Inferno

by Steven Hatch, M. D.

  But over this time his clinical picture had become a canvas onto which everyone painted different impressions: The more sanguine among us would view every stirring as an indicator of impending improvement, while those more naturally predisposed to pessimism noted that he wasn’t looking like the true survivors, who often had made such progress within twenty-four hours of their worst moments that one didn’t need to be a medical professional to see they would leave the unit intact.

  I am much more naturally predisposed to pessimism. When I try to think scientifically, I do my best to check this pessimism, along with any other emotions, at the door, lest they interfere with good clinical judgment. For me, in order to understand his prognosis, those emotions had to be corralled, which meant ignoring the small blips of improvement that would get reported and celebrated. Instead, a simple mental equation needed to be performed, and the equation went like this: Fever equaled fluid loss, fluid loss equaled dehydration, and dehydration equaled circulatory collapse. Which, no matter how many ways I turned it over in my head, equaled death. I couldn’t explain why he was able to hold on and have moments where he seemed to look, if not well, then definitely better. But unless we could figure out a way to get a lot of fluid into him, I just couldn’t see how this would lead to a happy outcome. I didn’t say so during rounds, but I wasn’t in the mind of putting forth a huzzah just because he was able to hold down a little orange juice. Still, with each passing night, I felt the longer he survived, the more likely it was that he was going home.

  Then one morning I came in, and I knew something terrible had happened. Everyone was silent. Steve Whiteley, the most unflappable person in the ETU, hardly made eye contact with anyone. The national staff moved about their tasks quietly, and the expat office space felt oppressive. Sheri Fink had been working through the night on a story, and I searched her bloodshot eyes for an explanation, but none came.

  “Sheri, what happened?” I asked.

  “Williams died last night,” she replied in a monotone voice. I blinked, surprised to hear this news, a part of me thinking, No, that can’t be right, he looked good yesterday, and then was surprised at my surprise, as if the hemispheres of my brain were unhappily squabbling about what to do with this information. I should have surmised instantly why such a pall had been cast over the ETU, and yet it made no sense to me in the moment. I shook my head once as if to rid my ears of what I had just heard, even though I knew not only that it was true but that I had sized it up pretty accurately in the previous days.

  What she didn’t tell me right away, and I would learn only a few days later, was that after Williams had died, George had stayed up the entire night, wailing for his lost son, speaking to him, entreating him to come back, wishing for him to be alive. His lamentations rang throughout the compound for hours. We all knew that the ETU was a place of hellish misery, for by the time that Williams died, about thirty souls that had come to the Bong ETU had been committed to the earth. And we knew there were more to follow, as we fed one new body each day into the maw of the beast. Despite that knowledge, we were able to keep on with our jobs and not let our spirits flag. Our cheer and hope were among our only weapons in the darkness.

  Yet what made the passing of Williams Beyan harder than the others was not only that we had all become deeply emotionally invested in his survival, but that we had asked George to cross back over in order to help achieve this. If there was a literal place that could be called hell on earth, for George Beyan, the confirmed ward was it, and we had willingly cajoled him into returning to that place of his nightmares only to provide him with one even worse. We asked him to make such sacrifices knowing that this might happen. Indeed, I was the one who had asked it of him.

  Rounds that morning were unlike any other, with the raucous banter that usually accompanied the handoff absent, and the morning meeting a quiet recitation of pertinent items. Everyone silently went about their tasks. I asked Godfrey, who was in charge of burials, when they would inter Williams. He told me it would happen around eleven. I turned to Sambhavi Cheemalapati, who was running the ETU while Sean was on his R & R, and told her that we needed to go. She reluctantly agreed.

  George came back out a second time through the decontamination chamber, glistening from the light bleach shower, and Sambhavi, Godfrey, and I formed the back of a small processional led by two members of the burial team, an empty cart, a sprayer, and George. We moved around the peripheral road of the ETU, stopping at the back fence abutting the morgue, and the staff retrieved Williams’s body, covered in two shiny white body bags. George began to wail again, and I struggled like mad to stop the tears from flowing down my face, for this was not my loss, and I didn’t dare guess whether such a show of emotion would be considered appropriate. Eventually I had to bite the tip of my tongue so hard to prevent my tears that it bled. We put Williams in the ground in a ceremony that lasted no more than two or three minutes. Godfrey, I believe, spoke some official words.

  It was the only funeral I attended in the outbreak. Sambhavi, Godfrey, and I had to return to work.

  6

  BEHOLD, A PALE HORSE

  Blessed is he that readeth, and they that hear the words of this prophecy, and keep those things which are written therein: for the time is at hand.

