he outbreak of Ebola in West Africa in 2014 and 2015 caused a global panic. The questions Ebola raised had to do with whether the panic had been warranted or whether we were seeing an outbreak of a different kind—of hysteria, xenophobia, science denialism, and the like. These questions hang over Inferno, a new book by the Massachusetts infectious-disease doctor Steven Hatch that recounts his work treating Ebola patients in Liberia. Inferno is a rare, vivid account, a testament to the bravery of those who volunteered to fight the spread of the disease, and an important glimpse into the needless hurdles they were forced to overcome just to help people.
But Hatch’s book is also the exploration of a startling sociopolitical thesis—that the outbreak was “Africa’s revenge” for historical injustice. This idea is, on its face, so insane that it all but invalidates the book—were it not for the fact that Hatch’s view sadly reflects and represents a significant body of opinion dedicated to politicizing that which should not and need not be politicized. Inferno makes us reckon with the selfless heroism and the arrogant posturing that were both on display during the outbreak, often from the very same people.
rior to the outbreak, Hatch had worked in Monrovia, Liberia, helping to restart a residency-training program that was shuttered during the country’s civil war. During the outbreak, he returned to Liberia for two tours of duty at the International Medical Corps’ Ebola Treatment Unit in Bong County.
Ebola Treatment Unit was the official name given to what was little more than a pole-and-tarp field hospital. So hastily had it been constructed that nails still protruded from boards, which posed the risk of puncturing a worker’s skin with infectious fluids from the outside of his protective suit.
The stories Hatch tells do indeed suggest a descent into Hell. A father is asked to overcome his terror of the ward in which he survived the disease so he can return to help care for his infected son. He does; his son dies. A woman who has just delivered an infant arrives dead in a taxi after riding around for hours being turned away from other hospitals. The baby dies within days. Delirious patients perilously wander the halls. A rumor circulates that another facility mistook one of its patients for dead, the patient screaming awake when her body was doused with bleach.
Horrific though these stories are, Inferno’s aim is to de-sensationalize the outbreak. Expressing a quiet indignation at the random cruelty of the disease, Hatch is effective in showing that the victims were real people.
The book also reveals the logistical absurdities faced by doctors and nurses who tried to volunteer. Hatch was initially bounced around between the Centers for Disease Control and aid-organization contacts who didn’t seem to know how to handle volunteers or to grasp how direly they were needed.
Perhaps most surprising, Hatch had to use his vacation days to volunteer. When he returned, the CDC advised he stay away from work for 21 days; Hatch worried about how he was going to keep his job. One wonders whether states, hospitals, and grant-making organizations can’t find ways to clear these hurdles and ensure that volunteers who risk their lives at least don’t have to imperil their livelihoods to do so.
ut along with the personal narrative, Inferno also sets itself the fraught task of offering a grand theory of the outbreak. The theory does not have to do with epidemiology. Rather, Hatch argues that the epidemic was the result of centuries of European and American injustice towards Africa: first slavery, then colonialism, now exploitive corporatism and a xenophobic “othering” of African people.
It is possible that a careful and thoughtful writer could use these historical antecedents to enlarge our understanding of the social factors that make Africa so vulnerable to infectious disease. Hatch is not that writer. He cites all of three sources to build his historical argument, one of which is an academic essay claiming that Joseph Conrad’s Heart of Darkness is racist.
He criticizes the Firestone Corporation for refusing to sever its business relationship with Liberian President Charles Taylor during Taylor’s blood-drenched rule from 1991 to 2003. But Hatch does not provide the context showing to what extent Liberia’s ongoing woes can be attributed to cases like this, or how the spread of an infectious disease can be blamed on a corporation’s lack of a conscience.
The book is interspersed in a tonally unnerving manner with commentaries on American politics: Hatch drips with scorn when describing CNN, Fox News, and New Jersey Governor Chris Christie, then is utterly neutral in recounting the routine rape, summary executions, torture, cannibalism, and other atrocities of Liberia’s horrendous civil war. At every turn, Hatch assigns maximal agency to American and European actors and minimal agency to those from Africa.
Hatch’s goal—to show that the epidemic was “Africa’s revenge…the ultimate payback for five hundred years of barbarity”—is bizarre. It is as though he is suggesting that the victims of Ebola were akin to participants in a hunger strike, albeit a mass, forced, and fatal one. That would truly have been an incredible price to pay just to teach the West a lesson.
he problems with Inferno are worth discussing because they stand in for how the Western response to Ebola became oriented around political symbolism, often at the expense of tangible interventions. As the epidemic grew, numerous infectious-disease specialists warned that research on whether Ebola could be transmitted through the air, especially at close range, was fragmentary. They argued that workers treating Ebola patients should take the precaution of wearing air-filtering respirators—face-fitting masks like the ones sold in hardware stores for about two dollars to protect from paint fumes, a standard item in American hospitals.
When researchers raised these concerns in medical journals, their colleagues accused them of fomenting hysteria. When they brought these concerns to the CDC and the World Health Organization, they were ignored. Several doctors argued that CDC and WHO guidelines should not be publicly questioned or exceeded, because doing so would undermine public confidence. Some even argued that Doctors without Borders workers in West Africa should not wear full-body protective suits, as this would create the impression that the far lower infection controls in African hospitals were inadequate—which was plainly and catastrophically true.
