Inferno

by Steven Hatch, M. D.

  In Bong County, we were much luckier. Time and space allowed us develop a proper cemetery, and all of the dead from the ETU were buried there. You got to the cemetery by walking the peripheral road next to the compound and then veering to the left down the hill where the jungle takes you back into its arms and the gravel, fencing, and blue tarp suddenly seem a distant memory. The trees stand about ten meters high and have vines that cascade down them. The clearing for the bodies is a little bigger than a basketball court. The gravesites are lined up in neat rows. The birds and insects assert themselves here, sometimes loudly, but even with this noise there’s a profound silence that hovers over it. I think it is one of the most beautiful places that I have ever been on earth. I also think it is one of the most horrifying.

  There are about five rows of graves, with the earliest victims buried in the first row, moving outward in time as the outbreak continued. I start to know the people behind the names at the end of the first row, and I stop knowing them midway through the fourth. Their names are marked on wooden markers about the size of a car’s license plate, and I can see them in my head. Winner Thomas. Moses Gboi. Freeman Sirleaf. Joe Bongo. Ballah Kollie. Robert Yini. Mamie Flomo. Willie Rancy. Yattah Singbeh. Dorcas David. Solomon Zonnah. There are other names there as well, people whose stories I do not know, who had died in the two weeks before I arrived and the two months afterward. Aaron Tokpah. Kammah Paye. Fatu Cyphus. Roland Sackie. Matthew Tarweh. Baby Kerkula. By the time the Bong County ETU had closed its doors, nearly 150 of these graves were occupied. Not all had died from Ebola. If a patient died in the ETU but their test returned negative, they still had to be buried there, because of the concerns that the body might have copies of the virus as a result of having been inside the Hot Zone. But most of the patients, at least one hundred of them, had died from the virus.

  A group of day laborers was hired to do the work of digging the graves. Although I only rarely saw them since I was pretty busy up the hill, when I came down I could see how physically demanding the work was. They required thick leather gloves to hold the wooden shovels and spades necessary to go two meters into the thick and muddy African soil. The repetitive motion caused so much wear on the gloves that they had to be replaced every few days. I promised myself that I would go down at some point to help out, but the weeks passed quickly, and then I found myself headed for home, and one of my major regrets from that time is that I never did assist in this simple yet challenging task, both for their dignity, and mine.

  John Jameson was one of the members of the gravedigging team. Ben Solomon of The New York Times interviewed him for a seven-minute clip called “Inside the Ebola Ward.” It was a masterpiece of journalism in Bong County, with Ben’s video accompanying Sheri Fink’s words and Daniel Berehulak’s photographs as the definitive account of one small corner in the Ebola battle. Two others were featured in the piece: Garmai Cyrus of the psychosocial team and Colin Bucks of the medical staff. Jameson, however, was given the last word in the interview, an editorial decision on Ben’s part that proved prescient, Garmai’s and Colin’s eloquence notwithstanding.

  “We won’t forget about Ebola,” Jameson said. “I’m working as a gravedigger. I’m not a doctor or a nurse. Instead of me spending the day doing nothing, I decided to join in the process to fight against Ebola. Our brothers and sisters, they are all dying. Day and night. Every day. They brought a baby here when the baby died. Four days old baby. So they could bury the baby close by her mother. No mercy from Ebola.

  “I have a family. I have two children. When my children grow up, they will see in magazines, in books, and they will see some pictures about Ebola. They will know, ‘Oh our dad [was] here. I think he was fighting through the process during the times of Ebola.’ They should be proud.

  “Ebola is affecting the world seriously,” Jameson concluded. “If I go and sit aside and just be looking at it, you know what Ebola will do? It will damage so many people in this world. So when I’m working here, I’m helping to save the world.”

  It is because of men and women like John Jameson that the world still stands.

  The baby to which Jameson referred was, of course, the baby that had been born to the woman whom I so hastily evaluated without adequate protection in the first week of October, whose name was Diana Flomo. As most of us had predicted, though without any satisfaction, the baby, who probably had Ebola, did not have long to live. To the best of my knowledge, that chain of death ended there, and no one else was infected.

  Stu Sia had been the person in charge of marking the graves. It is his handwriting that I can see on the markers in my mind’s eye. The strange quality of seeing your handwriting coming back to you in unanticipated moments has always fascinated me. My handwriting from this time can be found in the pages of our admission ledger, but Stu’s is a more public remnant of those few months. The initial lettering was done with a Sharpie because of a lack of black paint, an improvisation that was later corrected so the names could persist for posterity. Though what the jungle will do to some simple wooden markers, or how quickly it will do it, is unclear.

  In addition to the names of the dead, which are introduced by the phrase, “In Loving Memory,” the grave markers have one additional piece of information: the birth and death dates. Many older Liberians do not know their actual birthdates, nor do many who were born during the Civil War, since the accurate recording of time was a low priority then. Without knowing this, your eye might be caught by the shocking number of people who were born on January 1, but it is just a quirky by-product of those times. Unlike graves in the States, where these dates are usually provided by the sterile descriptors of “born” and “died,” Liberians have opted for a more poetic way to proclaim a person’s entrance into and exit from this world. Sunrise is your beginning. Sunset, your end.

