Of course, being resolved to help out is nice, but I didn’t have the first clue about how to get over there with the right kind of organization. During the last few days of July I looked around on the websites of MSF, which had been holding increasingly strident press conferences saying the international response was far too inadequate and which led me to assume there would be some place where one could easily find out how to volunteer. But no such luck. Being an academic physician, I didn’t know much about any other aid organizations, so I turned to the CDC website and decided to see whether someone at the Special Pathogens Branch might know something. The Special Pathogens Branch handles dangerous viruses that cause lethal outbreaks such as Ebola, so I thought that maybe someone there might be able to point me in a direction.
The Special Pathogens Web page listed the name of the director, Dr. Craig Manning, and a phone number. To my surprise, I reached him directly on the morning of August 1, and we began to talk. “Steve, it’s interesting. You’re the third call I’ve gotten this week, and I’m not sure what to say right now. Obviously the CDC is working on this but I don’t know what to say for someone like you,” he said. “I do have this friend from Ireland who works for WHO, why don’t you send him an e-mail and tell him I sent you, and see what happens.”
Off went an e-mail to Ireland. A few days later, I got a reply, the gist of which was: Can’t help you myself, Steven, but why don’t you try my friend at MSF Belgium, and if that doesn’t work try this person who works in a different division of WHO. So I wrote the woman at MSF Belgium. “Thanks for your interest,” she wrote, “but right now we’re only looking for people who have experience working in Biosafety Level 4 conditions.… If you’re interested in placement in a different location, we’ll be happy to send you an application.”
That caught me quite by surprise, for it seemed as if MSF was haranguing the world health community on a daily basis to step up its response. Now they were turning away people offering to help? Moreover, surely given the size of the outbreak, weren’t most of the people with experience in Hot Zone work already spoken for?4
Thus, a few days later, it was on to someone else at the WHO, this time in Germany. The next day or so came a reply. “You know, I have a colleague named Hilarie Cranmer, an emergency physician from Massachusetts General Hospital who is coordinating with International Medical Corps, and I’ve cc’ed her on this message,” said the note. “Hope that is a help.”
Over the span of about a week, I had pinged e-mail contacts almost completely around the globe, and at the end I found myself connected to someone who lived only a few miles from my doorstep. Hilarie and I spoke that week for maybe ten minutes in what I later realized was something of an informal interview, and I recounted in a very cursory way why I not only wanted to go over but was “qualified” to do so: I was an infectious disease doc who had more than a nodding acquaintance with hemorrhagic fevers, even if it was only the far less lethal dengue virus, and had been to Liberia, even for only a mere few weeks. “Got it, that makes sense,” she said in the highly succinct summary for which ER doctors are known. “Let’s stay in touch, and I’ll let the IMC human resource people know to look for your CV.”
By now it was approaching mid-August, and with each passing day the outbreak was on its way to becoming the lead news story in the world. Monrovia had been in chaos for well over a month, but now it was no longer a regional secret known only to those in the Liberian diaspora with direct contact with the city residents. The New York Times ran a long story about the turmoil, carefully parsing the various challenges that the central government faced in its beleaguered efforts to preserve order and stop the epidemic.
By that time, I was sitting in on weekly conference calls of a small group of physicians in the States keen to help in whatever way they could. For instance, Trish McQuilkin, working with contacts such as the head of the Liberian College of Physicians, Dr. Roseda Marshall, had managed to procure nearly $10 million in personal protective equipment for JFK—no mean feat that, given huge logistical challenges of obtaining that much material and sending it to a place that fewer and fewer shipping companies wanted to have anything to do with. All this from professionals whose expertise was in treating patients, not running international supply chains.
During one of these calls I learned that Borbor had been among the first people in the world to be given the experimental drug ZMapp, although my clinical opinion was that even if ZMapp were truly an effective drug—still an open question as I write this—it was probably too late to have an effect. ZMapp works by binding the virus with premade antibodies. It works a bit like a molecular vacuum cleaner: The body’s natural vacuum cleaner (that is, the naturally produced antibodies specific for the Ebola virus) takes a few weeks to activate, by which point most of the damage of Ebola is already done, and the patient—if he or she has survived—doesn’t require such antibodies anymore.
ZMapp provides a ready-to-go anti-Ebola cocktail in a bag, best used at the beginning of an infection. Borbor was probably already making his own antibodies by the time the ZMapp was being infused into him, so whether he lived or died had little to do with how much virus was in his body, but rather the extent to which his body’s own immune system had gone completely haywire. All that, however, was but a guess. The fact that he was still alive several weeks into infection was encouraging to me, although I wasn’t precisely sanguine about this.
I started alerting my superiors at UMass that I was looking for ways to get over there and work in an Ebola Treatment Unit. My division chief thought this was laughable almost before I could finish my first sentence. “You’re fucking out of your mind,” was his immediate observation.
Arguably true, but not fully relevant, I thought.
A few days later, after I took another pass at him: “Steve, I’m not letting you go over there.”
Um, Doug? You’re, um, not my dad.