  —Revelation 1:3

  The governments of Liberia, Sierra Leone, and Guinea did what they could to halt Ebola’s spread. Instituting a cordon sanitaire, as the West Point episode had demonstrated, was a dangerous and logistically nightmarish method of containment. The president of Sierra Leone, Ernest Bai Koroma, instituted a much larger cordon, restricting the movements of one million of his fellow citizens. International advisors howled in indignation, although not everyone in the West shared this opinion. Laurie Garrett, who had written the enormously influential The Coming Plague, wrote an opinion piece pointing out that in the Kikwit outbreak of 1995, the Zairean president Mobutu Sese Seko cordoned off the entire city, and the first truly large Ebola outbreak never spread to the rest of the country, or any other. But the Kikwit cordon may not have been the best model for President Koroma, for the Zairean military was much more organized, and there was only one road in and out of Kikwit, making it easily contained, while Koroma was attempting to seal off whole portions of his country. The debate wasn’t really about whether a cordon would be heartless or not. The debate was about whether it would be effective, or whether it might even take a critical situation and make it worse.

  At the same time, another solution was being scaled up. Instead of placing a cordon around an entire community, local communities could simply construct a miniature cordon and place those requiring quarantine inside the facility. In Liberia, they came to be called Community Care Centers, but everyone at the ETU referred to them as holding centers. All that was needed was active community surveillance. If someone had come down with symptoms that required ETU evaluation and was eventually shown to be positive, the people living with that person could be brought to the holding center where they could wait their twenty-one days. If they themselves became ill, they could simply be transferred directly to the ETU. The logistical issues were less complicated by an order of magnitude. You didn’t have to think about food and drink for the whole community, but just those members at the highest risk. In theory, it seemed a sensible way to at the very least cut down on Ebola’s transmission.

  In practice, however, holding centers were tricky places. They were often run by local groups who did not completely understand the nuances of risk stratification, so some people could find themselves placed in quarantine on the flimsiest of criteria and had little or no opportunity to appeal their detention once in. In the later months of the outbreak, unsettling rumors were circulating that some politicians held ever-greater numbers of people as proof of the success of their quarantine policies, even though the rate of infection was on a sharp decline throughout the country as 2014 came to an end and the number of cases was approaching zero even in places where nobody was held in quarant
ine.

  *

  Toward the end of my third week, Sean Casey came up to me after the morning staff meeting and pretty much ordered Colin, Steve Whiteley, and me to take a day off. We all gently protested to little avail. I wasn’t reluctant to rest for a day—we were all putting in fourteen-hour days, the work was physically grueling, the atmosphere was tense, we still weren’t sure whether the social structure was going to implode—but I had no idea what I would do with a full day off. Cuttington University was a ghost town, so all I could do there was wander around a picturesque but empty campus. Even if markets were open, it would have been risky in the extreme to go wandering about in a densely packed place, which was why the markets were mostly closed. Everyone I knew and had become friends with was going to work, so there were no social options. I hadn’t brought any books in my luggage. I did have my computer with reasonably decent Internet access, but between Facebook and The New York Times I might occupy two or maybe three hours of the day. What else was there to do besides sit around and brood?

  But Sean is not the type of person to take no for an answer and shrug it off, so while I pondered ways that I could avoid this micro-vacation, a solution presented itself after morning rounds. I had emerged from the decontamination suite in my usual sweat-soaked state and looked up to find Sam Siakor staring back at me. “Doctor Steve,” he said, “I would like for you to come to church with me on Sunday. We can get one of the drivers to take you into Gbarnga. Is that okay?” Well, I thought, there’s my solution: A big chunk of my day off was going to be spent sitting in the pews of an African church, which from the standpoint of a visitor coming to a new country is awesome. It would be a field trip extraordinaire.

  Sunday came and I made the half-hour trek to Gbarnga. Sam and I met, and he walked me around the Grace Baptist compound. Like many substantial structures that dotted the Liberian landscape, Grace Baptist showed the ravages of the Civil War, for it was obviously once a lovely building with a soaring interior, a pitched roof peaking at a height of more than twenty feet. Yet it had become shoddy and threadbare since its heyday, with missing doors, peeling paint, and a few broken windows to complete the picture. But the signs of slow rebirth were apparent as well, as I toured a construction area of what was to become a new elementary school. They were clearly finding their footing with limited financial means.

  Eyes followed me everywhere I moved. Sam introduced me to the various dignitaries of the congregation: the assistant pastor, the lead pastor’s wife, their family, the Sunday school principal. Children darted about, all stopping for one dumbfounded moment to see their visitor. A few of the more curious ones followed me around. Under normal circumstances I would sweep them up in my arms and turn myself into a one-man amusement-park ride for them, but I was hyperconscious of the no-touch rule as I made my way amidst the bustle. It felt especially strange to be offered a formal introduction to my hosts and not offer my hand in thanks and greeting, but I was confident they understood, even if the knowledge provided only a small amount of solace that such a simple gesture of respect had to be trampled upon.

  I had arrived midway through the services, and we eventually entered the main chapel during a break in the action. The chapel was big, with sea-green paint illuminating the interior, accommodating enough seating for what I guessed was about three hundred people. Nearly all the pews were full. I was unsurprised to be placed in the front row. Before the service resumed, a thin man approached me with wide eyes and said, “Doctor Steve,” expectantly. I had no idea who this was and quickly looked to Sam for help.

  “It’s Dennis,” Sam said.

  Dennis?

