~
U said we should marry just one woman in the
midst of plenty black angels, we reluctantly
agreed.
~
You asked us to use rubber in order to control
our birth rate, we agreed.…
~
Now U want our MEN to sleep with fellow MEN &
WOMEN with fellow WOMEN so that God would
punish us like Sodom and Gomora?
we say No!!
We don’t agree with U this time! Proudly African,
we say a huge NO to GAY relationships and
LESBIAN.
~
If U say NO to HOMOSEXUALS & LESBIANS type
NO!!!. And Share with your friends.…
~
Dont forget to Share with others
[Sic.]
*
“No,” would be the next line of the feed, entered by someone.
“NO,” came another line, and so on, the feed populating with enough “No” posts to seem as if someone had just pressed Enter on the keyboard and kept their finger on the button. If I had seen these kinds of sentiments expressed by my Facebook acquaintances in the States, I would simply have defriended them without a second thought. But it was more complicated here.
The reaction to the Obergefell decision did illustrate how cultural biases can affect scientific decisions. At the very least, sexual transmission was the most likely explanation of the Nedowein cluster, and that had real implications for the future. There were thousands of survivors, male survivors, whose semen was incubating a lethal virus. As with AIDS in the 1980s, if safe-sex practices weren’t emphasized to all groups, new chains of transmission could start, and the epidemic would drag on like a brush fire, possibly for months, possibly for years, as the virus managed to find a new home in which to accommodate itself until it could strike again. But emphasizing this to all groups meant that acknowledging such groups even existed, and no African government was in any hurry to bestow any legitimacy on these sexual practices. If this is how they could contract Ebola, you can almost hear the reasoning go, then they deserve to die. The fact that others might also contract the disease and die just by being in the vicinity of such people didn’t enter into the calculus.
Nedowein, though, quietly receded into a whisper. The story had barely registered back in the United States, but even here, it seemed to last not much past mid-July, as no further cases came to light. The dog story didn’t pan out but seemed to be the last explanation left on the table, since none of the public servants were going to explain that the index case had probably acquired the infection as a result of having sex. The episode had ended without any celebrations this time, with everyone hoping that this was the last they would hear from Ebola ever again. The forty-two-day clock, which now seemed to be an increasingly strained way of concluding the outbreak was over, began again, but the nation wasn’t collectively crossing off each calendar day as it had done before in April. When no further cases surfaced, people at JFK assumed the worst would not happen. I was less sanguine.
During this period, a patient had come to the Blue Room (since painted white) under murky circumstances from Grand Gedeh County, the area on the northeast edge of the country bordering Ivory Coast. He was lying there, moaning in bed, with a fever of 104 degrees, and my intern seemed untroubled by the fact that he couldn’t explain to me in any detail what had happened to the man or how he had slipped through the screens, given that he could easily have been considered a potential case. Normally I’m an encouraging teacher, but this time I had sharp words for one of the trainees and it forced me, as the attending physician in Dr. Njoh’s absence, into the unpleasant dilemma as to whether I was going to examine this patient without any PPE, since there was none to be had as far as I understood. It’s a story for another day; the fact that I’m alive and writing these words, having never developed Ebola, should indicate that the man, who died later that night, wasn’t infected. But I had Phil Ireland call his contacts at the Ministry of Health to run a confirmatory test just to be sure.
I spent the last two weeks of July with two primary goals: to enjoy my residents to the fullest extent possible, since I did not know when I would see them next; and to play the role of decadent American tourist and scour the city’s nicer bars in search of Monrovia’s best drink. The final Saturday before I left, I managed to find what I was looking for. It was a margarita, at a bar called Tides, in a section of the city that I had never seen before, on the far side of the city center on UN Drive. The bar was in a second-story walk-up and looked out north onto the Atlantic Ocean; the destitute West Point neighborhood that had seen such exceptional misery one year before could be seen to the right. There was only a sliver of moon in the sky, and so the night was dark. Tides has a patio that opens right out onto the ocean, and the wind was blowing hard that night. I caught up with Trish Henwood, who also had come back to train Liberian doctors to use ultrasound machines, and I also chatted with various others who were there to help out. I drank three of these margaritas—it really is the best drink in Monrovia—in fairly short order, and eventually wobbled my way to the patio and just stared out at the ocean and up at the sky.