After two nurses in Dallas contracted Ebola from their patient despite adhering to the CDC’s weak guidelines, the CDC finally reversed course and recommended air-filtering respirators. But it has never acknowledged that its prior guidelines were inadequate, or even that they changed at all, only that the new guidelines were “more detailed”—a demonstrable falsehood.
In a 2015 literature review, 21 leading researchers concluded: “It is very likely that at least some degree of Ebola virus transmission currently occurs via infectious aerosols.” A co-author of that review who was employed by the WHO was pressured by its leadership to retract his name, apparently because it undermined the organization’s message that Ebola cannot be transmitted through air. Around the same time, the WHO issued a recommendation urging doctors to avoid terms such as “fatal” and “epidemic” when naming diseases, in order to avoid stigma and “undue fear.”
As with so many other aspects of the Ebola outbreak, the research was simply too limited for decisions on quarantines to be based on anything but guesswork.
Craig Spencer, a doctor who traveled around New York City while unknowingly contagious with Ebola, saw fit to argue in the New England Journal of Medicine that the public response was beset by “irrational fear, fueled in part by prime-time ratings and political expediency.” Hickox, in an op-ed written after Spencer’s walk, said that “politicians are still escalating anxieties and giving the public permission to discriminate, stigmatize and even hate aid workers like me.”
Hatch offers his own version of Hickox’s bike ride. On his return layover at Dulles Airport, a few weeks after the Spencer incident, he was held in customs while officials tried to reach the Massachusetts health department on a Saturday night. After four hours, he decided he’d had enough and sauntered out of security, threatening to call the White House after he was stopped.
Hatch does not, even in retrospect, find any legitimate cause for his detention. This was a simple case of heroic doctor versus fear-ridden authorities. The officer who stopped him “apparently [thought] that someone was casually tossing polonium in her direction” and “started excitedly squawking like an enraged hen.”
As with so many other aspects of Ebola, the research was simply too limited for decisions on quarantines to be based on anything but guesswork. Highly uncertain risks of contagion had to be balanced against temporary restrictions on freedom. Prudential cases could have been made for and against quarantines under a variety of circumstances. There was not a strictly scientific choice.
But it is indisputable that health-care workers who treated Ebola patients were at significant risk for catching the disease. Spencer was one of several Western doctors who developed Ebola despite following the recommended precautions. As his case showed, an infected person would not be diagnosed until after they were already contagious, exactly the condition under which quarantines are useful.
There is little doubt that stigmatization of Ebola survivors was an issue. Yet rarely if ever in discussions of quarantines were claims about stigma backed by specific evidence, much less measures of scale that would permit for rational decisions about how to balance stigma against infection control. Nor did these discussions explore the possibility of programs to reduce stigma, such as the community-reintegration plan the Firestone Corporation implemented for its Liberian workers. Weakened infection controls were the sole remedy. It was very difficult to avoid the sense that stunts like Hickox’s and Hatch’s, ostensibly against stigma and fear, did not have much to do with the realities of the disease.
As with respiratory protection, numerous anecdotes validate the health officials who did not await certainty to take proactive measures. To name just one, Firestone also recommended voluntary 21-day quarantines for any of its workers who had come in contact with an infected patient. Many workers who developed the illness did so while already quarantined, and the incidence rate of Ebola among Firestone workers was less than half that of the surrounding area.
he most vivid scene of Inferno is when Hatch ventures out of the treatment unit and joins his Liberian colleagues for a local church service where the pastor reads at length from the Book of Revelation. Without speaking the virus’s name, the pastor poses the question of whether it spells the End Times: “For the great day of his wrath is come; and who shall be able to stand?”
Hatch approaches these proceedings with a kind of anthropologist’s distance: rather aghast, yet curious to understand how his friends are trying to make sense of the devastation. A self-described liberal atheist, he does not accept these religious interpretations. Yet his view of Ebola as “Africa’s revenge” bears more than a passing resemblance to the visions of the epidemic as a great judgment upon man’s sins. This search, this hunger to say what it all means, is eminently human.
Reader, let it be noted that you and I sat watching the epidemic unfold from a comfortable distance while the Steven Hatches, Kaci Hickoxes, and Craig Spencers of the world volunteered, at risk of gruesome death, to stop it. We are in their debt. To the great extent the global capacity to fight outbreaks depends on doctors and nurses who volunteer, we are even indebted to whatever motivates them.
Yet this impulse has also led a good number of us astray. For a great many Western leaders and policymakers, Ebola was treated as a study in alarm, stigma, xenophobia, immigration, African otherness, the legacy of slavery, the legacy of colonialism, science denialism, and cable-news sensationalism. It also featured in conversations about the midterm and presidential elections.
The problem with these interpretations is not that they were entirely wrong, though they largely were. The problem is that they made Ebola about everything but itself. In doing so, they encouraged unprofessional self-aggrandizement and unscientific euphemism. Medical workers eagerly cast themselves at the center of morality plays in which an aggressive posture against a novel and lethal disease could only be considered the product of racist hysteria. They lost sight of their profession’s core obligation, one that must bind even volunteers: First, do no harm.
Scientific thought leaders who should have known better let crucial discussions about infection control be influenced by a desire not to validate Fox News. Health officials misled, damaging the public confidence they claimed to be preserving. Ordinary skepticism that would have revealed obvious holes in CDC and WHO claims was cast as bigotry. Debates were stifled, common infection-control measures were scuttled, and lives may have been needlessly lost.
Amid the dazzling array of interpretations we assigned to Ebola, there was too little room for it to be an actual disease, indifferent to symbolism.