That’s how a few of the conversations proceeded in August.
As we neared the end of August, Monrovia nearly came apart at the seams. One of the densest parts of the city is a neighborhood known as West Point. Monrovia’s center is a spit of high land at the mouth of the Mesurado River where it meets the Atlantic Ocean. From this outcropping one can travel either north onto Bushrod Island or east into Sinkor (the site of JFK) and farther on into Congo Town and the outskirts at Paynesville. Basically the main human settlements of Monrovia are shaped like a V flipped on its side, thus: , with the city center at the pivot point. West Point is a small but densely populated peninsula, a dead-end nub of land just west of that northern corridor leading out of the city center. It had become one of the hottest areas of the outbreak, and with its concentration of human beings—somewhere between fifty and a hundred thousand people lived there, though nobody knew the population with any precision—the spreading virus had become the biological equivalent of a hydrogen bomb. President Sirleaf had made a fateful decision to institute a cordon sanitaire. That is, she placed the entire section of West Point under a quarantine. In effect, she was trying to dig a fire line with the hope of stopping the viral flames from spreading.
But quarantines are risky maneuvers even under the most optimal of circumstances, and these were not the most optimal of circumstances. Quarantines can be effective in small areas, say, a village of a few hundred people, but this was an attempted quarantine of tens of thousands, nearly all of whom were frightened, ill informed, and suspicious of the government—hardly a surprise given decades of civil strife during which time caution with respect to government pronouncements could be lifesaving. In doubting the reality of Ebola, they shared Dr. Brisbane’s cynicism but lacked his education and perspective, and so couldn’t easily shift their thinking in spite of the evidence accumulating all around them.
To cordon off that many people meant that at least some major and basic contingencies needed to be considered. These people needed food, they needed water, and a good many needed money, for a weeks-long quarantine meant
lost income in one of the most impoverished sections of an already extremely poor country. Yet from what I could tell reading the news, there was no clear plan beyond putting up a rope, having the army stationed at the borders, and saying, “Don’t cross this line.”
Mayhem, predictably, ensued. Residents attacked an ETU that had been set up in the neighborhood, regarding as lies the government pronouncements that the virus should be isolated to minimize the spread. They carried away sick patients in their arms, took the sheets and mattresses, and forced the health-care workers to run for their lives. Days later, the West Point mob directly confronted the Armed Forces of Liberia, who at one point opened fire on the crowd, killing a sixteen-year-old boy in the process, another casualty of Ebola without ever becoming infected. He wouldn’t be its last.
The West Point quarantine was not just a mess. It wasn’t even a disaster. It was a calamity. And Monrovia itself hung in the balance.
Then, more news: Borbor was dead.
*
Somewhere between the final few days in August and the first few days of September, the Human Resource staff at International Medical Corps called me to discuss work in their new ETU that was currently under construction in Bong County. Mainly it was a more formal repeat of the conversation that I had with Hilarie Cranmer a few weeks before. I was eager to talk about dates and whether they were going to commit, in part because it was now obvious that help was needed immediately, but also because I had to start making arrangements to have my outpatient clinic and inpatient service time covered. I told them I could be available starting the third week of September and I could go until mid-December. They said, “Well, we’re not deploying people more than six consecutive weeks given the stress of the environment, but mid-September seems good. We’ll keep you posted.”
But I did need answers from them, rather more quickly than they seemed prepared to provide them. Aid organizations, I didn’t fully understand at the time, are considerably nimbler with their staff deployments, and nurses and doctors are frequently notified of their assignments a few days before their departure. Academic medical centers, however, make their schedules a year in advance, moving at a glacial pace compared to aid organizations like IMC. The kind of doctors who were starting to emerge as volunteers for this effort—people like me—were going to need some lead time to put things in order. But a group like IMC can’t plan that far in advance; it’s just not what they’re built for. This interinstitutional tension was the first of many such instances in which doctors and nurses, myself included, found themselves trying to negotiate as best they could in order to serve in West Africa.
At any rate, about two weeks passed and I heard nothing from IMC. At one of the weekly conference calls of U.S. physicians focused on the Liberian crisis, someone mentioned that the Centers for Disease Control was in the midst of arranging a course for preparing health-care workers bound for West Africa. Until that point, the only way one could learn the proper procedures for working in the high-risk environment of an ETU was to be trained by MSF, which had developed the protocols years earlier based on its ongoing involvement in Ebola care. MSF had a three-day training session for expat workers in Belgium and was ramping up training in the affected countries, but more hands were needed on deck. The CDC had taken the MSF protocols and had created its own curriculum to increase the pipeline of properly trained workers. I knew I needed that training, for there was no way I was headed to a country filled with Ebola without it.
Having not heard from IMC, I contacted the CDC directly and was told that the course was already booked solid until mid-November. Did I want to put my name on the list? I had been lining up all of my colleagues to cover for me starting in late September and extend into mid-November. Was I now going to have to completely rearrange a schedule that I had painstakingly constructed and abuse the goodwill of my clinical chief, who was already gritting her teeth at the coverage chaos that my hasty departure would produce? I decided that I’d get over there when I could, and my division would have to deal with it. November it is for the CDC course.
