Inferno

by Steven Hatch, M. D.

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  APPROPRIATELY, FOR MARK

  Author’s Note

  When doctors, nurses, and other health-care professionals write about their experiences, they face a particular challenge in how to describe their experiences with patients. On the one hand, I believe that it is critically important to tell the story of the Bong County Ebola Treatment Unit, in no small part so that readers who have not been to Africa can know something about how Ebola affected real people there. On the other hand, patients are entitled to privacy, and should not have to worry about whether their doctor will inappropriately expose their lives for the world to see.

  I have tried to walk this fine line by leaving out of this story identifying details about the lives of the patients described in the following pages. In many cases, I have provided pseudonyms and altered superficial aspects of patients’ lives so that they are not identifiable. Patients whom I describe from, say, Nimba County may have actually come from Lofa or Margibi counties instead; a man with a daughter may have actually had a son; and so on.

  However, a number of the patients from the Bong County ETU had previously been interviewed by local Liberian media as well as a variety of international news organizations. I have not changed the names of those patients who had consented to such interviews, and also of some others whose names were already publicly known. Even as to those, however, I have avoided adding further details about their stays in the ETU beyond what is already a matter of public record.

  How I wish I was in a dream, and I’m waking up, and I discover, “Oh, that’s a dream.”

  —Joshua Blahyi, formerly known as “General Butt Naked,” circa 2013

  INTRODUCTION: THE ABANDONMENT OF UNWHOLESOME THOUGHTS

  I think we’re never going to agree, for our disagreement is one between sensibilities. I’d designate them as, on the one hand, the ironic and ambiguous (or even the tragic, if you like), and, on the other, the certain. The one complicates problems, leaving them messier than before and making you feel terrible. The other solves problems and cleans up the place, making you feel tidy and satisfied. I’d call the one sensibility the literary-artistic-historical; I’d call the other the social-scientific-political. To expect them to agree, or even to perceive the same data, would be expecting too much.

  —Paul Fussell, “Thank God for the Atom Bomb”

  Not long after I submitted the first draft of this book to St. Martin’s Press, I found myself sitting in a lecture hall at the medical school listening to a group of students who had won prizes for writing in medicine. Over the next hour and change, the prizewinning students read aloud their essays or poems to the crowd. For the most part, they told stories about the patients whom they encountered as they began their formal training. The patients one meets at the beginning of training tend to form an indelible impression, and these students wanted to preserve those memories for posterity.

  After listening to a few readings, I was struck by the similarities among the pieces, even though the writing styles differed from one another, sometimes starkly so. Virtually every student’s musings, whether in verse or prose, were preoccupied with what the process of learning medicine was doing to them as individuals. It was clear they feared losing an essential quality of themselves as the riptide of medical knowledge and the jargon of physicians pulled them away from the shores of some perceived humanity. You could practically hear all of them shout that they didn’t want their capacity for caring and empathy to abandon them, dreading that the system was grinding them into soulless automatons as they learned how to reduce their patients’ lives and hopes and dreams to a few terse lines summarizing their “history of present illness” and “past medical history” and culminated in some efficient medical plan. There was a shared poignancy to their laments.

  One particular student’s words caught my ear. The piece was written by a young student doctor named Haley Newman, someone whom I had known peripherally while she was doing her internal medicine rotation. Her essay described her relationship with a veteran who had been given an unexpected diagnosis of a devastating illness, a cancer with which he would have long and unpleasant battles. She had a gift for words and was able to paint a picture with a carefully selected image: “His Vietnam Veterans of America hat was always sitting on his bedside table, along with a bag of Lays potato chips and a Snickers bar” was but one image that struck me as coming from someone destined to write a weekly column, or a book, on medicine.

  Haley’s essay was an exercise in enumerating the misgivings that to some extent plague the lives of everyone who takes up the stethoscope as a calling. “Regardless of everything dehumanizing in the hospital—the blue johnnies, the tubes and IV lines, the meals on trays and red help buttons—these individuals are not just patients,” she wrote. “They are unique people with powerful stories, and their identities should not be erased by their illnesses.” To my ears, her eloquence masks a quiet rage against all the degrading aspects of medicine, a process she can sense is already changing her, hardening her in ways such that she may not even be able to recognize herself a few years hence.

  It’s even worse than she knows, for some of that learned insensitivity to suffering is pretty much required for us to care for our patients, and it constitutes one of the central paradoxes of being a doctor or nurse. The good news, I want to tell her, is that it really is possible to maintain the human element in medicine, although it takes some conscious effort. The bad news is that one almost never stops fighting this rearguard battle to preserve that element every day of one’s professional life, and even the finest physicians will have a career littered with defeats.