Trish, two other companions living at the Congo Town apartment, and I rode back home at midnight. We drove east on an unusually empty Tubman Boulevard, which only hours before was packed to the point that the five-mile distance to Tides took more than an hour to reach. It was like the entire population of Monrovia had disappeared in a puff—all the more amazing because I have seen Monrovia not teeming with people only once before, and that was at 3:30 a.m. after walking a friend home in the Sinkor neighborhood near JFK.
The car was quiet. We sat and listened to the BBC news on the radio. The length of the drive was occupied by an extended report of the Pluto flyby of NASA’s New Horizons spacecraft. The story had been taking place over the past few days, but I wasn’t able to fully appreciate it, since I hadn’t seen any of the new pictures of Pluto, given the limited bandwidth of my temperamental mobile Wi-Fi hot spot.
Even so, as I sat there listening to the radio program, I couldn’t help but feel a sense of wonderment at the magnificence of the event. This icy chunk of rock that circles the sun at an unimaginably long distance from our home had become linked to us in a new and utterly profound way. I was traveling on a road in Monrovia, a place that seemed no less distant to me than Pluto itself only two years before, hearing the voice of a reporter in London talk about a piece of metal built by my fellow Americans that was chirping out electronic signals to us just before it left the solar system on its own grand journey. It was humbling. It was wonderful. It inspired awe, true awe.
Earlier that day, I had stopped by JFK to check in on my resident, a woman named Joyce Bartekwa, who was taking call that day. A resident’s on-call shift in Liberia is old-school: They start work one morning and work all the way into the following afternoon, without ever catching sleep and having hardly a moment to sit down, and they do this on average once every three or four nights for a year. Joyce was one of Liberia’s most remarkable success stories, and so I had hoped to drop by to shower upon her every ounce of encouragement I could before leaving the country. She had started out her career as a nurse but had managed to make her way to Dogliotti to get her medical education, and she was now on the verge of advanced training. By my estimates, she was every bit as good, and frankly better, than many residents back in the States.
I didn’t find her. I moved about the Critical Care Unit on the first floor and saw a seventeen-year-old who had been admitted in terrible respiratory distress two days before. We knew from looking at the X-ray that she had an enlarged heart and her lungs had too much fluid, both inside and outside. I couldn’t tell you the cause, for without the resources to order the proper tests, all I could do was guess. Joyce had put a needle in the pocket of fluid outside her lung, draining the fluid off in order to give the lungs room to expand and bring more oxygen to her body. When I happened
to wander in that afternoon, the patient had smiled for the first time.
I do not know what became of that young woman. Her symptoms improved from the drainage, so she no longer required care, and hospitalizations are exorbitant affairs for the average Liberian family, so it was time to go home the following day. I have no illusions about her long-term prognosis; whatever made that heart so big and unable to pump was unlikely to reverse itself, and few of the medications that could stave off the worst effects of the heart failure would be affordable to her family. The tattered Liberian health-care system wasn’t capable of working that kind of miracle, and wouldn’t be anytime soon. But at that moment when I encountered her, she was thriving and happy to feel better. That night, as we drove home, the improvement in her status, however temporary it may have been, filled me with a certain hope, not only for her, but somehow for Liberia as well. Driving along Tubman Boulevard, going from the city center through Sinkor and past JFK, I spotted a Coca-Cola billboard advertisement that I hadn’t noticed before. Its message was one of pure optimism, simple in its presentation. It merely showed a man about my age, emerging from a car door, looking straight into the camera with a content appearance. “I’m confident of better days ahead,” read the caption.
It is not my nature to feel such confidence, but perhaps that night I was as well.
EPILOGUE: SUNSET, SUNRISE
We bury people for dignity. Their dignity, and ours.
