Inferno

by Steven Hatch, M. D.

  One night, as I was making my way over from the suspect ward, I rounded the corner, hardly paying attention to the screen, when I heard a pop! come from one of the movie speakers and caught a glimpse of red splashing at the periphery of my eye. I turned back to the screen to see what was happening. A man was lying on a table, shot and bleeding, and another man was over him. I tried to process this scene. A war film? It was some kind of foreign movie. I kept watching, and although I never did learn the actual name of the movie or what country it came from, it appeared to be about Middle Eastern terrorists settling their ideological differences with methods best described as medieval. And the kids were watching this—my kids were watching this, for I had suddenly found myself transforming into Doctor In-Loco-Parentis, charging up to the boundary and giving in no uncertain terms instructions to the WASH staff that these movies were Capital-O Out, and I would be having a conversation with their mothers—ahem, Godfrey—in the morning. “Show’s over, kids,” I said to the three boys, who looked crestfallen at the news. Hadn’t this country seen enough senseless violence?

  Other elements of life in the ETU, of which I had been only dimly aware, became featured during the night. Graft is a complicated subject in as impoverished a place as Liberia. Stealing from the ETU was commonplace. The thefts were generally petty, and I was only peripherally cognizant of them for the most part. For instance, I had a rude awakening to the practice my first day there, when I went to the communal locker room to change into scrubs. The cubby holes did not have locks, and I tucked away the clothes that I had hastily donned in Monrovia hours before, clothes that included a wallet stuffed with cash. Later that afternoon as I was driving to my flat in Cuttington, I noticed that the wallet was still there, but more than two hundred dollars of my money had vanished.

  The pickpocket was kind enough to take only the cash, so all the truly important items, including various forms of identity and electronic credit, remained unmolested. They were even kind enough to leave me a little cash in the form of Liberian currency, with former President Samuel Doe, a man with a gift for the related art of embezzlement, staring up at me, almost winking, from the front of a fifty-Liberian-dollar banknote, which could just about purchase a can of Coke. Although irritated, I took it as a lesson learned and became extremely careful about my valuables after that, especially since IMC doled out our monthly allotment of petty cash in a lump sum at the beginning of each month, leading me to squirrel away small amounts in hidden corners of various parts of my flat so that a repeat episode would not prove to be financially devastating.

  But I never paused to develop any moral outrage over the matter. Dating back to its modern origins, Liberia has always been a place where plunder of some sort had taken place—mainly the plunder instigated by corporate America through the intermediaries of the Americo-Liberians. We were, in some important sense, the thieves: Americans coming to this country and looting the land of its natural resources, walking away with palm oil and bauxite and, above all else, rubber. We just had developed the nicety of calling it trade to provide it with an air of civilization. But if trade was the great win-win scenario that gets those who claim to have read Adam Smith so jiggy, why, after more than a century of Liberia providing rubber and other valuable commodities to the United States, was Liberia still so appallingly impoverished? What had become of the wealth of this nation, other than to find its way onto the tires of my Toyota back in Massachusetts? There seemed to me to be a logic inherent in the theft, a small settling of accounts that had historically become wildly unbalanced on a massive scale.

  But I did come to see that there was something of a Catch-22 about an amoral approach to private property and ownership in a place like this. It’s true that Liberia had been plundered by the West for hundreds of years, setting in motion a system that hardly looks equitable and for which its penurious masses might be justified for thinking themselves entitled to institute on-the-fly policies regarding wealth redistribution. But if that was so, and people felt no sense of shame about pilfering from the international aid organizations or those who worked for them, how would an economy in a place like Liberia ever become anything beyond a corrupt mess? The aid organizations would continue with their work despite the graft, but that didn’t mean that small businesses would want to sign up for risky ventures if they believed their products had a high probability of being stolen. There was a highly determined group of Lebanese merchants in the country, bless them, but there wasn’t much beyond that. The problem of government corruption and the prospect of having to deal with a culture of bribery must also be forcing legitimate businesspeople, even those genuinely interested in doing work in a place like Liberia, to remain at a wary distance.

  Therefore, this cultural attitude probably kept all but the most ruthless of organizations from starting work in Liberia in the first place, and these outfits were the least likely to care about such trivialities as equitable pay and increasing the standard of living for the average Liberian. From my vantage point, as long as the status quo remained, the cycle wouldn’t stop. Though I had no idea how many people were stealing—and America is hardly without corruption itself—I did know from the grumblings of the logistics team members that the problem was widespread.

  IMC eventually handled the problem by locking away everything that could be locked away. The storerooms became increasingly secure, with fewer and fewer people having access to the keys to retrieve items except under carefully controlled situations. This dramatically cut down on theft, but theft never completely dissipated. A few items in the medical and general storerooms always seemed to be lower than the inventory would suggest. Every few days, someone would complain about it. In general, I shrugged my shoulders, thinking that this was the cost of doing business in a place like this, and tried to avoid simple moral judgments given the convoluted history of this nation. Yes, graft was a technical problem to be solved, but paternalistic lectures from mostly white people weren’t going to help matters in the long run, or even the short.

