Inferno

by Steven Hatch, M. D.

  The evidence to support this had been accumulating while I was doing my work. During the week I returned home in November, The New England Journal of Medicine published an issue almost exclusively devoted to Ebola. One of the articles dealt with a German expat who had been working as an epidemiologist for the WHO and had gotten infected in the course of his duties. He was eventually flown home and cared for in an intensive care unit, where he had the misfortune of having a bacterial bloodstream infection on top of his Ebola. Being in a Western facility, the team caring for him was able to quantify precisely how much fluid he was losing, how much fluid he was receiving, his body temperature, his weight, basic laboratory values—as many variables as could be mustered for the article.

  While his fluid losses seemed consistent with everything I had witnessed in Bong County, looking at the data on the printed page nevertheless shocked me. He had arrived in Germany ten days into his illness, and still fluid was pouring out of him. On the eleventh and twelfth days, he lost nearly ten liters through diarrhea and vomit each day. Ten liters is more than two and a half gallons of fluid. Moreover, these measurements didn’t take into account how much fluid he was losing from the fever, which was also substantial. Based on what I had seen, the worst of these “wet symptoms” started around day eight, give or take. If these numbers were to be extrapolated, that meant that over the course of an infection, a patient could lose something in the vicinity of three dozen liters of body fluid, or nearly ten gallons. Most Liberians are small or lean or both, so a reasonable guess is that many or most of our patients weighed somewhere in the range of 150 to 170 pounds. Ten gallons is equivalent to half that weight, which is so much that it can’t be believed, but whatever the real number, it gives a sense of just how severe this illness could be. No wonder so many people were dying. Bleeding wasn’t the biggest problem; fluid loss was.

  All that was required to turn this tide, at least in theory, was aggressive IV hydration. Everyone back in the States was obsessed with space-age drugs like ZMapp, but the answer might have been something much more mundane—and easily available for distribution within West Africa. Phebe, the hospital a mile down the road from the ETU, had an IV saline production plant that supplied much of Liberia with this critical product. Steve Whiteley had always advocated aggressive hydration as the optimal approach, and he used his time during the quieter night shift to hang as many bags of fluid as possible. Even before I left in November I could see the compelling logic, but I started to think about fluid replacement in new ways.

  For instance, we spent a fair amount of time gathering, distributing, and recording a number of medications given to patients, many of which were likely to have a limited impact on actually saving their lives. The problem with that approach was that it chewed up precious work time in the Hot Zone, which was always a race against the clock due to the physical stresses of wearing PPE. If fluids were the key, and we only had so much time, why were we prioritizing the less effective interventions? This was pure speculation on my part, but I wondered about the mortality impact of an ETU that had specialized “fluid brigades,” whose sole job would be to distribute nearly round-the-clock bags of IV saline or its equivalent. All that was needed was a good deal more labor, which is cheap in a place like Liberia, and more bags of fluid, which didn’t seem to have a supply issue (unlike, say, PPE suits, which were becoming increasingly more difficult to obtain given the huge increase in demand in the United States as every hospital cobbled together an “Ebola preparedness plan” for cases that they were incredibly unlikely to see).

  So I thought that if I could get back to an ETU, I might be able to make a difference, and I started to scheme ways in which I could return as soon as possible. I spoke with some people from the International Rescue Committee about working in a large ETU in Sierra Leone, and I continued to talk with Sean about how I might be incorporated back into IMC’s overall plans. It seemed like I had promising leads, and my hope that I would be back in Africa kept the despair at bay, at least in part.

  As before, getting my goals to align with the institutional imperatives of UMass proved challenging, and also as before, the details to explain the conflicts are tedious. But by mid-January, I had decided that I was headed back over there one way or another, even if it meant that I wasn’t in a position to mount my attack on Ebola with my fluid brigades. For by that time, there were plenty of volunteers for ETU work in the pipeline, and so I wasn’t needed for that kind of work, even if it was what I most wanted to do. What they didn’t have in full supply were trainers—people who not only had ETU experience but actually knew something about the virus, its history, its physiology, the purpose of infection control, and so on. They were looking to add another teacher to prepare this vast pipeline of volunteers for the ETUs that were belatedly popping up now across the country, and that played to my strengths.

  Bong County had proven an ideal site for the training, since not only was there an ETU in which genuine “hot training” could take place, but the campus of Cuttington University allowed for everything else that such training would require: dorms, classrooms, and a large-scale kitchen to feed the dozens of people in each training class. “Ebola University” was in its infancy as I was leaving, but it was fully developed by January, and I would be its scholar-in-residence for another five-week spin.

  When I got back to Cuttington, I found a completely transformed site. In October 2014, it was a ghost town, populated only by the IMC volunteers who numbered one or two dozen, as well as a skeleton crew. But the students had begun to return, at first in small numbers, but eventually it looked very much like what a college campus should. IMC, which had had complete run of the place previously, was now confined to one corner of the campus, occupying the dorms and classrooms of the Agriculture School that had yet to open. When the IMC staff, most of whom were white Americans or Europeans, ventured around the central portion of the university, we were greeted by curious stares from young, black Liberians. It was their campus and we were its oddball guests. I took it as a sign that normalcy was returning to life in Liberia, and that gave me great comfort.