—Bruce Borowsky
On January 14, 2016, the World Health Organization issued a press release declaring the West African Ebola outbreak to be over. Technically, it marked the first time since Emile Ouamouno had fallen ill that the forty-two-day clock had run its course in all three countries and no cases could be found.
In the United States, it was a small news item, little noticed except by the global health community or those who had become Ebola junkies. The front-page news had been dominated for weeks by the increasingly divisive battle for the Republican nomination, the tenor of which had been determined in part by some of the anxieties that the outbreak itself had unleashed. Even though the announcement hadn’t generated much of a splash, it did allow the WHO to declare some kind of a victory, finally affixing a stop date to the unprecedented epidemic, allowing the world to say in one collective sigh, “It’s over.”
The virus, however, wasted no time issuing a sharp rebuke to the WHO for even considering this feel-good moment. The following day a new case cropped up in the Port Loko District of Sierra Leone; the young woman who had been diagnosed with the infection, named Tunis Yaha, was already dead. The staff of the WHO had, in fact, predicted this. The press release was careful in its wording, stating even in the headline that so-called flare-ups were likely to occur. Ten of these flare-ups had been recorded thus far. Vigilance, the press release noted, would need to be maintained well into the future. But since they knew other cases might well emerge, that only raised the question of why anyone would “declare” a cessation of the outbreak at all. Because of the sheer bad luck of the press release’s timing, coming as it did within hours of the announcement of one of these flare-ups, the WHO appeared foolish at a time when it desperately needed to shore up its image. Of course, shoring up its image was the whole reason for the press release in the first place. It was a gamble that did not pay off in terms of public relations.
In a related effort to prove that it was not asleep at the wheel of global health, and perhaps feeling the sting from the miscalculation of the Ebola announcement, two weeks later the WHO declared a public health emergency surrounding what until then had been a little-known virus called Zika. Zika is a mosquito-borne illness belonging to a family known as flaviviruses, whose relatives included dengue, yellow fever, and more distantly, hepatitis C; my early postdoctoral research had been on dengue, so I knew flaviviruses pretty well, and even I had never heard of it. Now, however, two clinical syndromes had been spotted in Brazil that might be linked to the virus, leading public health authorities to investigate further. The first syndrome was a neurological condition known as Guillan-Barré syndrome: Clinically, it behaved as though a person was getting a rapidly progressive version of multiple sclerosis, and it had the potential to be lethal. The second syndrome, which garnered much more attention as 2016 began, was the appalling condition of microcephaly, in which a baby’s brain and head do not develop completely. Severe cases showed babies with faces but no forehead at all, and the skull would just drop down after the eyebrows to the back of the neck. Our innate facial-recognition software, a biological program that functions deep within the most primitive centers of our cognition, goes haywire at the sight of such a child.
The early epidemiologic research on Zika suggested a link between the two, but by the time of the public health emergency declaration, the fact that Zika caused these conditions had not yet been firmly established. The conclusions about Zika’s danger certainly seemed rushed, given that public health officials work hand in hand with scientists, and science is an inherently conservative field, cautious in its suppositions and rarely in a hurry to announce hard conclusions. Had the Zika outbreak been killing indiscriminately, like Ebola had done, then arguably caution needed to take a backseat. But Zika, whatever its putative harms, affected very few people and could not be supposed, even under worst-case scenarios, to threaten tens of thousands of people or bring the world economy to a halt.
As I write these words in March 2016, the current estimate is that Zika might lead to microcephaly in one live birth per one thousand. That statistic is not far from the incidence of Fetal Alcohol Syndrome in the United States, a condition with equally devastating consequences for the baby and, because it damages the developing brain, for much the same reasons. Yet one would be hard pressed to find the same level of disquiet about Fetal Alcohol Syndrome in the press, even though this condition can be entirely prevented by a sharp reduction in the alcohol intake of heavy-drinking pregnant women. By contrast, individuals themselves living in endemic areas can do effectively nothing to prevent Zika, and public health measures such as mosquito control could very likely have unintended consequences that could be just as bad or worse than the Zika problem ever could produce on its own.
