Journey to the Center of an Epidemic

MONROVIA, Liberia — The journey to Liberia tests the mettle of any American wanting to help the nation in its Ebola crisis. The trek really begins with fears about how the Samaritan will be received once he or she returns from the epidemic, facing quarantines and stigma. And the first leg lands the traveler in a political and cultural climate in steamy West Africa marked by resilience in the face of genuine threat.

As I prepared to come to Liberia, New Jersey Gov. Chris Christie and New York Gov. Andrew Cuomo issued tough mandatory quarantine edicts for medical volunteers returning from Liberia, Guinea, or Sierra Leone, and nurse Kaci Hickox spent days inside a tent in Newark despite having tested negative for Ebola infection. Secretary of Defense Chuck Hagel ordered mandatory quarantines of soldiers returning from a tour of Ebola duty. And the Centers for Disease Control (CDC) issued far less stringent guidelines for most travelers from the Ebola-hit countries, under which it seemed I would face little more than daily temperature checks upon return. I delayed my departure in hopes of gaining clarity, but left without knowing how long I may be confined, if at all.

In my case the uncertainty is inconvenient, but ultimately it won’t affect my financial or personal well-being in any way. But many physicians, nurses, and students of medicine as well as public health employees, officials, and volunteers fear difficulties with their jobs, hospital affiliations, or, for example, having their studies interrupted if a leave of absence for Ebola service ends up extending upon return. And these fears and uncertainties are having consequences — very real ones. In meetings just prior to my departure with top officials in Washington, I learned that would-be volunteers were cancelling plans to fight Ebola due to quarantine concerns and because insurance companies were cancelling medevac coverage.

On the latter I, too, found medevac guarantees all but impossible to obtain. One provider, AIG, cancelled all medevac provisions outright a few days before my departure, and all others claim the right of force majeure, allowing them to void contract provisions under extreme conditions. Many medical volunteers face the same predicament — even if they work for such organizations as Doctors Without Borders or the International Medical Corps. State Department officials told me last Tuesday that they are scrambling to increase the government’s medevac capacity, but right now have only one Gulfstream jet and an evacuation unit that can accommodate a single patient. At the Department of Defense, I learned that the Pentagon hopes to build a four-patient medevac unit, but it does not now exist.

So American Ebola-fighters now face three fearsome challenges: death from viral infection, lack of clear routes of return to the United States should they become infected here in West Africa, and forced quarantine and stigmatization once they get home.

Once those hurdles are overcome psychologically — and it’s decided that the journey’s goal, the Ebola fight, still outweighs the risks of infection, the inability to medevac home, and the quarantine and stigma that potentially await — the trip offers its own set of challenges. Only two commercial airlines still fly a couple of times a week to each of the Ebola-stricken countries: Brussels Airlines and Royal Air Maroc — the former routes through Belgium, the latter via Casablanca. I chose the Belgians.

The 28-hour trip included a seven-hour layover in the Brussels airport and a 90-minute stop in Dakar. In addition to regular luggage, it was necessary to pack extra supplies for this trip, including sufficient hand wipes, masks, gloves, and other such protective gear — enough to incur $150.00 in overweight baggage fees. The airport security check at JFK featured a 40-minute grilling from TSA, which included questions like: why I was going to the epidemic, whom I did I plan to see, and what I did I plan to do in Liberia. At the boarding gate in Brussels I was given a fact sheet on Ebola, detailing my risks and the symptoms I should pay heed to.

I spoke with several Brussels Airlines employees, both on the planes and at the Brussels airport, and found them to be proud that their company remained the last European carrier willing to service the epidemic-hit countries. And it seems to be good business for the airline, as each leg of the journey the flights were sold-out.

On board the Brussels-to-Dakar leg, I was given several forms to fill out, one of which asked if I had attended any funerals recently, if anyone had vomited upon me, or if I had lost a family member to Ebola. "Have there been suspected or confirmed cases of Ebola Fever declared in your family or in your neighborhood?" it asked. Though the virus has infected one human being who now resides in Bellevue Hospital in New York, I could happily check the "no" box for all such queries.

