Inferno

by Steven Hatch, M. D.

  Death disrupted our neatly organized plan of assigning patients to rooms. If a patient died, the roommates immediately fled to other rooms and would not return even after the body had been removed. The spirit world made itself known at these moments, and no amount of coaxing could bring any of the patients back. It added layers of complication to our memorization schemes, since we would go in expecting to find George in room C5 but instead see him on a bed in C8 where you thought you’d find Fatu. As long as there were enough beds to go around, the staff dealt with the problem as best we could. But what would happen if we hit full capacity?

  Depending on how physically brutal rounds had been, after we ran the boards we’d spend usually a half hour or more recovering, just sitting in the medical staff quarters rehydrating and reenergizing. We had a small refrigerator that housed dozens of cans of a popular Liberian soda called Rox, which I thought of as the West African taste equivalent of Diet Mandarin Orange Slice, and as such I avoided it unless I thought that my blood sugar was running at dangerously low levels. I had gotten used to the taste of oral rehydration solution—or at least I was so desperately thirsty after emerging from a spin in the high-risk area that drinking saltwater didn’t seem so bad. But no wonder it wasn’t popular among the patients. When a shipment of Coca-Cola arrived, it seemed like manna had fallen from heaven. And because my weight was starting to plummet from all the sweating, it marked the only time in my life when I could drink as much Coke as I wanted without any guilt whatsoever.

  I liked to round in the morning and let Colin take the afternoon shift. That allowed my afternoon to be set aside for paperwork: filling out death certificates, cross-checking the demographic data in our logbooks, moving the charts from suspect to confirmed folders and so on; or checking the inventories of our supplies and tending to other administrative tasks. There tended to be downtime during the afternoon activities, a chance to catch up and talk about how the patients were doing, think aloud about the physiological changes wrought by Ebola infection, and, when we took a deep breath, socialize.

  By four we usually heard from the Navy lab as to which samples were positive and which negative. They tended to run half and half, which meant that we would bring news to those in the suspect ward that would seem either like a liberation of ecstatic proportions or a death sentence. Someone from either the psychosocial team or the medical staff or both would return to the suspect ward and escort the infected to the confirmed ward, and guide the others through a symbolic River Jordan of bleach solution poured on their heads and bodies, thence to freedom. Not surprisingly, emotions ran high in the wards during this time in both directions.

  Then, we waited for the ambulances to arrive.

  It usually happened around six, just before sunset, and the short equatorial sunset made the gathering of histories of the patients a hectic and somewhat chaotic exercise, as darkness soon engulfed the proceedings and writing in the weak light of a single incandescent bulb became a formidable task. The ambulances were nothing more than pickup trucks with a metal frame attached to the back part and an orange tarp laid over the flatbed to provide the patients with privacy as they were shepherded to the ETU. On the flatbed were foam mattresses for the patients to lie on if they could not sit and pickle barrels to serve as commodes on their journey. These were the very same commodes that they would find in their rooms.

  The conversion of a 4 × 4 into an “ambulance” may sound like the ultimate in résumé padding, but they were in fact a good deal safer than the few true ambulances zipping around the Liberian countryside at that moment, such as the one that bore Phil Ireland to the ELWA ETU. The complete separation of the driver’s cab from the patients meant that the drivers could not be exposed, and thus they required no special training provided they kept the doors closed on their runs. Actual ambulances, with their open communication between the driver’s seat and the back portion, were real hazards to drivers. Sometimes we would see these ambulances operated by groups other than our own, with drivers wearing full PPE, in theory totally contaminating the interiors, the drivers not knowing anything about proper doffing and spraying of bleach to inactivate the virus. I felt sorry and mildly embarrassed for them for their misunderstanding that the wearing of the suit was the key, as if the polymers that formed the barrier left them totally safe when in the presence of patients and could just be casually peeled off afterward. We had no time to convey to them that the tricky part was getting out of the suit and was the time when they were at greatest risk of becoming infected. I have no idea if any of them actually did become infected, but I wouldn’t be surprised if a percentage of them did.