  Bendu Howard is a name that you will not find in that cemetery, as her sunset, I hope, is still far off in the future. A sixteen-year-old, Bendu fought off the virus, and in her convalescence discovered she had an appetite for caring for others. At the time she was nearing complete health, there were many children in the confirmed ward, and Bendu had started following the nursing and psychosocial staff around to learn about ways in which she could help. Before any of us had processed it, we were training Bendu. By the time her viral load was negative, she had made the unfathomable request to stay on in the unit and help out for a few days. When I heard about the request, I just blinked in astonishment, and I was hardly the only one.

  The few days passed, and then when she was ready to return home, she asked if she could come back to work for us. If she really was immune, she reasoned, she would be an asset in the confirmed ward because she could stay in all day without PPE and help in the daily tasks. So each morning she came to work, passed through into the Hot Zone, and then emerged at the end of a shift through the decontamination shower just as every patient did on discharge. When I last saw her, she had declared to me that her life’s calling was to be a nurse, an idea that took shape as a consequence of being in the presence of the very finest that profession has ever produced.

  There were other sunrises that took place in defiance of Ebola’s deadly menace. As the worst of the outbreak had passed and the streets of Monrovia were returning to normal by late 2014, there were news reports of an upsurge in weddings. In mid-2015, one of the more unexpected weddings took place, one to which the IMC staff had become connected. Two of the staff working in the operation’s headquarters in Monrovia, one a Liberian and the other an expat, had fallen in love. Had the outbreak never happened, they never would have met. I did not know the happy couple myself, but I followed the event on my IMC friends’ Facebook feeds. The pictures included several of the people I knew, no longer appearing grimy and wearing the cheap clothing or scrubs in which I had become accustomed to seeing them, but decked out in formal finery, all beaming.

  The burials that took place that terrible year were designed to provide a sense of dignified closure, even those bu
rials, like the ones in Bong County, that were finished within a minute and performed with few words and often no tears. But the weddings that returned to Liberia, Sierra Leone, and Guinea were the ceremonial bookends to the Ebola outbreak—communal assertions that, whatever setbacks lay ahead, happiness and contentment would still triumph. There were more sunrises to be witnessed.

  Notes

  Chapter 1

  1. While the above etymology is from Peter Piot’s memoirs, an alternate explanation is that Ebola is a corruption of the French colonial l’eau blanche, which means “white water.” Given the behavior of the French, Belgians, Germans, and British in the Congo River Basin in centuries past, it may be harder to come up with a better name for the virus than that, on second thought. The articles explaining both versions are cited in the bibliography.

  2. I am following the timeline supplied by the World Health Organization. On August 9, 2014, The New York Times reported Emile Ouamouno as having died in early December 2013, although in a later story in the Times entitled “How Ebola Roared Back” (December 30, 2014), a picture of a list of the victims transcribed by one of the villagers of Meliandou showed the dates consistent with the WHO timeline. Likewise, the BBC reported that it was a midwife in Meliandou who sought care in Guéckédou rather than Koumba Ouamouno, but WHO’s flowchart indicated otherwise. Moreover, it is also worth mentioning that Emile was sometimes identified as a one-year-old in the news reports by these organizations. All of these minor discrepancies highlight the difficulties of recording accurate information in the midst of this fast-moving epidemic in a place as remote as the rain forests of West Africa, especially given the potential for misunderstandings between Western reporters working on tight deadlines and rural African villagers. (NB: “How Ebola Roared Back” is essential reading for anyone wishing to understand more details about the problems in the early global health response, of which I relate only a small amount here.)

  Chapter 2

  1. I modernized the English, lest the crude spelling distract from the searing message.

  2. The Americoes were also commonly referred to as Congos by the natives. The origin of the term is not fully clear, as the Congos may originally have been slaves from the Congo Basin who never made it to the West but were repatriated to what is now Liberia by the British navy, and thus constituted a distinct group from the American immigrants. Whatever the truth, the people referred to by these names eventually became the ruling elite, whether their origin was a village near modern-day Washington or modern-day Kinshasa.

  3. Ian went to medical school and did his early training in Zimbabwe, where he met his Liberian wife. She convinced him in the late 2000s to come with her back to Liberia. Health care in Zimbabwe is significantly more advanced than in Liberia, which made me wonder about the professional sacrifices that Ian has made for his family life. “Ian, do you ever say to your wife, ‘Hey, we could go back to Zimbabwe?’ Like, the situation there has got to be better, right?” To which Ian dryly responded, “I have that conversation quite often, in fact.”

