Rumors started to circulate that ETUs were a government plot to spread Ebola in order to secure further international aid as the flood of dollars unleashed by the end of the Civil War was beginning to abate. The proof could be found in the workers who walked all around the ETUs, and throughout the city, spewing fine liquid droplets onto patients and the surfaces they contacted with a two-foot-long nozzled stick, the tank of liquid strapped to the back of the sprayer clad in PPE. This strange mist contained Ebola, they said. The government and the aid agencies weren’t putting up the ETUs to treat it, they were doing so to bring people in and incubate them with the virus.
Never mind that this was totally preposterous even after a few moments of concentrated thought, because nobody in their right minds would waltz into an ETU without symptoms in order to be sprayed by someone who would give them the virus. If that really was the case, how was it that that people were becoming deathly ill before they were ever hit by the spray? But reason wasn’t winning the day on the streets of Monrovia. Terror was.
*
Compared to that, life in Bong County by contrast seemed to be perfectly ordered. Not only was I meeting patients, I was becoming acquainted with the national and international staff. Simultaneous with my arrival, another emergency medicine doctor from California named Colin Bucks had joined the group. With three fresh M.D.s now holding down the fort, Pranav took a much-deserved break, heading back to the States. Colin and I took to one another immediately, and I couldn’t help but fancying our fast friendship as a kind of modern version of Hawkeye Pierce and B. J. Hunnicutt. My life’s goal in some ways was to be Hawkeye, so having a wisecracking doctor from California in my midst provided the perfect Hunnicutt equivalent.
But there were many others as well, among them Godfrey Oryem, a Ugandan in charge of the WASH team who had been working with IMC for years; Rosa Nin-Gonzales, a Spanish nurse doing her first stint in Liberia; A. Weheley Duo, one of the Liberian physician assistants who would often round with me; and many others. I reveled in the companionship. The stimulation from finding myself in such company was balanced by the steady flow of death that took place on the other side of the plastic orange fence that separated the high-risk area from everything else.
Sean Casey, who presided over all the activity, was fascinating to me. About ten years younger than me, he had grown up in the suburbs of Philadelphia, but after high school had made one in a series of unorthodox but intriguing decisions by attending the American University of Paris. Since then, his life had been equal parts business administration and international aid work. He was as comfortable, and authoritative, talking about stock portfolios as he was about the latest educational reform measures in Zimbabwe. With the epidemic banging and shimmying its way through West Africa, each day brought a new crisis, but Sean approached the running of the ETU with a coolness that was enviable, as I only rarely exhibit such poise, and even then usually with the help of medications. Nevertheless, he pulled off this Spock-like calm while being entirely approachable, as quick to laugh about the little absurdities of our work situation as anyone else in the room, which was of immense help when a laugh was needed. You wanted this guy to be your leader. I have known many accomplished managers, but I had never met anyone who had quite the combination of skills that Sean seemed to possess, and who could utilize such skills so effortlessly. I didn’t know if we would ever work together again (assuming that we both got through the next month alive) but I did know that if it ever came to it, I’d walk on hot coals if he asked me to. He was a singular leader.
At the end of my first week, early one morning not long after the morning staff meeting, a small commotion was taking place at the main entrance. Sitting in the administrative hut, we poked our heads outside to see what was going on. A beat-up old Nissan hatchback sat next to the guard post, and nearly a half-dozen people stood around an older couple, though all kept their distance. Sean was already on his way over; I looked around for a pair of gloves and goggles, but nothing more, and joined them afterward.
The Nissan was actually a taxi, which is to say it was a car owned by a man who made a living out of driving people around. Cars, and the petrol used to power them, are incredibly expensive assets for the average Liberian. I surmised that the man sitting in the driver’s seat was of pretty high stature in the community simply because he owned this vehicle. But as I looked at him, with his hands gripped tightly onto the wheel at ten and two, I saw the slightly wide-eyed look with which I was becoming increasingly acquainted in the high-risk ward. He was scared, very scared.
