Inferno

by Steven Hatch, M. D.

  The program was being run out of John F. Kennedy Hospital in the Sinkor section of Monrovia, on Twenty-first Street and Tubman Boulevard, which is the main thoroughfare running from the city center out to the eastern parts of greater Monrovia. JFK had been built by the Kennedy family following the president’s death as a gesture of goodwill between the two nations and in the hope that America’s former colony was on its way to being on an equal footing with the rest of the nations of the earth. You can sense the optimism in the modernist, late 1960s architectural style; it must have been magnificent to look at when it was first built. Standing five stories tall—nearly a skyscraper by Monrovia standards—and washed in white, the building faced onto Tubman Boulevard buffered by a huge lawn, the last real uninterrupted spot of urban greenery as one approached the city center, with two enormous fountains on either side of its main, central entrance point. Standing there, picturing what it must have looked like in the late 1960s, you can almost feel the pride that the nation must have taken in such a specimen. JFK was known as the main referral hospital for the country, but it also catered to a good number of West Africans from other countries. It was a destination hospital, in the same way that I remember the Cleveland Clinic as a child, when the local TV news reported when King Hussein of Jordan had come there for his annual checkup.

  But the JFK of 2013 was looking at those glory days through the rearview mirror, like anything else that was once the jewel in the crown of a country that had gone through such terrible suffering. The fountains were just large holes, empty pools with rusting ironworks where the water had been piped. The shining white had gone drab gray, and what had once seemed soaring modern architecture now appeared more nefarious, vaguely Stalinist in its tone. Much of the interior had been shuttered because the hospital’s caretaking capacity had been severely reduced; there were entire floors that had been mothballed. During rainstorms, the water seeped through the walls by various leaks. Floor and wall tiles that had fallen off were left unrepaired. Paint peeled from the walls. The treatment bays on the floors housed bed frames older than many of the oldest people in Liberia, with torn-up mattresses and fraying linens. The windowless central hallways on the ground floor, which did not admit much ambient light and whose lightbulbs were not quite up to the task of illumination, were so oppressively dark that it felt like perpetual night. For Americans who have never visited a sub-Saharan African hospital, the JFK of late 2013 would approximate their worst fears.

  The one piece of splendor at JFK that remained undiminished was that great front lawn, still pristine in its greenery. But like everything else of what I would come to discover in this country, it too was tinged with the blood of the Civil War. Quite literally, in fact. During the conflict, JFK and many of its staff somehow managed to find a way to soldier on, despite having essentially no resources with which to care for patients, other than their wits. The locals would bring loved ones either sick from some actual disease or from wounds sustained during the violence and put them on the front lawn to be tended by the mostly helpless staff. Given the dearth of equipment, many if not most of these patients died, and the JFK acronym, along with its great lawn, took on a new meaning in Monrovia parlance: “Just for Killing.”

  One of the interns to whom I took an immediate liking was a man named Phil Ireland. I’m used to referring to residents and interns as young men or women, as I am in my mid-forties, dealing with doctors fresh out of medical school who are usually two decades younger than me. I don’t describe Phil as young now because I did that once when speaking with his classmates, a description that was met with a short burst of laughter. Not getting the joke, I asked what was funny. It turned out that Phil was hardly young—he was, in fact, a year older than me, with a family of five children. He certainly didn’t look it, standing six feet tall, with a perfectly shiny bald head, wide eyes, and a huge smile that could not always be found among other Liberians, though whether the lack of smiling was due to custom or cautiousness around an outsider is something I don’t know.

  At any rate, Phil had earned his M.D. as an older student because Dogliotti, Liberia’s only medical school, was shuttered during the Civil War, and even after the cessation of hostilities, rebooting the curriculum and reestablishing its courses with the remaining few faculty members left in Monrovia didn’t happen for some time. Thus, when I met him, he had just completed his degree and was moving on to the next phase of his career. But there was scant advanced training to be had in Liberia, for similar reasons. He was enthusiastic about Emergency Medicine, which was lacking in Liberia, given the level of trauma caused by car and motorcycle accidents in a country that had almost no traffic laws and hardly any domestic police, to say nothing of workplace injuries due to the lax protective equipment in virtually every industry. We talked about the possibility of him coming to the States for specialty training, but when I learned of his age and his family life, I realized that probably wasn’t going to happen given the immense sacrifices that such a plan would entail.

  The residents working at JFK were under the supervision of the chief of Internal Medicine, a man named Abraham Borbor. Borbor had come from Lofa County, up in the northwest of the country, the descendant of a tribal chief, and had been working at JFK for decades, through the Civil War, having manned his post in what must have been hellish conditions. In his late fifties or early sixties, Borbor was a big man with a big presence. He had a high, reedy voice and was quick to laugh while teaching his charges. He was feared by the residents but deeply respected as well. He struck me as a natural teacher who loved having an audience; I imagine that the end of the crisis and the ability to train new doctors must have come as a massive breath of fresh air for someone who had practically lived at JFK for years on end with little hope in front of him, watching the best and most productive years of his career being frittered away while his country tore itself to shreds.