  The ambulances would proceed along a path that abutted the wards, and the patients disembarked from the flatbeds and entered the triage hut. There we would talk to the patients, obtaining their histories—that is, the stories of what symptoms they had, the timing of those symptoms, whether they had been in contact with anyone ill, and so on—while documenting these details onto forms sent by the Ministry of Health. Processing the Blue World’s new arrivals took at least an hour, after which a member of the medical staff escorted them to their assigned rooms for the night, almost certainly among the longest nights of their lives. And with those tasks behind us, and the night-shift workers now in motion, we would head home to our flats in Cuttington.

  *

  The more days passed, the more acquainted we all became with the virus, and although it did not ravage the body in quite the way most of us would have guessed, its ability to destroy human flesh was still impressive. Each day brought at least one death. We would round and find ourselves having to recalibrate our census as the WASH team would send a group in to move a patient to the morgue.

  The first lesson hit me completely by surprise: The hemorrhagic fever of Ebola wasn’t so hemorrhagic. I already had a notion that this might be true. When I was applying for training programs in infectious diseases, still fueled by the adrenaline rush that reading The Hot Zone had provided a decade before, I told my mentor that I was interested in working with hemorrhagic fever viruses. At that time, the only research being done in Massachusetts on hemorrhagic fever was by a group at UMass working on a mosquito-borne tropical virus called dengue. The classic presentation of dengue was something known as “breakbone fever,” which is about as painful as it sounds and is caused by the severe muscle aches the infection produces. But the less common, lethal form is called Dengue Hemorrhagic Fever, or DHF. That was what interested me when I started out in infectious disease. After all, The Hot Zone said people bled. The question that had gripped me in this phase of my career was simply, Why?

  But after I came to UMass and worked with the dengue group and I learned more about DHF, I realized how rare it was for patients to have frank bleeding. Hemorrhage was a misnomer, reserved for only the worst of the worst cases. As the years passed and I read more and accompanied my mentor to hemorrhagic fever conferences, I would come to discover this to be equally true of other viruses that fell under this category, such as Lassa Fever, Hantaviruses, Rift Valley Fever, Yellow Fever, and several others. Still, I assumed that the filoviruses of Ebola and Marburg would live up to their reputations.

  And when I arrived in Bong County to work, almost immediately they did. The first few days that I had rounded, I met a woman named Fatu. She was in her mid-thirties, perhaps five foot five, and had a stocky frame, her hair a tangled mess from having been lying prostrate in her bed in the ETU for several days. When we first met on my very first day, I had come to her room at the end of the hallway of the suspect ward to find her vomiting into the commode bucket. When I retrieved the bucket, the liquid was unmistakably tinged with red. I assumed that she had almost no chance of surviving, but I came back the next day to find her doing the same—still with blood—and was surprised to find her still sitting up in bed the next day. I got down on my knees that day and looked into her eyes, which were not scared so much as weary, and I asked her to tell me she was going to survive. She just looked at m
e, blinking. Then I asked again, and she looked at me again. And I asked a third time, and she slurred out the words that she was going to survive. I made her repeat it. I left to round on the other patients, assuming it would be the last time I would see her alive. She looked terrible.

  The following day came, and with it, the official confirmation from the Liberian Ministry of Health that she was infected. (This was before the Navy had shown up and provided that same-day turnaround time on tests.) If she was still alive, I would finally tell her that her test had come back positive and that she would need to be escorted to the confirmed ward. She was sitting upright, looking more animated than I had ever seen her. She looked at me with a certain level of rage and summoned the energy to say, “I’m gonna beat this virus!” And sure enough, she did, and was among the first survivors that I had cared for from the beginning of their hospitalizations.