I then darted my eyes over to the couple, a man and woman probably in their sixties, who were already talking to Sean. They held a bundle that I couldn’t initially make out, but they were gesturing to the backseat of the car. Sean looked over to me and told me there was still a passenger in that seat, but the car windows had a dark tint and I couldn’t see anything. Then Sean came over to explain.
“They have a baby,” he started, and I quickly processed the mental image of the bundle I had observed, realizing almost with a smack to my forehead that of course that’s what they were holding. “The mother is their daughter, and she bled during the delivery. They said her boyfriend had recently been treated for Ebola and was discharged from an ETU in Monrovia.” We quickly decided that I would talk to the mother and we would make a decision from there about what to do.
This was not how the triage process was drawn up in the playbook. Until that moment, when I encountered patients suspected of being infected, I saw them at a safe distance in a special “triage hut” in the high-risk area where patients and the staff were separated by a metal mesh divider. But now I was only feet from a potentially infected woman in the backseat of a car, who had delivered a baby who was quite alive, being held by two individuals who were clearly exposing themselves if she was infected, and had now possibly exposed an unassuming third party in the taxi driver.
I put on two pairs of gloves, a light disposable molded face mask to keep out fluid particles, and the green, polyvinyl chloride splash-safety goggles used in high school chemistry classes. This was the triage hut safety kit, and in that setting, where we stood usually between one and two meters from patients, that was a perfectly safe combination. But I didn’t put on the ski-mask goggles and N95 face mask, each with their tight seals, that we used for the Hot Zone work. Nor did I get into the suit. The splash goggles and gloves served as protection, but at close quarters, it was definitely not ideal protection.
I walked over to the car, and when I got to within three feet, I asked the driver to lower the back window so that I could look in and ask her questions. The electric window slowly slid down about three inches, and then went no farther. The driver gave me a look as if to say, That’s what you get, buddy, like he knew something of the international code of taxi driving despite working in rural Liberia. I got up on my tiptoes and peered in but couldn’t see a thing.
What happened next is one of those Rashomon-like moments where different people who were present will describe the events differently. I no longer trust my own memory of what took place, but the next action I took was almost certainly the most lethally stupid mistake of my time in the ETU—actually, you can drop the “almost” from that—and indeed in my career in medicine.
To get a better sense of what was happening, I opened the car door.
Nothing in the dark interior was moving. As my eyes adjusted to the contours of the form a little more than an arm’s length away from me, I could see a woman spread across the seat and rolled into position with her head facing the back. There was no way for me to make eye contact with her, assess her breathing, ask her questions, nothing. I thought I saw movement but could not be sure. I inched closer to try to glean any information I could.
We’ll never know just how many inches separated my suboptimally protected face from this woman, who I realized later was, as a statistical matter, almost certainly infected with Ebola no matter what her clinical state. But I do know t
hat I should never have been that close. My recollection is that I got to within about two feet of her. Some say they saw my head go completely inside the car. Whether that’s true or not, there is, thank goodness, no photographic evidence to confirm. But even if I did not put my head inside the car, I definitely put my head inside the mouth of a lion with very sharp teeth, and this wasn’t a circus act. As I realized what had just transpired over the past thirty seconds, I backed away, and felt the ticking of a twenty-one-day clock start inside my head, waiting for the onset of fever and muscle pains. Audrey Rangel, one of the core expat nurses from the States, looked at me as if I had just emerged from one of those science-fiction movies, playing the character who has been jabbed with a substance that will melt them away in a matter of minutes. Sean, whatever thoughts were flying through his head, displayed no reaction.
