By Dr. James Appel - August 15, 2014

I step out of the Kenya Airways jet and into the muggy air of Monrovia, the capital of Liberia.  The sky is overcast with cracks of white letting in a little sunlight.  The tarmac is wet from a recent rain.  It’s cool and breezy.  Across the runway is a small airport with cracked paint on the walls.  We get in a bus for the short trip to the door marked “Arrivals”.  A sign half falling off one of the double doors gives a list of do’s and don’ts for Ebola.

We are let out of the bus in groups of ten. Right inside the door is a short man in a short white coat with a digital thermometer with which he is taking temperatures.  As soon as each passenger is declared fever free they move to a water cooler constantly dripping chlorine impregnated water into a plastic bucket sitting on a stool.  Hand painted signs point us to one of three lines:

“VIPs/Diplomates,” “Liberians” or “Foreigners.”  I choose the appropriate line, passport without visa clutched nervously in my hand along with a letter I just printed off that morning inviting me to come to Liberia a relief physician for the Cooper Adventist Hospital, one of the few hospitals still open during the Ebola epidemic.

When it’s my turn, I nervously go up to the Immigration booth and talk to the woman inside through 5 holes haphazardly drilled through the plexiglass.  “I don’t have a visa.  Someone’s supposed to meet me here to give me one.”

Without saying a word she takes my passport and letter and walks out the back of the booth.  Soon another woman comes up and says, “Follow me.” I go into a dingy back office with a desk piled with scattered papers.  The woman shuffles through one pile and pulls out an official looking document with the words “Airport Visa” emblazoned in bold across the top.  I’m relieved to see it has my name on it.  We go back to the booth where the first woman quickly stamps my passport and waves me through.  I show my passport to the  customs official who waves me outside where a crowd has gathered.  I see a few people with signs.  None of them have my name.  A man comes up to me and we start talking.  I explain the situation, but he says he hasn’t seen anyone from Cooper Hospital.

Just then a large man approaches from behind me and says in heavy African English “Coopuh 'ospitawl???  He’s holding a hand written sign that reads “SDA Cooper Hospital.”  I nod in relief and we weave our way through the sea of people waiting to leave Liberia and into a fairly new looking Land Cruiser hardtop with “Cooper Eye Hospital” written on the doors in green paint.  We rush off on a nice paved road through lush tropical vegetation reminding me of a South or Central America.  Palms and banana trees poke out amidst the sprawling jungle interspersed with brightly colored wood or block houses and restaurants.  But it’s obvious for many miles that we are still in the country.  In fact, it appears the airport is at least 30 miles from Monrovia. 

As we approach the city we pass a huge walled compound to the left, just between the road and the ocean.  “Dat’s da ELWA ‘ospitawl,” says my host, who has identified himself as an immigration officer but who is an Adventist Church member.  The ELWA Hospital is where the Ebola cases are being referred to and where the American Doctor and Nurse stricken with the disease were cared for for over a week until the experimental drug ZMapp arrived from the US and turned there cases around enough to allow them to be evacuated to the US where they are making a recovery.  It’s also where one of my former attending physicians from residency, John Fankhauser, is spearheading the medical care of the Ebola patients.  

We whiz on by and enter the capital which is like so many cities in the developing world: crowded, a mix of modern and primitive.  Lots of cars, but no electricity unless you have your own personal generator.  We stay on the main road for a long time through town until we turn right on some pothole filled roads and stop in front of a dilapidated building with “Cooper Adventist Hospital” emblazoned over the front doors leading from a small circular courtyard.  All the staff is sitting outside on a low wall.

Apparently, two days previously, the rumor had got out that the Cooper Hospital also had an Ebola case, so patients had stopped coming.  Today, though, a real possible case had come through and just died in the hallway.  The patient had been sick for a week with fever and vomiting and went to another hospital who saw that he also had an incarcerated hernia, and instead of first checking him for Ebola, sent him straight over to Cooper.  Dr. Gillian was doing triage on patients and was suspicious but also felt he should be examined for his hernia. She took precautions and allowed no one else around the patient, gloved up and was able to reduce the hernia.  Then the patient vomited on her arm  and died. The body was quickly doused in chlorine and wrapped in plastic bags and OR wraps and placed in the unused X-ray room on a bench.  Everything was then properly dosed with chlorine water and clothes disposed of.