  Yet Fatu proved to be the exception, and in the days that followed I saw essentially no other cases of bright red blood. I sheepishly confess to a degree of disappointment—I had come all the way to an Ebola outbreak, and yet I certainly didn’t feel like I was walking around in Richard Preston’s account. In more flippant moments, I thought about writing his publisher and asking for my money back. One day in the first two weeks I saw a young man in the confirmed ward who appeared to be more stable than the others, a good harbinger in this part of the ETU. As I came in to talk to him, however, a small trickle of red blood ran out of his left nostril. My pulse quickened. Here it was, I thought, the Ebola epidemic! “Your nose is bleeding,” I said to him gingerly, worried that the observation alone might cause him to shrivel up.

  “Oh, yeah, I’ve had problems with bloody noses since I was a child,” he said, casually waving his hand as if this were a tedious subject. I couldn’t stop from feeling deflated, and that left me deeply irritated with myself, for I certainly was not there as part of a grand hemorrhagic fever tour, starring Bright Red Blood. At any rate, that was about as close as I ever got to seeing the precise kind of horror that I had come to expect. But I still encountered horror in abundance.

  What I did see was a lot of gastrointestinal fluids. The amount of diarrhea and vomit that went into the commode buckets of the patients was remarkable. As we continued to care for patients, we used our laptops to read up on the scientific and clinical literature of filoviruses as much as we could, and it became clear that, while bleeding was very much a known quantity, it was the vomiting and diarrhea that dominated the pathology of Ebola. They usually started about a week into infection and were such a cardinal feature of the disease that they received their own special designation in the clinical literature of the “wet symptoms.” The phrase doesn’t sound nearly as terrifying as the word hemorrhage, but it was easily as efficient as blood loss in terms of how it could snuff out a life. Phil Ireland’s early illness, when he still was lying in his bed in his house, weren’t marked by wet symptoms, but within about twenty-four hours of coming to the ELWA ETU, they hit him with such force that he could still wince when describing the sensation to me nearly one year later.

  The wet symptoms were much more important to Ebola’s deadliness than hemorrhage, and they were also much more prevalent. That managed to explain why it had been confused with cholera in the early phases of the epidemic. I have never seen a case of cholera. The one major epidemic in my time was a tragic episode in Haiti that started in 2010, a few years after its calamitous earthquake; thousands of people died, although that outbreak didn’t receive anywhere near the same amount of notoriety as Ebola. Despite never having encountered a patient with this infection, I used it as a template for my revised clinical impression of Ebola.

  There was, of course, a range of pathology in Ebola, with some patients having some symptoms and other patients having different presentations. But if one were to boil it down into a bite-sized morsel for a medical student or a resident, a simple way to remember the typical course, it was this: You started out with a week of influenza, and then you graduated to a week of cholera. By the end of the second week, you were either dead or on the very slow road to recovery. I would also tell those students and residents to get bleeding out of their mind-set and perhaps in suggesting that, take away a little of the primal fear that the word Ebola can induce.

  *

  During these first weeks several of us had noted that we had gone from watching the world’s leading story to being the world’s leading story. Along with MSF and the other aid groups, IMC was engaged in a worldwide media blitz to raise consciousness, awareness, and impel governments, foundations, and anyone else who could make a tangible contribution to contain the outbreak to do so. Every few days we’d have some reporters, mainly based in Monrovia, come up for a day to tour the facility and interview people. We hosted some French writers from Le Figaro (who managed somehow in the midst of the damp African heat to nevertheless look chic, one casually taking notes and ambling about the compound wearing blue jeans, a dark gray T-shirt, and a fedora). There were two amiable TV crews, one from Germany and the other I think from Sweden, each spending a day or two shooting and interviewing. An American photojournalist named Morgana Wingard, who was working for USAID, the U.S. government agency whose money had in part funded the construction of the Blue World, came around a few times.