  He was also among the few Liberian doctors who had been outside the country for stretches, having done some coursework in England. So he knew something about how someone like me might view a place like Liberia, and from the start, he and I spoke about medicine not simply in the narrow terms of this drug or that disease but of how an infrastructure can shape a person’s life. One weekend day he picked me up to take me on my first tour of Monrovia, and we drove through some of the most destitute neighborhoods of the city. As I looked around, I noticed some old electricity poles, clearly erected before the Civil War, but sure enough, there was electrical wiring running from one to another.

  “Dr. Borbor, is there a nationalized power grid in place? I’m seeing these wires, but it’s so dark here at night.”

  He cackled at my suggestion of some Liberian power plant. “Oh, that is definitely electrical wiring. It’s hooked up to someone in the neighborhood who owns a generator and sells the electricity.”

  “Oh, I see. And how much does that cost?”

  “Probably eight to ten dollars a month.” An average working Liberian in 2013 made about two U.S. dollars per day.

  “And what does that pay for?”

  “It keeps one lightbulb working at night.”

  Later that afternoon we drove out toward the edge of the city in the Congo Town neighborhood to a popular Liberian haunt known as A La Lagune. We ordered a few drinks and sat talking about our careers, what he had seen during his years in Liberia, and where the country had come. Being November, the dry season was fully underway, and it was hot, so our cold beer and Coca-Cola got warm fairly quickly. As the liquid came to ambient temperature, my enthusiasm for drinking diminished. Borbor took his can of Coke and, as if struck by inspiration, poured it into his glass of Club beer. He looked at the drink and said with that cackle, “Well, it’s going the same place anyway,” and gulped down the remainder.

  I knew from working with him for several days that I admired and respected him, but that’s when I realized just how much I liked Abraham Borbor.

  *

  During the first week I was there I w
ent to help out in the HIV clinic after rounds. We had just finished rounding on the inpatients, twenty in all. The patients presented with a mix of illnesses not too dissimilar from those in an American hospital: a few pneumonias, some strokes, uncontrolled diabetics, a case of heart failure, and some complications of HIV. It was the severity of illness that was different, for these patients were much sicker than their American counterparts. Most of the medicines required to care for these people were in good supply. The hospital pharmacy didn’t have the newest antibiotics or fanciest insulins or the most expensive beta-blockers, but what they had was enough that their outcomes shouldn’t have been completely different. Of the twenty patients on the floor that day, all had been there for some time, and they seemed stable. I felt confident of their plans moving forward, even in as profoundly limited a place as JFK.

  On the way down to the HIV clinic, my phone rang. One of the visiting obstetricians, a doctor from the University of Maryland named Kiran Chawla who had spent years in Liberia working for MSF, said there was a patient in the maternity wing of the hospital that she wanted me to take a look at—could I come over right now? I said sure. When I got there, I found a young woman who looked to be mostly baby—that is, the baby she carried inside her—and the rest bones. She was emaciated in the extreme; I doubted that she’d be capable of standing. She was hooked up to an oxygen tank, a huge, clunky apparatus that was probably used in the United States in the 1970s or maybe early ’80s, whose pump generated such an insane amount of noise that it was difficult to hear someone speak in its presence. But what impressed me most was how fast she was breathing. A healthy adult typically gets through one minute taking somewhere between eight and twelve breaths. Her respiratory rate was almost sixty. I got tired just looking at her.

  Kiran looked at me. “She’s twenty-four weeks, Steven,” she said, referring to the gestational age of the baby. Even in the States, a baby delivered at twenty-four weeks has poor odds of survival, and in Liberia, without the availability of certain drugs to keep a preemie alive, no child could survive being born that young. “There’s nothing I can do for her. The procedure would probably kill both of them. I think she needs to go to the medicine service and see if you can stabilize her.” It made perfect sense, so I called Ian Wachekwa, a Zimbabwean doctor who was one of the residents in this new medicine residency, and asked him to come over so that we could facilitate getting her to the medicine floor, which was in the adjacent building.3 Once he did, we made the arrangements to get her over, and we headed to the clinic.

  In the clinic, I saw two young women in quick succession who were obviously quite ill and were going to need to be admitted. One came stumbling in, helped by her father, her body shaking in one prolonged tremor. It was hard to find out anything meaningful from her, and besides getting a blood count, there was nothing we could do until we could get her to the floor and arrange for a spinal tap. So we called to inform the floor resident and sent her upstairs. The next woman had much the same story but was confused and had been losing weight. For her, we added an X-ray, since she had a mild cough, since at least it was something we could do. Both of them had fairly advanced HIV infection which meant that almost anything could be wrong with them, and we had virtually no tests by which we could make any meaningful diagnosis. We had blood counts and chemistries and a malaria test. Whatever was going on with these women, malaria would have been only the beginning of their problems.

  By the time we got back upstairs a few hours later at the end of clinic, all three had died. The woman who came from the maternity ward had died even before she made it to the floor. Transporting a patient at JFK involved moving the bed over some bumpy spots, and the physiologic stress of those bumps, along with the general movement of the bed, was too much for her tenuous respiratory status, for she had been holding onto her life by her fingernails. I went back to the dorms on the campus of JFK that night, dejected.