Aboard the Africa-destined flight, I strolled the aisles taking note of fellow passengers — most of them Americans and Liberians. Many conferred over blueprints of ETUs (Ebola Treatment Units) or spreadsheets of patient data. Some compared notes on prior voluntary service in Africa. As I passed two men staring at an ETU layout I overheard one say, "So, the green zone is here. Be clear about that." (The "green zones" indicate the areas populated with workers and visitors; the "red zones" indicate where the infected persons are.) I returned to my seat to devour a brilliant Natacha Tatu piece in Le Nouvel Observateur, "Ebola: en Guinée, au coeur de la course contre la mort," telling the saga of Doctors Without Borders’ battle against the virus in Guinea. And then I read pop star Angélique Kidjo’s New York Times op-ed, "Don’t Let Ebola Dehumanize Africa." Behind me, two well-dressed Liberians discussed the "horror and disrespect" of false rumors about Ebola and travelers, clucking and saying, "It is very bad, very bad," repeatedly. Feeling depressed, I turned to the movie offerings, selecting Dawn of the Planet of the Apes, but it opened with a lengthy montage on a plague that overran the planet, obliterating most Homo sapiens.

Liberia is a nation so lacking in electricity that our plane’s nighttime landing swoops into pitch-black darkness — only the landing lights visible. On the only plane arriving for two days to Monrovia’s Roberts Airport we offloaded onto the tarmac and were ushered to our first chlorine wash, compelled before entry into the terminal. The crowded baggage claim area was filled with Americans, including about a dozen unarmed U.S. soldiers dressed in camouflage uniforms. Everybody claimed unusually large amounts of luggage, including boxes and crates full of personal protective equipment, medical supplies, and special gear relevant to their respective duties in the Ebola fight. We collectively craned necks in search of our bags as the heat and humidity of Liberia drained what energy the 28-hour journey had failed to sap up.

During my first morning on the ground I was met with the African smells and sights I have known so well during my three decades of travel on this continent, but with one crucial difference — no hugging, wild gesticulations, comradely macho handshakes, or girlish kiss-kiss greetings.

The well-paved Monrovia streets buzzed with commerce but humanity felt unusually stiff and aloof by African standards.

Everywhere one looks, Ebola warning signs can be seen declaring the virus "is real" and that danger lurks in funeral ceremonies and with every touch. The faint odor of chlorine is pervasive, as hand wash stations are at nearly every commercial and government portal. In the most densely populated neighborhood, the shanty slum of West Point, a Red Cross vehicle causes consternation when it blocks traffic, but the riots of September from slum residents are no more. When the Red Cross volunteers appear from a tin shack carrying a full body bag the congested area hushes and residents whisper among themselves, while traffic yields to the exiting van. Moments later a throng of some 30 teenagers dressed in brand-new white T-shirts blocks the narrow West Point main road, holding Ebola banners meant to raise public awareness and chanting, "Liberian people — Ebola is here!"

But despite all of these Ebola-isms the mood in this country is cautiously optimistic. Ambulance drivers who hauled 150 disease victims daily to ETUs now say somewhat grudgingly that business is off — fewer than 10 calls come in per day for their services. For the first time since July, the ETUs have empty beds. And the population, which as of Oct. 31 finished the three-day national campaign called Fasting and Prayer to Stop Ebola, dares to believe God has heard their cries.

Whether or not Liberia now has Ebola on the run will not be certain for several days, as teams of U.S. CDC epidemiologists and their Liberian counterparts scour remote communities all over this country in search of hidden disease victims, embers for fresh outbreaks.

But one thing is clear: Life goes on in impoverished Liberia in the face of this calamitous epidemic.

Laurie Garrett is in West Africa covering the Ebola epidemic and will be reporting regularly from the ground over the next two weeks.