Fortunately, I didn’t have more than a moment or two to ponder any of this. We told the driver to take the path used by the ambulance service and head to the formal triage area, where I could properly suit up to examine the patient, much to the relief of everyone who had just witnessed my ill-considered, unprotected spur-of-the-moment evaluation. In the meantime, we still had to deliberate on what to do with the baby—a girl. If the mother was infected, which was something we suspected but could not yet prove, then this baby was coated in virus, and at very high risk to become infected herself. But should we take her into the suspect ward? How would we test her blood, which would be a challenge for even one of the best nurses to draw from such a small child? Who would be able to care for her in high risk? The tenants weren’t exactly predisposed to care for newborn infants requiring twenty-four-hour attention. We would probably be sentencing the child to death if we brought her in.
But what to do if we sent the baby home? Here the dilemmas multiplied and were even more worrisome. I strongly doubted that she could survive Ebola. If the grandparents were to care for her, they put themselves at risk of infection. Would the couple try to find a wet nurse? I didn’t know enough about the cultural practices of rural Liberians to know whether they even utilized wet nurses, but if they did, then that meant other people besides direct family, not unlike the taxi driver, might die in the wake of this micro-outbreak. The longer that baby lived, the more people she potentially threatened, and I rapidly oscillated between my misgivings about the lives that might end the longer she hung on and the horror that I was secretly hoping for this beautiful wonder of creation to die, and die soon, so that the web of death might stop there. Barring a miracle, which was a scarce commodity in Liberia at that moment, there was simply no good way out of this, no happy conclusion to the usual story of hope and promise that accompanies the birth of a healthy child.
Sean called a contact, an MSF Ebola expert named Anja Wolz, to see what protocols they had in place for such a situation. After several minutes of talking with her, he returned to the group. “She’s never heard of anything like this before,” he said. She didn’t think it wise to bring the baby into the suspect ward, and what ensued was a long discussion with Sean and Audrey about how to give formula and what supplies we should equip the grandparents with in order to nurse the baby while allowing them to remain relatively protected. Since formula and the health needs of a newborn infant were far beyond my clinical expertise, I merely noted my concerns about having a wet nurse involved, then headed to the gowning area to suit up and go see the mother.
Ensconced in the theoretical safety of the space suit, I opened the car door again and this time put my hands directly on the woman and shook her. She didn’t move. She was hot to the touch. I had placed a thermometer under her arm and it got to 104. An “axillary” temperature like this meant that her core temperature was hotter still. I felt for a pulse on her neck, and felt again and again, and nothing. She had died, though whether it was from a postpartum hemorrhage or from Ebola, I couldn’t say. But that fever—though fever is really too meek a word in this instance—didn’t bode well.
The story of the boyfriend seemed highly suggestive, but it also didn’t make complete sense if we were to believe that he had infected her. We didn’t know the details about when he entered or left the ETU, but assuming that he had been seen in one of the Monrovia ETUs, he probably had been there for at least two weeks and wouldn’t have been discharged unless the viral load in his blood was undetectable. So he shouldn’t have been able to infect her after his discharge. However, if he infected her before he was admitted, then why had she taken so long to incubate the virus? Until the West African outbreak, the maximum incubation time ever witnessed was twenty-one days. We know this because a few people in previous outbreaks had brought the virus to their previously uninfected villages, serving as the “index cases,” and their travel histories were traced to attending funerals where Ebola was in circulation exactly three weeks before their illness began.
At the time, I hadn’t carefully considered this. It wasn’t until many months later, when some new information had filtered in, that I could conceive of a different scenario by which she was infected. At any rate, as I informed the burial team that they would be required to suit up to retrieve the woman and prepare her for interment, I had to explain to the driver what was happening and offer him what preventive measures we could. At the very least we were going to recommend that the inside of the car be completely sprayed with the high-grade chlorine solution. As for him, we urged him to step out of the car and take a bucket with the low-grade chlorine solution meant for human skin and wash himself off. This, of course, meant he was walking into the Hot Zone totally unprotected, and even if he knew at some level his car was quite likely contaminated, his driver’s seat must have seemed like a life preserver in the midst of a heaving ocean in which he suddenly found himself. He did it though, and jumped back into the car, turned it around, still wide-eyed, and headed back down the jungle road.