  But working nights changed my view of the matter, at least to a degree. The days were hot, but the nights had a coolness that reminded me of summer camp in August in a place like the Poconos. The temperatures would drop to the low seventies or high sixties, and when combined with the damp, it meant that two layers of clothing were needed to stay comfortable. We would round in full PPE before midnight, and the gear brought a comforting warmth. My longest spin in PPE happened this week, when I once spent four hours, in no real hurry to finish my work since I was comfortably, thermally neutral.

  It was a different matter for the patients. We could not wash their clothes, because every object in the high-risk area had to be incinerated, so the stockrooms were always supplied with donated clothes so that we could offer something new to patients every few days. We plowed through an astonishing amount of clothing. Sometimes it meant that someone was wearing pants five inches too long, or a man would wear a frilly pink taffeta shirt obviously intended for a woman, but I never heard anyone complain about such indignities.

  But trousers, a T-shirt, and flip-flops were not enough to keep one warm in the confirmed ward. What was plainly, desperately needed were blankets. Yet blankets remained among the few items apparently so precious that whoever was stealing stuff would try to circumvent every roadblock the leadership threw up in order to take them, whether for personal or business—that is, black market—ends, I cannot say.

  I can go along with the notion that property and theft is a good deal more complicated in Liberia than it appears at first glance. I can offer up any number of justifications for why it behooves Americans or Europeans not to reflexively judge their Liberian cousins who might swipe some goods from what they perceive to be an organization with endless supplies and limitless resources. All this I can do and be genuine when I say it, but all that becomes intellectual claptrap when I am forced to watch my patients, the most vulnerable people on earth, suffering one of the worst diseases imaginable, sitting there
shivering because one or two of their fellow Liberians think it’s okay to steal a blanket knowing full well the consequences it has for these people—people who could just as easily have been them were it not for chance alone. So quit taking the motherfucking blankets! Good grief, these are your people! I am still furious as I write this.

  *

  My final night shift took place on Halloween. There was some talk of a gathering of expats that night, which would have been one of the only times we socialized as a group after hours, since everyone worked long days and nobody wanted to come to the ETU groggy from a late night, but I couldn’t come. Over the course of the week, the moon had been waxing, so maneuvering around the ETU had gotten progressively easier, and by then there was a half-moon lighting up the night. I moved into the donning station to take my last nighttime spin.

  Just before I put my leg into the Tychem suit to start the process of gowning, one of the staff came to tell me that we had a problem. In the suspect ward were a father and his six-year-old daughter. Their test results had returned negative earlier in the afternoon, but due to a variety of logistical glitches as well as a big bolus of new patients, nobody had dealt with their discharge planning until now. It was late, and there weren’t exactly evening buses running on the Gbarnga express, especially two miles up a dirt road into the jungle, so there was no way they could get home. Normally, getting our negatives out of the suspect ward was the highest priority for obvious reasons, as nobody wanted them to remain in a Biosafety Level 4 environment for an additional twelve to sixteen hours. But what to do?

  On the corner of the campus we had constructed a visitor’s center, but it was almost never used, owing to the stigma involved with the place. Even the love of family wasn’t enough to convince people that it would be safe—or that their neighbors wouldn’t shun them after they had visited. We made a plan to set up a couple of mattresses and provide sheets and blankets in the visitor’s center, which, needless to say, was outside the high-risk area, so that they could sleep the night away no longer inside the ward. All we had to do was decontaminate them and take them there.

  The path to the visitor’s center had to be accessed by walking the entire way around the compound from the opposite side. Because of the manner by which the Hot / Not Hot boundaries had been constructed, there was no direct route from the suspect ward to the visitor’s center, even though a visitor would have looked across a mesh divide to their loved ones only feet away. The problem was that one side of the ETU is nestled up right against the rainforest; the small part of clearing that skirted that side was occupied by the ambulance path, which means that part was still high risk. Thus, to get to this structure, visitors were forced to walk nearly the entire perimeter in the opposite direction.

  This would have been nothing more than tedious, but as the ETU’s needs changed over the course of the outbreak, there was additional construction at the far edge of the compound. Weeks before, when the epidemic was still raging at full tilt (and still was, for all we knew), plans were in place for more beds on the confirmed side. The back of the ETU was the only place where this new structure could go, so what was originally a clearly demarcated path had been torn up, with piles of dirt, wooden beams, corrugated tin roofing, and nails lying all over the place. I learned all of this as I accompanied this pair through the dark, with a cheap flashlight that I had to keep banging to get the current to flow.

  So I began Halloween by taking a terrified girl and her father all the way around our Little Shop of Horrors, after she had already endured one otherworldly experience, and walking her through a postapocalyptic landscape, only to deposit her on a cold, damp bed. The maneuver was meant for their safety, but good luck explaining that to a six-year-old unfamiliar with the subtleties of filovirus transmission and the need for strange forms of infection control.