  When I returned the next day at the morning meeting, the house officer, a young man named Zoeban Kparteh, ran the list, where he reviewed the events of the evening: There was one other admission in addition to these three. Then he went on to note that four of the floor patients had passed away, all but one quite unexpectedly, and all under the age of thirty.

  That meant, of twenty-four total patients, seven had died in that one-day span.

  I’m a doctor, so I’m used to people dying as part of my work. I’ve worked in Haiti and I’ve seen hospitals in other parts of Africa as well as South America, and I routinely consult on very sick patients in ICUs in North America, all places with high mortality rates. But I had never before seen that level of death, coming in such quick succession, and in so many young people. After I left the hospital that day, I walked a few blocks to the nearby supermarket, a Lebanese-owned bodega called The Exclusive Super Store, bought a large bottle of Johnnie Walker Red, walked back to the dorms, and drank most of it that night by myself, with a little help from Kiran, whose sentiments were, “Welcome to Liberia, Steven.”

  In the coming days I made inquiries about the mortality rate at JFK, and my mind reeled. “Oh, it’s about 40 percent,” Ian told me, almost with the casual air of someone who had been following the price of Apple’s stock. “The problem is that people know that if you go to JFK, you’ve got a pretty good chance of dying, so they delay coming when we might be able to make more of a difference, and then they end up coming so far along in their illness that they don’t do well, and you have this high mortality rate, which reinforces the sense that you come here to die.” The mortality on the surgical service in 2013, according to the residents with whom I spoke, was an astonishing 70 percent, for much the same reasons.

  Most of us in the developed world don’t pause to think how amazing it is that we drink water from a tap and never once worry about dying forty-eight hours later from cholera. Spending some time in Liberia might help to reveal just how amazing that really is. In a two-week tour, I saw examples of how the lack of such wonders as running water, the ability to summon light at any moment of a twenty-four-hour cycle, and cheap and efficient transportation all led to people worrying about dying from any number of maladies, even including cholera. Liberia’s rudimentary infrastructure underscored how these normally invisible advances that make life so livable elsewhere are crucial to the chances that you’ll live to see thirty.

  That one night was probably the best preparation I could possibly have for working in an Ebola Treatment Unit, whose mortality rate wasn’t appreciably different than that of the combined adult specialties at JFK Hospital.

  *

  After I returned to the States from my introduction to Liberia, the early months of 2014 proceeded apace. Trish McQuilkin and I talked about working on a research project in Monrovia, and I schemed to figure out a way to return in the coming year. It wasn’t where I had originally envisioned working in Africa, but with the promise of Borbor’s company, some very nice residents who seemed genuinely appreciative of my presence, and decent Lebanese food to be had in Monrovia without much effort, I thought it an opportunity worth pursuing. Trish had gotten a small grant funded, the goal of which was to investigate all the potential causes of fever in children: Because there was virtually no laboratory testing available in postwar Liberia, nobody knew with any certainty whether a child presenting with a fever had malaria or typhoid or scarlet fever or any of a dozen other causes. Everything was a guess, and Trish’s project was to take out some of the guesswork. As winter turned into spring, we bounced a few e-mails back and forth, and I tried to clear some time to return the following fall.

  Then, on March 22, I noticed a headline in The New York Times with the title “Guinea Confirms Fever Is Ebola, Has Killed Up to 59.” It seemed odd to me at the time. Ebola had been almost exclusively a Central African problem, so having an Ebola outbreak turn up nearly three thousand miles from there was, to say the least, unusual.

  Technically, it wasn’t unprecedented: In 1994, one lone case of Ebola turned up when a veter
inarian had found a chimpanzee carcass in the Taï Forest National Park of Ivory Coast. She had performed a necropsy on the animal and several weeks later had become so ill that she was flown to Switzerland for care. Specific antibody tests for the Zaire and Sudan strains of Ebola were negative, but the less specific antibody test lit up, indicating there was yet another strain.

  To this day, this is the only known human case of what is now called Taï Forest Ebolavirus. The patient survived after a prolonged critical illness, which technically means that as of now, the mortality rate of Taï Forest Ebolavirus is zero. Yet were it not for that single instance, West Africa would have never known Ebola, and even then, the Taï Forest case mainly served as an answer to a trivia question for hemorrhagic fever buffs like me. Eerily, during my time in Liberia the previous November, before the outbreak, I had given a presentation to the residents at JFK about hemorrhagic fever viruses. Most of that hour was devoted to talking about Lassa Fever, the one hemorrhagic fever that they were likely to encounter in their careers, as Liberia has among the highest number of Lassa cases in the world. But when I took a brief detour into Ebola, I pointed out the location of the Taï Forest virus to drive home that Ebola could, in fact, be found in West Africa, then drew a circle around the two adjacent countries of Ivory Coast and Liberia, and flashed the caption “Not Too Far from Monrovia!” I thought it amusing at the time, because I didn’t believe they’d ever require this knowledge.