  We ran weeklong sessions for cohorts of twenty or more trainees. The on-campus training was a split of classroom time and “cold training” where people learned to don and doff PPE and simulate basic tasks required for care of patients with Ebola right on campus in a mock ETU. That was followed by the hot training where they went to the Bong ETU and tended to the patients there under careful supervision of the existing IMC staff. Mainly my job was to provide three or four lectures about the epidemiology, science, and clinical aspects of Ebola, and help out during the cold-training exercises. I had no hand in their hot training, although I did usually accompany the trainees at least once or twice to the ETU, in part because I wanted to make sure they transitioned nicely, in part because the wireless there was perfect. Either way, it meant that I had a lot of downtime, and although I was a good deal happier to be back in Liberia, I still had some difficulty pushing back the darkness that seemed to have ingrained itself into my outlook.

  I don’t think I was the only one. The after-hours socializing among the staff, who unlike me had mostly not returned to their home countries for a prolonged convalescence but had been gritting it out for three or four months, almost always involved a moderate to heavy amount of alcohol consumption. There was never any real drinking in October and November, with alcohol being used sparingly, nothing more than a social lubricant, with one glass of wine per person on the rare occasion when everyone got together for a group dinner. By February, a river of gin and tonic water was flowing through Gbarnga, and the local merchants must have been delighted supplying the newfound demand. Fortunately for me, gin is among the few types of alcohol I really don’t like, and so I kept my drinking to not especially tasty Liberian beer and only the occasional desperate binge, during which times I did enjoy myself immensely.

  In particular, I suspect that the team tasked with witnessing the devastation the virus h
ad wrought in the community was coping with an absurd amount of grief. During the ETU’s heady days in September through December 2014, the psychosocial support staff had tried to find answers to such heartrending questions as what to do with a child who had survived the infection but now would not be accepted back by her village or had no family to return to because they were all dead. They also tackled issues such as helping adult survivors find jobs, encouraging villages to accept survivors back into the community, and simply figuring out how to get patients from the ETU back to their homes, which could often be several hours away. These were among the issues they dealt with on a daily basis. It was clear to me not long after I had arrived in October that the psychosocial support staff had the hardest job in the ETU, for while the medical staff tended to the destruction of the body, their team saw the damage of the outbreak through the lens of human connection and loss and suffering and grief.

  Now in January the outbreak was nearly over: There were no cases in Bong County or its neighbors, and only a few suspect cases trickled in each day to the ETU. But the psychosocial support team was still hard at work dealing with the aftermath, as the entire country was in the midst of a genuine posttraumatic stress disorder. Liberians had faced what they thought would be the end of the world, and now they were trying to piece their lives back together. The psychosocial support staff, or “PSS” as we called it, of which about half were Liberian but the rest of whom came from all corners of the globe, were going to try to bridge a huge number of cultural barriers to aid in this transformative process. It was a tall order.

  When I was doing my ETU work, I never had the time to do anything other than work in the Hot Zone and tend to the patients. There was a sufficient amount of paperwork that needed to be done during the downtime, and that meant that I had little chance to see the other workings of the operation or to witness the work of the PSS team up close. PSS was led by a German expat, Dr. Fredericka Feuchte. Fredericka had been living in Monrovia for a few years prior to the outbreak; she came here as part of a research project on the psychological health of the Liberian community in the wake of the Civil War and quickly realized that such work could not be done, or at least done well, by bouncing back and forth to Germany. So she had set up shop in Liberia, doing her research and collaborating with colleagues back home.

  Then Ebola came and everything changed, and she found herself running a crisis response to the innumerable social and psychological problems that the outbreak had introduced. During September and October she worked with a staff of about ten nationals, some but not all of whom had formal training in psychology or social work. Despite these rather harrowing working conditions, Fredericka somehow managed to maintain the brightest smile in all of Bong County, one so pleasant that I would actively seek it out on especially rough days.

  One of the nationals that worked in the psychosocial support team was Garmai Cyrus, the woman I became friends with during my previous deployment. When I first came back to the ETU, within a day or two I wandered over to the psychosocial hut to find her. The outbreak was still technically on, and the rules regarding not touching anyone were still in force. We looked at one another when I came to the door, and I thought, To hell with the rules, and wrapped my arms around her, the first moment I had touched anyone in Liberia since this whole mess began. Let ’em send me home if they have to. Nobody seemed to care as we held each other for a few moments, trying to use that time to process what we had seen together.

  Because there was downtime in February, I wanted to take the opportunity to see what they did. As IMC’s Liberian operations had expanded to include the Kakata ETU, Fredericka’s work likewise grew, and she came to oversee two separate staffs, splitting time between Bong and Kakata in addition to returning to her apartment in Monrovia. And unlike the rest of the workers in the ETU, the PSS team was still very busy, although obviously its work had shifted from sorting out immediate matters for patients and their families to assessing the psychological impact of the outbreak on some of the harder-hit communities and helping those communities process some of the loss. But that required poring over the records to see which communities were hardest hit, organizing trips to those places, establishing rapport with the locals, and maintaining those ties over time. They had become, at least partly, a traveling psychotherapy outfit, making weekly stops at some of the more deeply affected villages.