A day or two later, IMC called again. “Are you available to attend the CDC course on September 21?” someone asked me. “We could then deploy you within a few days of the training.” Oh, they are serious about me going, I suddenly realized.
“Well, yeah, but they told me they’re booked solid until mid-November,” I said. “I can’t go over there without being trained.” I was told to sit tight, they’d be in touch. Three hours later I received an e-mail from a woman named Martha Mock at the CDC telling me that I had a spot reserved for the pilot training course, could I please confirm that I will be coming?
Whoa.
A few days later I was sitting in on an IMC conference call with a small group of nurses and one other doctor to discuss the situation on the ground in Liberia. IMC still at that point hadn’t formally offered me a contract, nor had they provided precise deployment dates, but by this point I was taking things on faith. They had gotten me to the head of the line for the CDC course, which I assumed they wouldn’t have done unless they were very serious about getting me to Bong County.
Leading the conference was a man named Sean Casey, the head of operations for IMC’s response in Liberia. Sean was calling from Monrovia, and he was the first person with whom I had spoken who was actually on the ground. I don’t remember much of the call; mostly I sat and listened. The other doctor was talking a lot about convalescent plasma transfusions—that is, giving the serum from survivors, in theory rich with anti-Ebola antibodies, to infected patients in ETUs, a kind of poor man’s version of ZMapp. I didn’t know whether this would be within the capabilities of IMC’s Bong County ETU, but based on what I had seen at JFK ten months before, my sense was that this doctor was running before walking.
My biggest concern was less about whether it was a reasonable suggestion (it seemed so) but the kind of urgency with which he spoke. I knew enough from working at JFK, as well as working in other countries with major resource limitations, that sometimes you have to just make do with what you’ve got. If you go into this environment with strong feelings—indeed, almost a sense of moral righteousness—about what should constitute standard of care and then the conditions fall short of it, you can become very dispirited. I was a little concerned that this person didn’t realize what we might face.
I can recall one exchange from this conversation with crystal clarity, however. Sean had summarized the situation according to the latest tallies supplied by the World Health Organization. I don’t remember those numbers, but I’ll forever remember what he said next. “The current estimate is that Liberia requires twenty-seven ETUs to care for patients and prevent the outbreak from spreading further,” Sean said, and paused for a split second before adding, “as of this moment, there are six.”
*
On that same day in Guinea, the tremors that the world was sensing about the difficulties of containing a region-wide outbreak turned into an outright earthquake. A delegation of officials, doctors, and journalists, as well as a pastor for good measure, went to a place called Womey, a quiet village a few hours east of Meliandou, to aid in community educational efforts about Ebola. The idea was simple: Provide presentations about the virus and explain how it is spread so as to encourage optimal behaviors designed to stop it in its tracks. By now, the Nzérékoré Region in eastern Guinea had been inundated with Ebola cases, and hundreds were dead. Villages were being decimated and paranoia was running high.
The presentation began, but almost immediately the visitors sensed something was terribly amiss. At the sight of these outsiders, village women began to chant, “They are coming to kill you.” Soon, several men from the village emerged with masked faces, armed with machetes. It was clear that many villagers thought they had come to Womey to spread Ebola instead of help prevent it. The educational session quickly turned into a massacre. Eight members of the visiting party were hacked to death and their bodies were thrown into a community latrine; the remai
ning few ran for their lives into the jungle.
The story of the Womey massacre reached the outside world two days later, on September 18. It was a worst-case scenario. The very people who could provide the best hope of stamping out this pestilence were being rejected, and in as dramatic and violent a manner as could possibly be imagined, by those most at risk of being mowed down by the virus. Womey was a warning that those who wanted to turn the tide had to be prepared to make two potentially lethal gambles: The first was of becoming infected; the second was of being chopped, quite literally, to pieces. Or perhaps in the opposite order.
*
With the sobering reality of Womey on my mind, a few days later I found myself on a plane to Atlanta to attend the pilot CDC Ebola course. I had spoken with Pranav Shetty, the lead physician in charge of the Bong ETU, which had just opened for business about the time of the conference call. All was proceeding briskly, although I still had no contract and no assignment. I assumed that this was going to be rectified shortly, and I formally halted all of my clinics and told my division chief not to expect me back for six to eight weeks. I was told again that I was fucking out of my mind, and again I thought he may have had a point, though not for the reason he said.
Throughout September, I had spent so much of my waking energy thinking about how to get myself to Liberia that I hadn’t taken so much as a second to reflect on what was driving me there. The explanation you read above is mostly a post hoc justification. At the time I had operated on pure instinct. Now I was reasonably sure it was going to happen. During the three-hour flight from Boston to Atlanta, I opened my laptop and with very little forethought just started writing. As if to compose an explanation to myself, and maybe the broader world, for what was about to happen, I typed the words “Why I Go” at the start and wrote for the next three hours, 2,800 words without ever raising my head. It was the shortest flight I ever took.
Inferno Page 7
