How to Manage a Plague

On the day the first Ebola case was reported in New York City (a physician returning from treating victims of the epidemic in West Africa), I was in Brussels to audit the training program Doctors without Borders (aka Médecins Sans Frontières) had created to prep its staff before sending them to Liberia where an outbreak of the haemorrhagic fever remained out of control. Collecting material for a feature I expected to write later, I arrived back at my hotel with a 90-minute deadline from my editor-in-chief, Josh Tyrangiel—what you get when you work for a veteran of Time, I guess, and there’s an Ebola patient in one of the five boroughs.

Reporting for a same day story and a feature for later are different practices, and I fell into a brief panic in the hotel lobby (where the best Wi-Fi was). Then I looked at my iPhone, and some snaps I’d taken earlier in the day, and started typing what’s below. My colleague Bryant Urstadt removed a clause from every sentence, and rendered it readable.

Eventually, I did write the feature, too, on how the decentralized chain of command at MSF allowed them to move faster than anyone else in responding to the 2014 Ebola outbreak. I finished that draft at 5 a.m. in an unheated beach cottage in Maine where we staying for my father in law’s funeral. He’d not been well for some time, but still his death was sudden. It felt like more than coincidence was in play.

Arguably the most valuable part of this project, though, was what Dr. Darin Portnoy shared via weekly Skype calls from Monrovia during his tour on an Ebola ward. Josh’s insistence on a dispatch that first night in Brussels inspired me to do an as-told-to diary with Portnoy; we, along with Sheri Fink, in the New York Times, were the first to report that recent survivors of Ebola had enough immunity from the disease to safely touch and hold stricken children. A small stay against despair.

Later, I edited Brendan Greeley and Caroline Chen’s excellent road-not-taken Ebola cover story, which got a (brief) hearing on the floor of Congress the day it was published…

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…Not our subtlest effort, I admit.

What Does Médecins Sans Frontières Teach Its Doctors?

Brussels, Belgium (Apr. 25, 2014) —

Here is a picture of my friend Dr. Darin Portnoy.

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Friend might be premature. We only just met. But already I’m worrying over him like an old friend, because we met on a break between two all-day sessions that he spent preparing to work in the Ebola clinic in Monrovia, Liberia, which is operated by Médecins Sans Frontières/Doctors Without Borders, a 43-year-old nonprofit organization. It’s the same group that Dr. Craig Spencer, New York’s first Ebola patient, worked for.

The training took place in a few tents on a former rail yard on the outskirts of Brussels and was led by several doctors who had recently returned from Sierra Leone and Guinea, as well as Liberia, where the deadly virus remains out of control. Portnoy, 52, leaves in a few days for a four-week stint in Monrovia, followed by three weeks when MSF will pay him not to work while he waits out the virus’s incubation period.

Portnoy was in surprisingly good spirits given that he’d spent the previous 10 hours learning about the right way to move through a ward he was assured would be damp with vomit, diarrhea, and blood; to put on the now familiar personal protection equipment (PPE), which includes the yellow suit (as well as its far trickier safe removal); the constant, constant rinsing of gloved hands in a chlorine solution; and the use of cheap surgical gloves as a tourniquet (so they can be disposed of). Even though he’d never worked on a hemorrhagic fever, however, Portnoy did not find much of the practical instruction surprising. What was shocking was the reorientation this crisis had forced since his last mission with MSF in 2011.

“We always trained to use every tool at our disposal to save a life,” he said. “That’s MSF—we are there in an emergency to save lives.” In Monrovia, Sierra Leone, and Guinea, where Ebola has infected 9,932 and killed 4,876, MSF had had to resort at times to triage—to accept and care for only those who stood the best chance of survival. “In this crisis, you can not do everything possible for everyone. And we”—he meant MSF, but Portnoy was clearly speaking of his own instincts as a clinician—“we have always been very attentive to our patients, almost aggressive about comforting them. The bedside manner has been key to our reception in the communities where we serve, to gain people’s trust. Now we keep our distance.” It pained him to think of it, but he was preparing his mind to always think of his personal safety before providing the help he might wish to.

Portnoy is a family physician at Montefiore Medical Group’s Family Health Center in the Bronx. He and his wife had long talks about the risk involved in his going (they are raising a 5-year-old together). And that was before the news broke that another MSF physician from New York had tested positive for Ebola. Such news is unwelcome at any time, he said today, pulling on scrubs for an exercise at the training where he’d pantomime taking a patient’s blood. Speaking of him and his wife, he added: “And the timing couldn’t be worse for us.”

The training, he said, made him more confident. Still, there were plenty of small decisions to make that took on a sudden, existential dimension. Like his glasses. They did not fit well under the goggles, and if they fogged up, and the goggles did, too—well, they’d be worse than no glasses. They’re mostly for reading, so maybe he’d skip them.

Portnoy made excellent “horse kicks,” as the instructor encouraged, to free his booted feet from the PPE. On that he was a natural. He will have to work at the upper-body motion—imagine “dancing” in your seat, left and right shoulder coming forward in rotation, shake ’em if you got ’em—that loosens the protective suit from the shoulders without touching it. He found it harder still to undo the ties of the string that cinches the hood. Fortunately these can be ripped off in the field. And he will always have a buddy to watch him as he disrobes to alert him to any “breach.”

What else do MSF trainees learn as they’re about to ship out? That the virus, though incredibly infectious once in the body, is not that hearty outside it. Ultraviolet light kills it. So does bleach and direct sun. Only in puddles can it live for a couple of days.

They learn that they must complete their rounds in less than two hours. Even 90 minutes is a dangerously long time in the protective suits in temperatures that regularly reach 90F to 100F. They can’t risk passing out in the high-risk zone. 

They come to understand that the “wat-san” will be their best friend in the wards. Short for “water and sanitation,” this person shadows each doctor as they treat patients, and carries a plastic canister full of chlorine solution. They look like an exterminator or an OCD gardener liberal with the pesticide. The wat-san must learn where to aim so as not to make a bigger mess of excreta on the floor, or get bleach into a sick person’s eyes as they lie on a cot.

There wasn’t much time for chitchat or reflection at the end of the second day. Like most at MSF, he understood the preoccupation with a patient closer to home, and, of course, the danger is real—Dr. Spencer was the 24th MSF caregiver to become sick with Ebola in the last seven months. Thirteen have died. (Almost all of those were locals on MSF payrolls, which is why the organization is deeply uncomfortable with all the focus placed on the three “internationals” who have taken ill; it’s West Africans who have done most of the medical work.)

That the outbreak is still out of control wasn’t going to keep Portnoy away. It was what finally convinced him—and his wife—that he had to go. “West Africa is where the most help is needed,” he said, “and it’s also the place it must be stopped.”

At the MSF training there wasn’t all bad news. MSF is near to containing an unrelated, overlooked Ebola outbreak in the Democratic Republic of the Congo. And its mobilization in Guinea had almost snuffed out the virus there in August, before it came back, through Sierra Leone and Liberia. They got close. And in Monrovia, where Portnoy was going, the doctors, nurses, social workers, and wat-sans had taken a moment last week to celebrate a major milestone: 1,000 Ebola survivors. As of this writing, Portnoy is en route to Liberia.