  These student essays also underscored another feature of how we medical professionals cope with that kind of paradox: We simply bear witness to what happens to our patients. All of the essays told stories of sadness and loss, and that kind of activity continues well beyond medical school. We tell these stories to one another in conference rooms, quick conversations in hallways, longer rap sessions with spouses or friends, and for some of us, in formal writing. They provide our way not only of coping but of reaffirming why we chose the work of caring for total strangers in the first place. Nearly all great literature is an affirmation of humanity, and the act of bearing witness is what the best writers have done for millennia. But doctors’ stories are our special means by which we can say to the world that the lives of our patients matter and the practice of medicine is essential to humanity. We tell these stories by using the technical language of anatomy and physiology, as we elaborate upon the privileged access we are granted to our patients’ bodies and, on occasion, souls.

  At its core, this book is no different than Haley’s essay and those of her classmates whose work illuminated that day; it possesses the same structure, with the same goals in mind. As the title proclaims, Inferno is a doctor’s story of the Ebola outbreak. It is an attempt to use my experiences as a physician working before, during, and after the West African outbreak of 2014 and 2015 to provide readers with an understanding of something
beyond much of the news coverage at the time—especially the television news, which so greedily chewed up and spat out images of workers in space suits moving alongside dying Africans.

  The West African outbreak, an unprecedented biological catastrophe that killed tens of thousands, completely shut down the three countries of Guinea, Sierra Leone, and Liberia, along with the twenty-two million people who live there. During that time, Ebola’s tendrils reached far beyond this small patch of African soil. The virus itself managed to find its way to ten countries in all, although the fear it engendered caused governments around the world to hastily alter travel policies and infection control procedures. An Ebola story simply focused on what took place in air travel could easily fill a volume; a different story about what happened to the world stockpiles of, say, latex gloves (a rudimentary yet critical piece of Ebola protective gear) could, in the hands of a good writer, make for gripping reading. But this is a doctor’s story, one that focuses its gaze on the destruction of the body as part of a doctor’s daily work.

  My goal, in writing this story, is to ask a few simple questions. Why did this Ebola outbreak kill so many, when twenty prior outbreaks never infected more than a few hundred? How does the virus spread, and ultimately kill, with such ruthless efficiency? What impact did it have on the lives of the people who lived through the epidemic—those never infected, as well as the survivors? And what could have been done differently so that there was less aggregate misery once the virus jumped into its first human host? My experiences—what happened to me in real time—are what I use to frame these questions.

  Answers of a sort can be found in the pages that follow. However, I am less interested in providing the reader nice, clearly defined solutions to these questions, as if they were a kind of mathematical equation, than I am in wanting to impart a sensibility about the meaning that the story of the West African outbreak holds for readers everywhere. If after reading the final page you have a distressing sense of the depth of the problems the Ebola outbreak unmasked and just how fragile the idea of optimism is in this troubled part of the world, then I have achieved at least one of my aims in writing this.

  In the late 1980s, the essayist, literary critic, and political commentator Paul Fussell wrote a provocative essay with the even more provocative title “Thank God for the Atom Bomb,” which, as advertised, offered an explanation of why he was thankful for that act of ultimate aggression. It appeared in the pages of The New Republic; after its publication, Michael Walzer, the author of Just and Unjust Wars, took Fussell to task for what he perceived was the defense of a morally indefensible act.

  Far from being a far-right-wing nationalist screed about extremism in the defense of liberty not being a vice, Fussell’s reply to Walzer’s critique sketched out the importance of experience in shaping one’s thoughts about the world and how the further away from a complicated and contradictory situation one gets, the easier and more tidily such ambiguities get resolved in the minds of those who did not live through it. His objective was, in some sense, to scramble the debate about the ethics of dropping the atom bomb since it presupposed a clarity of moral choice, yea-or-nay, that was far foggier in the moment.

  Fussell’s quote that opens this introduction encapsulates his philosophy: an explanation that demands we cradle a sense of tragedy and irony when we encounter history, and not simply banish it to the far reaches of our consciousness. Since the tragic sensibility is, almost by definition, so painful to maintain, it is asking a lot of readers, and it is understandable why so many social scientists and other commentators can hold forth on a variety of historical horrors with a sense of happy certainty. If only X hadn’t taken place, then Y wouldn’t have happened, you hear the arguments go, and suddenly history transforms into a series of easily correctable mistakes, instead of an appalling slog of frequently stupid, inane, and self-mutilating events as we collectively slouch toward Bethlehem.

  I’m not here to relitigate arguments about the ethics of the atomic bomb but only to note that this book takes its cues from Fussell and attempts to locate itself in that literary-artistic-historical tradition of which he writes. And I partly follow his lead in thinking that experience can shape perspective. Not everyone could experience the Ebola outbreak in order to arrive at such a sensibility; this book is an attempt to help translate that experience for readers.