  It was damp that night, and by the time I returned a half hour later, I was a yucky muck of dirt and sweat. Going into PPE already schvitzy is not fun, especially since my sweaty skin always became irritated from rubbing against the PPE, so that night I was giving my eczema a head start. But I was a soldier, so off I went into PPE without complaint. By the time I had made it over to the confirmed ward, I was not surprised to find one of our patients, Joe, had passed away. At the evening handoff, the team said that they didn’t believe he would survive the night. He must have died not long after he was last seen in the afternoon, for by the time I arrived, he was in rigor. His daughter, who was recovering from the worst, was three doors down and blissfully unaware of this; we decided to let her sleep the night and inform her in the morning.

  By this point it was just shy of eleven, and Kelly and I found the two young men from the WASH team who were spraying down the surfaces of the confirmed ward, a nightly practice, to tell them we needed to prepare Joe for transfer to the morgue. They looked at each other quickly and then at us, hoping that they hadn’t actually heard it right. “Oh, we can leave this until morning,” one of them said casually, trying to inform me of the standard operating procedures on the night shift that I, a mere greenhorn, had failed to grasp.

  I looked at them and said, “No, there’s plenty of us, we can do this,” and although they were masked, I could sense their faces fall. There was simply no way we were going to leave this kind of work for ten more hours. Certainly the patients did not want a dead body in their midst, even if that body posed no physical threat.

  I went to get two body bags for the move: The first bag, after being zipped up, is then sprayed down from the outside and placed in the second, where another round of spraying takes place for maximum infection control. We placed Joe into the first bag. He was heavy and stiff as a board, with one arm held out crooked. Because the room had tight corners, simply moving him into the bag involved contorting ourselves just so.

  We eventually succeeded, and then got the second bag in place and zipped up. We then placed him onto a stretcher and sprayed everything a third time, which included ourselves. At that point the WASH staff were backpedaling, hoping that they would not be asked to perform any further tasks, but I pointed at one and said, “Okay, it’s you and me who are gonna take him to the morgue.” Because I had spent the better part of four weeks among the national staff managing the tricky maneuver of acting like a goof while also simultaneously being deadly serious about the work, I felt that I had earned their goodwill, so by then most of the staff who knew me would do what I asked of them without protest. While he raised no objections and stayed behind to help me bear Joe on the stretcher to the morgue, you could tell he hoped this highly unpleasant activity would end as soon as possible, or that some other staff member would magically materialize in front of us to take over his duties.

  We picked up Joe and headed out the back. The entry and exit points to the high-risk area were basically flat, but this part of the ETU was where the hillside sloped back down into the valley and was the steepest decline in the Hot Zone proper, the one place where one could easily stumble, especially while wearing rubber boots that didn’t quite fit. The back stairs were tricky, for not only were the steps themselves not perfectly flat, tending to slant downward, but the distance between the risers of each step was wildly variable, some being inches apart and others more than a half foot, so that one could not ascend or descend these few stairs without carefully looking down. That, however, was obviously out as we carried Joe, so we moved slowly and deliberately. I did not want either of us to fall down and tear our PPE on the rocks while bearing Joe, who in such a stumble could land on us, or we on him.

  Even with the moonlight, it was dark between the buildings, as the shadows of the latrines were cast on the back exit of the confirmed ward. And, per usual, I still couldn’t see anything through my misted-up eyewear. Carrying Joe to the morgue proved to be the most adventurous thirty-foot walk of my time in the ETU, which given my recent misadventures escorting the father and his daughter to the visitor’s center only hours before, was saying something. After this brief journey, we ar
rived at the morgue. Effectively, the morgue was just a concrete platform over which a framed tent of tarp was draped since it hadn’t been intended to be used as anything other than a place to put the bodies prior to burial. The entrance was a tarp flap rather than a door, so pulling it aside while keeping the stretcher steady proved to be, like everything else associated with this move, awkward.

  The morgue didn’t possess electrical wiring, and so once inside it was pitch black. I couldn’t see a foot in front of my face. The phrase “dark as hell” leapt to mind, and I comforted myself by the fact that I didn’t actually believe in hell. But my WASH companion would have felt otherwise. Fortunately, since there were no other bodies in the morgue at that time, we walked into the center of it without being able to see and lowered Joe to the floor. As soon as the stretcher touched the concrete and Joe’s temporary resting place was secured, my colleague bolted for the flap, scurrying out as fast as his legs could safely take him, leaving me in the absolute darkness.

  I decided to linger there for a few moments and soak the moment in. It was midnight of Halloween, and I was standing in the middle of a morgue, in complete darkness, over a body that had just succumbed to one of the most frightening viruses known to humans. Who needs a ghost story? I thought. I’m living in one! I stood there and, with apologies to Joe, started to laugh.

  It was then that I was hit with a sudden, powerful, and inexplicable feeling. I couldn’t explain why, but at that moment, I had the realization that I was probably going to get out of this thing alive after all.