tripping over someone who worked for the CDC or the WHO or one of dozens of aid organizations. The contact tracing system even at the end of the outbreak revealed that an impressive display of resources had been directed at finding every possible case. I wouldn’t be surprised at all that a case or two might go unnoticed by the surveillance teams during the worst of the crisis in August or September. However, for this scenario to be possible, people would have to have been infecting other people for three straight months, all without anyone ever knowing about it.

  4. The virus had attenuated—that is, caused milder symptoms that would not be thought of as Ebola—in several people, causing a subclinical chain of transmission, until it hit this young man, and the full force of the virus’s pathology returned. This seemed a stretch.

  5. There was a reservoir for the virus that we weren’t aware of. We had always thought the main reservoir was bats, but what if other mammals could become infected and pass it along as well? Cows were rare in Liberia, but dogs were not. Millions of people back in the States had gone temporarily nutty about the dog-can-transmit-Ebola angle when Nina Pham, one of Thomas Eric Duncan’s nurses who had become infected, had to have her Cavalier King Charles Spaniel, a preciously cute animal named Bentley, put into quarantine while she recovered. The CDC had to include a page on its website addressing this question. My attitude had been that this was what comes of a scientifically illiterate society coping with such news. Mosquitoes don’t transmit AIDS for the same reason that dogs can’t pass Ebola: The virus is just not adapted to live in that organism. We would have been hearing about a sick dog epidemic in West Africa during this outbreak because the opportunities for cross-species transmission between humans and their furry friends were far too great, but there was never once a report of such a problem. We humans just happen to be the unlucky mammals whose molecular biology is welcoming to the virus, and dogs aren’t. But would this new case make me reconsider this stance?

  I contemplated each of these scenarios in order and dismissed all of them with a shake of the head as if something intellectually icky had been placed on my mental plate. They all seemed outlandish. Over the next few days at least three people had become infected, making it a true outbreak—and making me take a deep breath before I plunged into the work at JFK each morning with the air of Oh, what the hell that had made the ETU work go so smoothly, but this time there was no PPE nearby and no spray team cruising the halls.

  By this point the international media was starting to report what I was hearing through the back-channel gossip: The concern was about a dog. The three infected people were reported to have eaten a dog together and fell ill soon after. Lest you recoil about the dog consumption, understand that Liberia is a protein-starved nation. A hamburger is an expensive luxury, and a steak, decadent; the red meat that gets served on roadside stands looks more like roasted beef jerky and gets sold for the price of a few sodas. What meat that does get consumed is overwhelmingly chicken, as the birds are fairly easy to raise and don’t tax the land resources. So dogs, of which there is an abundant feral population, often get snatched by hungry villagers and turned into food.

  The authorities in Liberia were taking the dog hypothesis seriously. My friend Christine Wassuna, who was running one of the Biosafety Level 4 laboratories in central Monrovia, said that they had found where the dog’s corpse was buried and would be exhuming it for PCR testing. I was floored by this news, as it seemed to be grasping at straws. There were actual, responsible scientists who thought that dogs could be the reservoir? That the virus could hide out and just happen to infect humans? I was incredulous.

  Reservoir, I thought. Where does the virus hide out? I wondered.

  And then it hit me, and I felt stupid for taking as long as I did to realize the answer that had been staring me in the face all along.

  Liberia had actually had a near miss with declaring the outbreak over much earlier than May 9. The problem was that, as the epidemic wound down, they got to zero only to find new cases pop up a few days later. The intervals between these cases got longer and longer, however, and eventually the forty-two-day clock started in earnest in early March. Then on March 20, after two weeks of Liberia seeing no new cases, a woman in Monrovia named Ruth Tugbah fell ill. The tests for Ebola were positive, and she would die of the disease in the following days, having again started a new chain of infection that led to a few hospitalizations but, mercifully, no deaths beyond her own.