  Despite coverage from news organizations that exhibited a wide range of depth and quality, the media portrayal of the Ebola outbreak was surprisingly uniform in terms of how it portrayed the “bigger picture.” By my reckoning, it could be summarized thus: Ebola was a major catastrophe that was stopped through the heroic efforts of aid organizations working in conjunction with local governments, with significant help from several countries outside Africa. That is the social-scientific-political way of understanding the events of the largest Ebola outbreak in history. There is a certain truth to it. But Inferno tries to add a deep sense of disquiet to that mostly upbeat, but largely shallow, narrative. Yes, the outbreak was brought to heel, and people’s lives are better in West Africa today as a consequence. But to provide a more complete perspective on what took place, it is necessary to lace a good deal of despair around a tenuous thread of hope, and the stories I tell in the following pages have that objective in mind. I would like to think Inferno isn’t oppressive in its outlook, for I do mean to try to convey a kind of hope. Nevertheless, reading it may well make you feel terrible, at least for a time.

  Anyone who has read Richard Preston’s work of horror The Hot Zone knows that Ebola stories center on the virus’s astonishing lethality and the grisly manner by which people die—namely, bleeding from every orifice. That story has been written, however, and Inferno tries to offer a different perspective (and, on occasion, correct some misunderstandings that Preston created) so that the word Ebola conjures up more than mere fear but rather a tragedy created by the virus, one that affected real humans whose lives have been thrown into chaos because of the contagion. In The Hot Zone, the central character is the virus itself, while the people it infects are mere props. Most of the news coverage of the outbreak, especially the television news coverage, followed Preston’s lead in this respect.

  Inferno by contrast puts the spotlight on people: principally the Liberians infected by the virus but also others who worked to see it halted. I’m not interested in engendering fear but, instead, a sense of loss, for there was much of that as a result of the epidemic. To understand the contours of that loss, to feel that loss, is to veer away from the vicarious thrills that much of the news coverage encouraged, even if it was mostly subconscious.

  I have studied lethal viruses and bacteria for most of my adult life, and I can assure you there are a good many other infections whose reputations should be equally notorious as Ebola’s. The Nippah and Hendra viruses, for instance, cause encephalitis (infection of the brain), can be lethal in up to one-third of cases, and have been associated with person-to-person transmission; the movie Contagion was based on an imagined version of an easily transmissible Nippah variant. Plague still continues to plague civilization, as it were, and we may well hover on the verge of a massive outbreak of plague’s agent, Yersinia pestis; the last episode of airborne plague occurred in Surat, India, a city of four million people, in 1994. Then there is SARS, perhaps the one virus that I find truly frightening, as it is about as lethal as Ebola but spreads much more efficiently, since it is a respiratory virus whose transmission dynamics are not much different from those of the common cold. I could go on like this quite happily for some time, and you would lose sleep for a night or two.

  The question, then, is why does Ebola occupy the starring role among the cast of lethal viruses? I would argue that the features that make Ebola so terrifying are plainly visible in the news coverage devoted to outbreaks over the years, as well as nonfiction books like The Hot Zone, and even fictional accounts based on the virus, like the 1995 box-office hit Outbreak. They revolve around three basic themes: blood, faceless
ness, and, of course, Africa—a region about which Westerners in particular have much angst and guilt.

  In short, it is the legacy of slavery that lurks beneath the surface of the anxieties unleashed by Ebola. The profound otherness of Africa and its people is a direct consequence of European government policies that lasted generations on end, which led to unspeakable acts that debased the humanity of all the participants. But the termination of slavery as an institution did not end the mutual mistrust, and the iniquities of our European forebears have been visited upon us in countless ways. (They need not be literal forebears, either, for we have all inherited their model of government, as well as their notions about liberty, despite the concept of “liberty” resting on the backs of the millions of African slaves without whom the building of the modern world might not have taken place.) The sins of slavery have been ingrained into our consciousness, even without our consent, and continue to make discussions of race so discomfiting today. Richard Preston described Ebola in one metaphorical fugue as “the revenge of the rainforest,” but what makes The Hot Zone in part so disturbing is that the virus is just as easily understood as Africa’s revenge, and all the baggage that goes with it, the ultimate payback for five hundred years of barbarity.

  Inferno starts with the assumption that one must rob the virus of its metaphorical power, which requires calling attention to the institution of sub-Saharan African slavery and the changes it wrought on at least three continents. While I am not writing a book about slavery, one cannot truly grasp something essential about the outbreak unless one begins to come to terms with it, and in particular how slavery has seeped into the American worldview in ways about which we are often only dimly aware. To talk about the “meaning” of the outbreak is to shine a flashlight on the nearly imperceptible threads that link Westerners, West Africans, and a good many other people to the decisions made by, say, ministers who lived in London or Amsterdam four hundred years ago.