  4. Based on my brief experience with them, MSF appears to be less a single unified organization than it is a conglomeration of several semiautonomous groups: MSF Belgium, MSF Spain, MSF New York. Over the course of August I spoke with not only MSF Belgium as related above but also MSF New York, who gave me the same basic response after having me fill out an interminably long application. When I arrived in Bong County, I discovered that IMC had “picked up” several MSF alumni who had gotten a similar runaround. I wasn’t completely surprised that MSF wasn’t going to take me sight unseen for work in an Ebola unit, but I was nearly stunned that their organization’s HR wing couldn’t streamline their procedures for their own physicians, some of whom had worked for them for longer than a year.

  5. Now LCDR Elizabeth DeGrange.

  Chapter 3

  1. R & R was mandatory for the full-time workers for International Medical Corps in disaster situations. It typically consisted of a ten-day spin pretty much wherever the staff person wished to go; many of the staff traveled to sunny, beachy places across the globe. The purpose of R & R was, as the letters imply, to get some rest and relaxation so they are fit to return to the hard work in the stressful environment in which they work. Ironically, however, it was not unusual for staff to return from R & R more spent as a consequence of partying a bit heavily, at least in part as a coping mechanism to deal with the psychological trauma of the work.

  2. Trish Henwood, whose specialty within ER involves expertise in using ultrasounds, effectively performed an end run around the stethoscope problem by bringing portable ultrasound technology to the confirmed ward. Ultrasounds are basically higher-tech versions of stethoscopes that provide even greater detail than Laennec’s invention and avoid the infection-control problems associated with the stethoscope. But the ultrasounds arrived at the Bong ETU after I left.

  Chapter 4

  1. Trish Henwood, seemingly the whiz kid of the physicians, later found a better way around the data-extraction problem by taking pictures of each chart page with an iPad as I held the page up at the boundary, then the data was manually reentered on the other side. Again, it’s one of those logistical matters that seems the obvious solution in retrospect, but we were thinking about a good many other challenges at the time, which is why she got a publication to her name in The New England Journal of Medicine and I did not.

  Chapter 5

  1. On the whole, I was right about this. 60 Minutes aired “The Ebola Hot Zone” a few weeks later. The good news about the report was that it did an outstanding job of providing a viewer with a sense of how an ETU works in about fifteen minutes and included two great interviews with Colin and Kelly Suter. Watching it back in the States, I thought it helped provide people with a real understanding about the form and the function of the ETU, and I was impressed. But the bad news was that Liberians, who comprised two-thirds of the staff, were almost completely ignored. Even the patients themselves mainly served as window dressing. Unfortunately, it was exactly what I expected from a TV crew working for a major U.S. network. By contrast, Ben Solomon’s video dispatches of the outbreak for The New York Times included extensive interviews from many locations throughout West Africa.

  Chapter 6

  1. ECOMOG stands for Economic Community of West African States Monitoring Group. As an aside, among the many aspects of Liberian culture with which I became enamored is their impish and sardonic sense of humor. From what I can tell, Liberians love to be creative in providing alternate interpretations of national organizational acronyms. The military junta that Doe led was named the People’s Redemption Council, but on the street this was renamed People Repeat Corruption. As Doe’s tenure ended and the Civil War began, a group of exiled Liberian politicians claiming to represent the various Liberian political factions met in the Gambia to develop a power-sharing arrangement. They dubbed the conference Interim Government of National Unity, which cynical Monrovians almost immediately rechristened Imported Government of No Use. When the largely Nigerian forces of ECOMOG arrived, whose troops were only marginally better than the actual Liberian combatants during the Civil War since they displayed a special talent for looting privately owned goods, the locals took to calling them Every Car Or Moveable Object Gone. In the midst of the Ebola outbreak, the International Medical Corps was sometimes wryly referred to as International Money Comes!

  2. Johnson continues to reside in Liberia and serves as the senior senator from Nimba County.

  3. A useful hour can be spent watching Frontline’s special “Firestone and the Warlord,” made in conjunction with ProPublica. It is wise not to eat prior to the screening.

  Chapter 7

  1. In terms of the patients who had recovered, there was one major incentive to remain, so powerful that, however bored or annoyed they might have gotten, none dared leave the ETU even when they were fully restored to health. When patients had finally cleared the virus, they were given a stamped and signed certificat
e saying that we at IMC vouched for their recovery and that they were no longer contagious. Patients were perfectly able to walk right out of the ETU whenever they wanted, but without that certificate, the chance that they would be shunned by their neighbors, and quite possibly attacked to the point of death, were quite high. They all seemed to know this, and so nobody ever hinted that they were going to leave.

  Chapter 8

  1. Or that’s at least more or less what I said. I can’t find the damned clip on the Internet anymore.

  2. My daughter’s idiotic math tutor had already backed out even before I returned home, despite multiple reassurances that I would never even touch her during the monitoring period. The silver lining was we got a much better math tutor out of the process.

  Acknowledgments

  While I wrote the words, this book could not have been possible without the help of the following people, through their intelligence, their warmth, and their willingness to give.