That covered about an hour’s worth of work that day.
*
As the first week progressed into the second, we fell into routine.
Wakeup for me was just after six. I can’t function in the world without a morning shower, even when working in an Ebola Treatment Unit where nobody cares how my hair looks, so I was an early riser. My flat at Cuttington had a bathroom that was not much different from any standard bathroom in the West, although it was more weathered, with fixtures that hadn’t been replaced in more than thirty years and tiles missing here and there. The plunger to the toilet didn’t work, so flushing it consisted of pouring a pitcher of water into the bowl, the water retrieved from a large blue fifty-five-gallon polyethylene drum that took up about half the maneuvering space in the small area. The shower head came directly from the faucet in the tub, with a long metallic snake to reach upward. There was no place to attach the shower head, so bathing consisted of holding it above my head to let the cold water run down, then placing the apparatus on my shoulder while I shampooed, and finishing with a rinse. It was a cumbersome production but worked, all things considered. One morning I entered only to find a spider—a huge spider, whose body was a little larger than a quarter but whose legs stretched out beyond the size of my hand—on the wall by the bathtub. He moved quickly at the sight of me and was halfway across the wall before I could even catch my breath. Give me Ebola any day over that spider, I thought. That day I went to work grubby, and I tiptoed around my bathroom for days, performing an elaborate series of checks before I felt comfortable enough to tempt fate by bathing or utilizing the toilet.
Ebola seeped into every corner of our lives, even in the humdrum routine of daily grooming. During my training at Camp Ebola with the CDC, I had a long conversation one afternoon with Navy commander James Lawler about the philosophy of shaving. You read that correctly. His thoughts were carefully considered and the result of years of work with Biosafety Level 4 agents. He pointed out that male facial hair presents a dilemma with respect to Ebola. The virus enters the body most efficiently through the mucous membranes. Touch an infected person and wash your ha
nds, you stand a good chance of never getting sick. But touch that person and then rub your eyes or touch your lips, and the virus has its opening. (As I mentioned earlier, this was the reason the lack of running water was so important to Ebola’s spread in West Africa. Give people plumbing, and it’s far less likely that thousands would be suffering from the disease.)
Therefore, to stop the virus from finding its entry into the body during work in the Hot Zone, the two most important pieces of protective gear for someone working with Ebola patients were the goggles and the N95 face mask. If the seal on your wrists wasn’t perfectly airtight, it didn’t guarantee Ebola an entry since you washed your hands in some form of bleach solution more than two dozen times before you emerged from the Hot Zone. But if your goggles missed the seal against the rest of the mask by even one millimeter, it could be a lethal error. So too the mask. You needed to breathe, but you wanted as little as possible beyond air to enter that mask.
Back to the shaving issue. The problem for men and masks is that, as their beards grow, they push out against the mask and ruin the seal. Given just how much sweat your body could produce during rounds, it was not too hard to think that the virus could enter from the outside, hitch a ride on a bead of sweat, and get sucked up into the mouth during the labored breathing that was certain to ensue.
It would seem the obvious solution was to shave, but shaving introduces its own problems in the form of microscopic cuts. Even when men have a “perfect” shave and there are no appreciable nicks in the skin, they are nonetheless there, and from the standpoint of an Ebola particle, such a tiny cut must look like the Grand Canyon. Colin, Steve, and Pranav remained clean shaven during their time in Bong County; the African staff, whether the Liberian national staff or expats like Elvis Ogweno (who is Kenyan) or Godfrey Oryem (Ugandan), generally didn’t grow big, bushy beards for this to be a problem. I opted for a different approach and settled on keeping my Vandyke trimmed so that the mask seal remained as tight as possible and shaved the rest every three or four days.
Inferno Page 12