  When I showed up asking questions about sitting in with the PSS team, I met a young Irishman, Eoin Ó Riain, who had been in Bong since early December, along with Marco Morelli, a somewhat free-spirited American who was working on his Ph.D. in psychology in California and came to Liberia to help out while organizing his thesis materials. I ended up living with both of them in the dorms at Cuttington, and when I inquired about joining them, they said, “Hey, we’re going to Mawah on Saturday. Garmai herself is running one of the group sessions, she’d love to have you come. We’re going to stop off at the Kakata ETU for the night and drive to Mawah at first light. What do you think?”

  That was a no-brainer, so I packed up my belongings on Friday the 13th of February (yes, truly) and took the exceedingly bumpy, dirty, hot, and long car ride into Margibi County. As we drove on one patch of dirt road adjacent to a stretch of the highway that was under construction, we finally made the turnoff to the Kakata ETU just past five in the afternoon.

  The living quarters for the Kakata ETU staff were immediately adjacent to the patient care areas, housed in a building originally intended to be a county outpost of the Liberian Ministry of Health. The permanent construction was two stories and made of concrete, with the medical and staff offices on the first floor, and what amounted to dorm rooms on the second. In Bong, the staff were scattered across various residences on the Cuttington University campus, but here many of the staff, including all of the expats, were concentrated on the second floor of this building as well as in a few satellite cottages within a hundred meters or so. The conditions were clean and, in relative terms, luxurious; a lounge sat in the middle of the building and had an enormous flat-screen TV with a satellite hookup, and a well-stocked fridge stood nearby. I took to calling it Hotel Kakata during my brief stay.

  Though somewhat haggard from the bumpy and dirty ride, the PSS team immediately arranged a debriefing in anticipation of the following day’s events in Mawah, so that everyone knew the plan. The five members of the Bong PSS team were joined by three of the PSS staff from Kakata. Because the other office space was occupied, we convened the meeting in a small but well-lit storage room that held the toiletries for the ETU, making space amid cubbies filled with soap bars and toothbrushes, and large, trash-barrel-sized bins that contained clothes for patients, since they would have to leave their current ones behind to be burned as they left the high-risk area.

  Mawah had been one of the main villages the PSS team targeted early on as being in special need of help. About eight hundred people live in Mawah, a typical Liberian village tucked into the jungle about an hour’s drive from Kakata and roughly a five-mile walk to Hinde, the first community on the paved road. On the last day of August 2014, the virus crept into the village in the form of a young man who had lived in Kakata. He was twenty-two and was a student but had fallen ill days before and had ventured to Mawah to seek help from his mother’s family, as she hailed from the tiny village. He stayed briefly before returning to the town of Bong Mines, halfway to Kakata, where he died and was buried by other family members on September 4. From there, the nurse aid who had cared for the patient himself fell ill and traveled to two other villages named Monokparga and Kalikata Meca, where at least nine other people became infected, though what became of them and whether it spread further, I do not know. The events of the Mawah cluster, which included the information about the other two villages affected by this illfated young man, were being reported by the CDC in its “Morbidity and Mortality Weekly Report” at almost the exact moment I was walking around the village.

  Once Ebola had made its entrance to Mawah,
it started to pick off the villagers one by one. By the time the virus vanished, more than twenty people had become infected and nearly all of them died. Everyone in the village was linked to the dead by blood or friendship or mutual work. Nobody could escape anguish of some sort. Now, four months later, they were beginning to process some of that grief. IMC’s team had been busy, making weekly visits and running group sessions of about twenty people per group lasting two hours or more.

  Each of the leaders of the four group-therapy sessions reviewed the main topics of discussion from the previous week and what they anticipated was likely to happen in the next session. Garmai sketched out the particulars of her group: There was to be a bit of a “truth and reconciliation” moment, and she wanted everyone to be alert to the potential for explosiveness.

  The matter related to the death of one of the villagers, whom we’ll call Alex. Alex’s best friend was Elijah. Elijah was from Monrovia and had come to the village a few years ago after having met and married Alex’s sister Esther. It must have been a huge adjustment to come from the bustle and density of Monrovia to the isolation and quietude of Mawah, but Elijah settled in, helping the family with planting the crops and gathering the fish from the river that ran beside the village. He and Alex became close, and as I heard this part of the story, I was struck by how Elijah’s story was a Liberian version of an archetypal tale often told in the United States or Britain, that of the grizzled city dweller who came to find peace and happiness in the sleepy countryside, though instead of some quaint little hamlet lush with grass and maple trees, this was a complex of mud-brick houses with dirt floors and palm trees.

  But you know that this story doesn’t end happily. Alex got infected sometime in September and died not long thereafter. For reasons that weren’t yet clear to me, Alex’s mother—that is, Elijah’s mother-in-law, Matta—apparently held Elijah responsible for Alex’s death.