  As part of the contact tracing process, Tugbah was noted to have a boyfriend who had survived his own bout with Ebola, for he had been discharged from an ETU months before. A sample of his semen was obtained and tested for the presence of the genetic material—which is to say, the test just looked for pieces of the nucleic acid of Ebola rather than a complete, intact virus, because that test requires more elaborate scientific infrastructure than Liberia had to offer. Still, a positive test would be suggestive, and it was, the sample having been provided 175 days after the onset of his symptoms, which was 74 days longer than the virus had ever been known to persist in a human.

  Ruth Tugbah’s sad story couldn’t be considered definitive proof of anything, but it certainly suggested that Ebola now had to be thought of not only as a zoonosis—that is, a disease humans obtain by being exposed to animals to which the microorganism is evolutionarily adapted—but also as a sexually transmitted disease. Because the virus persisted in semen but not in vaginal fluids (as considerable testing had shown), the sexual transmission was unidirectional: Men could infect women, but not the other way around.

  There were hardly dozens of data points to make ironclad the conclusion that Ebola “lived” in semen much longer than anyone had previously thought, but what data points did exist were highly suggestive. The index case in the new Nedowein cluster still had no known cause, but sexual transmission made a great deal of sense.

  The problem with this theory didn’t lie in its intellectual and scientific consistency or its Occam’s razor–like economy. As far as I was concerned, barring some startling new revelation, it was right. The problem was having sub-Saharan Africans acknowledge that men having sex with men actually took place on the continent and wasn’t just practiced by morally perverse, white-skinned Westerners.

  Ironically, at almost precisely the same time the story of the Nedowein cluster was reaching the outside world, a newsworthy event was taking place in Washington that would have almost as much of an impact as the new cases of Ebola were having back in the States. On June 26, in a case known as Obergefell v. Hodges, the U.S. Supreme Court in a 5-to-4 vote declared that same-sex couples had the constitutional right to marry. I felt a great deal of pride upon hearing the news just as I was traveling through the airport to catch a plane to Liberia. Sprinkled in between my dread about the Nedowein cluster was pure euphoria that the United States—my country—had made human decency front-page news. God bless you, Anthony Kennedy.

  The reaction among my African friends was far more subdued. I had become part of a new Facebook community after working in Bong County, so now I periodically viewed the feeds of these friends, and many of them reacted to the news of the SCOTUS decision with bewilderment. Aside from their inability to comprehend how a nation governed at least in part by decent Christians could resort to such a policy, many had an especially difficult time understanding the Obergefell decision in relation to President Obama, who is as revered in Africa for being the first African-American to hold that office as he is by African-Americans back home. They thought, somehow, that this was Obama’s policy rather than that of a different branch of government, as unaware of the separation of powers as a typical American would be of the complicated political power distribution in Iran. Robert Mugabe, the ninety-one-year-old longtime leader of Zimbabwe, almost became crazed after the decision. “I’ve just conclud
ed, since President Obama endorses the same-sex marriage, advocates homosexual people and enjoys an attractive countenance—thus if it becomes necessary, I shall travel to Washington, D.C., get down on my knee and ask his hand,” he said in mock, well, something. The fact that the attractively countenanced president wasn’t technically responsible for this, even if he did support it, made little difference.

  Obergefell served to remind those of us working in Africa (or at least it reminded me) that whatever goodwill had been earned by bringing Ebola to heel, there were still deep cultural fissures where misunderstandings could quickly escalate to hostilities, and not all would be sweetness and light in the months to come. Not long after the decision, a Facebook post circulated among several of my African friends, taking direct aim at not merely gay marriage but even the most casual tolerance of the “gay lifestyle,” or call it what you will:

  LETTER TO WHITE MEN …

  Dear white men, U asked us to wear coats under

  hot sun, we did;

  ~

  U said we should speak your language, we have

  obediently ignored ours.

  ~

  U asked us to always tie a rope around our necks

  like goats, we have obeyed without questioning.

  ~

  U asked our ladies to wear dead people’s hair

  instead of the natural hair God gave to them, they

  have obeyed.