  Sean mostly escorted those brief flybys around. I wasn’t paying a huge amount of attention to their comings and goings, but it seemed that the print journalists were there to understand people by asking questions and listening carefully to the answers, while the TV types already seemed to know what they had in mind and barreled in with an I-came-I-saw-I-shot-pictures approach that, at least speaking for myself, underlined why I have such contempt for TV journalism in the first place. A big CNN crew had come to do some shooting, and I don’t think they were there for more than an hour or two, perhaps because they were so skittish about being out and about in such a dangerous place and were eager to return to the relative safety of Monrovia, probably at the posh Mamba Point Hotel, hoping they could get back on a plane to get the hell out of this country. Two hours is enough time to, well, pretty much do nothing at all except take some moving images of people milling about in PPE, allowing CNN to drive home what was almost certainly a message of absolute fear that was working its way up to full steam in the wake of Thomas Eric Duncan’s infection in Dallas.

  Among the print journalists, three reporters working for The New York Times had become part of our hastily arranged family. The Australian photographer Daniel Berehulak had been shooting in Liberia since at least September, and his photographs had penetrated my consciousness well before I met him. One picture stood out in my memory. The article, which appeared in the Times in mid-September, detailed Obama’s plan to step up the U.S. military presence to three thousand troops and equip the region with a variety of supplies for the outbreak.

  Yet for all the article’s verbiage, it was Daniel’s photograph that seared into the memory banks: a picture of a man, obviously dead, lying on a street in the city center, a rug under his body and covered by a sheet, with a crowd surrounding him. A stream of fluid that appeared to issue from his own body flowed to the right, directly into the midst of the crowd. Standing to the left of the body was a man wearing latex gloves, gesturing at the corpse with both palms open as if to say, This is what we are left to cope with on our own! Possibly his intent is to warn the crowd away from coming any closer. Regardless, this gesticulating man was just feet away from a biological bomb with no real protection to speak of. Standing near the body’s head was another young man wearing latex gloves but clad in nothing but shorts, a T-shirt, and flip-flops.

  Daniel’s work was remarkable not only for its ability to capture the terrible essence of Monrovia at that moment but because of the risks required of him to obtain such shots. It was phenomenally dangerous work, making our efforts in the ETU look like a walk through a rose garden. Six months later, I would end up speaking with a reporter for NPR named Nurith Aizenman who had been
present at the West Point riots. When I learned of this, my reaction was similar to how I responded to Daniel’s work: Are you totally insane? It was bravery of the highest order. Now Daniel had come to Bong County to document the workings of the ETU and the patients and families who found themselves caught up in this death trap.

  In addition to Daniel, there was Ben Solomon, an American in his mid-twenties doing video journalism. He interviewed people about their jobs with a video camera and as such was doing much the same thing as any television reporter. But unlike the TV reporters, whose work usually finished in a matter of hours, Ben stayed with us for at least a week, making long, detailed videos that I couldn’t watch until I returned to the States because of the limited bandwidth in Liberia. Like Daniel, Ben had an easygoing manner, and his levity provided a much-needed distraction amid a busy and sometimes tense working atmosphere.

  Finally, Sheri Fink was fully embedded with the team for several weeks. Sheri and I had met at Camp Ebola, and we had talked a few times in the interim while I sat around my hotel room waiting for a flight and Sheri sat around waiting for the Times and IMC to pound out the details of her embed. Sheri was a doctor by training but had become involved in journalism devoted to humanitarian crises. Her first book dealt with the war in Bosnia; her second, Five Days at Memorial, based on a Pulitzer Prize–winning article, was a bestseller about the terrible decisions that medical staff faced while tending to patients who could not be evacuated from the Hurricane Katrina disaster in New Orleans. Because of our brief acquaintance, her arrival in the first few days provided an emotional anchor in the tumult of meeting dozens of new people, acclimating to a new work environment, and settling in to new living quarters. Her presence was a great comfort to me not only because I enjoyed her company but also because at that point I had known her longer than anyone else.