The Ministry of Health was called to evacuate the body and test it for Ebola. No has come yet.  So, I arrive with the staff refusing to go back in the hospital and our doors temporarily shut to new patients.  I’m introduced to some of the staff and then Gillian takes me and shows me my room.  It’s inside the courtyard under the OR and Labor and Delivery which are upstairs.  It’s a lot of buildings crammed in a small space.  The rooms were the dwelling of a Phillippino couple, she was the staff OB/GYN before fleeing the Ebola epidemic. The cabinets are sagging, half the drawers are swollen shut by the humidity, small cockroaches abound, and most of the furniture is about to fall over.  The couch and chairs are nice though, as is the bed and mattress.

Gillian brings me some excellent pasta and a Greek salad from a nearby restaurant which I devour.  I haven’t really eaten well in the four days since I left Abeche in Eastern Chad to cross the desert, head to Eastern Africa and then fly almost the length of the upper horn of Africa to Liberia.  I feel much better with a full stomach and despite the pit in my stomach from the fear of Ebola and the unknown I fall into a deep sleep.

The next morning, I awaken, prepare a breakfast of yoghurt, oatmeal and peanut butter & jelly and go out to the lobby where I meet and talk with many of the staff. The body is still in the X-ray room. The Ministry of Health has shown no signs of action despite continued calling. I’m told that in at least one case, they took 5 days before they came for the body leaving many people exposed since Ebola is often passed from the dead body to those handling it. We have worship upstairs on the wards and in the middle of rounds, we are told the family has come to reclaim the body.  Our idea is for them to take the body and then count on the police to arrest them, take the body to test it and then bury it safely in a secret grave site they have reserved for just that.

The family is obviously Muslim and they pull in a beat up small pickup into the side yard near the outdoor kitchen where some soup is being boiled over a wood fire on a grill.  The three pallbearers are called up to the hallway just outside the X-ray room.  Gillian explains how to put on the protective gear given us by the Ministry of Health.  Full body suits with hoods are zipped on. Booties are put over the feet part of the suits. Two pairs of gloves are put on and we realize the sleeves are too short and pull out easily from under the gloves leaving the wrists exposed.  Brilliant design!  Gillian solves the problem with her pocket knife.  We make thumb holes in the sleeves and loop them over the thumbs before reapplying the gloves. Now the sleeves stay under the gloves.  We give them heavy duty masks and then instruct them on how to remove them eventually and place them in the red biohazard bags to avoid further contamination. I see right off this is a weakness in the system and even if we were there to observe, the likelihood of contamination is high.

The three men go into the X-ray room and pick up the whole bench where the body has been laid. Then they take it down the hallway, down a flight of stairs and through a hallway, past the kitchen and into the open air where the truck awaits. I have spread a large impermeable OR drape in the bed of the truck so they can further wrap the body and hopefully contain the bodily fluids which may or may not contain the Ebola virus. They lift the whole bench in the truck and then slip the body onto the drape, remove the bench and wrap the body.

I look at the bench which has a huge wet spot under where the man’s abdomen and thorax had been:  bodily fluids soaked into the wood. The truck drives outside and Gillian goes upstairs to prepare the death certificate. I spray some chlorine water on the bench’s wettest spots and then go upstairs. A new problem has arisen. The head of the family states that they can’t go out dressed as biohazard personnel. They’ll be arrested immediately (of course, that’s the point, but we can’t say that).  So now we have to have them come back in the courtyard, take off their suits and give them new suits to put on once they get to the graveyard.  I’m sure they won’t use them.  Even in taking the suits off, there is a lot of disorder and things touched that shouldn’t be. They wash in bleach and take off.  I use the rest of the bucket of chlorine water to douse the entire bench.  When I’m done with the top, I grab a stick from the ground to push it over and soak the bottom of the bench as well.

I wash up well and we finish rounds. There aren’t many patients from the earlier scare and there will be none the rest of the day. I spend the afternoon talking to Gillian about the challenges of the Cooper Hospital and after a hefty supper of lentils, rice and fried plantains I go to my room. I wash my clothes by hand, hang them up in the bathroom and living room, take a shower and fall into a deep sleep.