It is certainly possible that events in the months or years to come will vindicate the WHO for its choice to label the Zika epidemic a public health emergency, and I will be as chastened as I hope Gregory Härtl currently is. Härtl, you will recall, is the WHO official who had engaged in the Twitter war with MSF, accusing them of exaggeration, insinuating that they were fomenting panic in the early hours of the Ebola outbreak. Maybe Zika will really be all that, and my dismissal of it as a truly serious health threat on a par with TB, HIV, and drug-resistant bacteria, among several other issues, will be seen in the sharp and unforgiving light of hindsight as another misstep by an arrogant doctor infatuated with his own judgment. The point I’m trying to make, however, is that what can’t be disputed is Zika’s provisional status as a threat. The global health community, as well as the international media, is already reacting, and reacting emphatically, to Zika’s menace, but at least at this moment, the scope and the magnitude of this epidemic is far from clear.
How to account for Zika’s current infamy, which might ultimately be seen as an overreaction? I think one need look no further than the debacle of the Ebola-is-over declaration. The phenomenon of Zika as a cultural and scientific force can be understood as a direct effect of the Ebola outbreak.
And it is but one such effect. World travel restrictions to the outbreak nations are another effect. International agribusiness and transcontinental trade in material commodities have both been affected by the outbreak. The current political landscape of the United States—which at the time of this writing in mid-2016 is highly fluid and dynamic, and routinely includes frankly disturbing rhetoric that now passes for respectable opinion among the leaders of one major political party along with tens of millions of its voters—has been influenced mightily by the events that unfolded
in remote African villages throughout 2014 and much of 2015. One doesn’t have to search too hard to find these effects, both direct and indirect, of the West African outbreak.
But the most important effect of the Ebola outbreak is, of course, the dead.
By the time the WHO issued its final situation report prior to declaring the outbreak over, the tally was staggering. Officially, there had been 28,601 cumulative cases—that’s the kind of fixed, reified number that will be committed to memory by people fascinated by and drawn to Ebola and the disaster-porn titillation it can induce. Yet “cumulative cases” is a deceptively simple epidemiologic phrase reflecting the difficulties of tracking the epidemic given the numerous impediments facing the workers. It includes confirmed cases—those with a positive blood test—but also takes into account those who probably had Ebola but never came to formal medical attention, either because they had avoided ETUs or because they were dead already. Of the final tally, just over half fit into this category.
Similarly, the final death count stood at 11,300. Both the number of cases and the number of dead are universally agreed-upon undercounts, though by how much nobody can be certain. “The majority of these cases and deaths were reported between August and December 2014,” notes the WHO situation report, and given that we know the virus had been running rampant in May, June, and July of that year before the international organizations had put many boots on the ground, thousands more must have been infected and succumbed.
No matter the exact number, by the time August 2014 had rolled around, so many deaths were taking place in Monrovia that there was not enough space and time to bury all the dead. The Sirleaf administration was forced to make the unenviable decision to cremate the bodies. Until then, Ebola skepticism still largely ruled the day among the populace, but the cremations caused a seismic shift in perception. Since burial is a deeply sacred rite in Liberian society, not even the most cynical Liberian would resort to a policy as extreme as mass cremation unless something truly unprecedented was taking place. And, moreover, that it posed a genuine threat to everyone. “It started to sink in when the cremations began,” Phil Ireland told me in July 2015. One of the medical students who had been working at JFK had contracted the disease and had now died. Phil, by that point, had survived his infection, and along with some of his colleagues they placed the young man in a body bag and took him to one of the burial sites on the edge of the city. There, instead of hearing the quiet of the cemetery, they were confronted with the sounds of a crematorium running at full tilt. When the skulls exploded from the pressure, there was a grenade-like sound. “It was so chilling. Sends something down your spine when you hear it,” Phil said to me as he shook his head and tried to rid himself of the memory.
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