  The Dennis I knew was from two weeks before. His clinical course had been typical for those who survived: He felt lousy for the first few days, then hurtled toward the abyss for the next three or four, and had his “crisis day” to which so many others had succumbed. When we returned the following morning, there he was, lying in bed and blinking at us, saying he actually felt a little better, and we knew he would walk out the front of the ETU instead of being borne out on a litter, shrouded in a body bag, through the back. That was followed by a gradual restoration to health, which included more than a week where he sat in the confirmed ward, perfectly healthy but still with detectable virus in his blood and therefore still potentially infectious, but with very little to do. Dennis had requested a Bible be brought into the ward, and during his convalescence he spent much time reading and preaching to his newfound, and quite captive, flock. Many members of the national staff would also congregate at the psychosocial workers’ hut, which sat only feet away from the boundary of the confirmed ward, to hear his message.

  So it shouldn’t have been surprising for me to witness him here. However, as razor blades were rather frowned upon in the high-risk area, by the time I knew him Dennis had already sported a thick, bushy, white-and-gray beard. During the times when I made rounds while he preached, I couldn’t help but think I was looking at Charlton Heston, tending to his flock of Israelites as they stood at the foot of Mount Sinai. Only the encampment was gravel bounded by plastic fencing, and Moses had dark brown skin.

  That was the last image I had of Dennis, and in the two weeks that had passed, much had happened in the ETU and I had forgotten his face enough so that I could not process what he might look like without the beard. The Dennis of the ETU was almost prophet-like in his appearance; the Dennis in front of me was a lean, healthy-appearing man with a wide grin. As with the children, I had to stop myself from wrapping my arms around him in a giant bear hug out of the sheer joy of seeing one of my patients truly on the other side, back to something resembling a normal life, no longer tethered to that place of their nightmares, that place where I continued to work.

  Dennis and I exchanged some pleasantries for a few moments, and then the service resumed. Unsurprisingly, there was much singing, but the organization of the service and its choral music was initially a curiosity, and then a fascination. For there were two choirs, each with its own particular structure and function within the service. To the right of the pulpit stood the English choir: a group of about twenty people, both men and women, dressed in Sunday finery. A young man in his twenties sat in front playing an electronic keyboard that added music through a temperamental speaker, and next to him was the choir director. They sang nineteenth-century hymns that could be found in many mainline Protestant white churches in the United States or the UK. They were sung with an African inflection, but the music was purely Western in structure, and I was able to follow along in the hymnal and sing them without much trouble.

  On the opposite side of the pulpit, however, stood an altogether different group known as the Dialect Choir. This smaller group, about twelve in all, was all women and had no director. The service was vibrantly punctuated by their songs, as they turned the words of the Bible into their native Kru, Bassa, and Kpelle languages. Content-wise, it was standard church fare: At one point Sam casually mentioned that one of the leads was telling the story of David and Bathsheba, and I wished that some of my more religious Christian friends from youth could have joined me on this church excursion to witness this choir sing about King David in this particular way.

  The music of the Dialect Choir was simply breathtaking. The tonality of the music was completely different, sounding almost but not quite like a minor key that would veer into something else. Usually there was one lead who would “sing” while the other women chanted in the background. Only it wasn’t quite singing. It wasn’t quite yelling. It was something in between and yet more. I kept searching my brain for a way to describe the not-exactly-singing-not-exactly-speaking quality, and the best I could come up with was the vocal style of someone like Bob Dylan or Tom Waits, but the pitch was much higher. The words, the sounds, the spirit were from somewhere else entirely. I had never heard anything like it. I wouldn’t describe it as pleasant, but it definitely wasn’t unpleasant, and it was most certainly compelling. I resisted the temptation to take out my smartphone and o
pen a recording program.

  These two choirs, both in some sense complementary but also in conflict with one another, couldn’t have provided a better representation of the kind of split personality that constituted Liberia. It was like watching their history play out over the course of the service, a demonstration of ontogeny-recapitulates-phylogeny as ecumenical exercise. Here was this church, Grace Baptist Church, bearing the exact same name as a church from my hometown of Mansfield, Ohio, with its mission written right into its name, a flock searching for divine favor, deep in its belief of the redemptive power of purification through the immersion of baptism. It was a church in some ways indistinguishable from its Ohio cousin, the worldview of the parishioners shaped by stories compiled long ago in a land far from either congregation. Yet Grace Baptist in Gbarnga was also very much of Africa, and the tribal culture lived on inside this new and alien religion, its animistic DNA incorporating itself into a Western faith that was at once liberating and oppressive. Appreciate these two choirs and the tension inherent in their different aesthetic messages, and you know something essential about Liberia.

  After we were treated to David and Bathsheba, the congregation settled itself into the next phase of the service: the reading of the Gospel, followed by the Pastor O’Malley Moore Segbee’s homily. Although I only rarely find myself in a church, I had been to enough services to have a general feel for the flow of the morning, and I eagerly waited to see what part of the Bible was going to be read, since my acquaintance with the New Testament was fairly limited. My enthusiasm quickly turned to shock, however, for the text of the day was from Revelation. We were going to read about the opening of the seven seals.