Friday, October 17, 2014

Why I Go, uncut

It's been a rather big day here in Billy Rubinland, where against all odds there appeared this op-ed in the Paper of Record about my reasons for wanting to be in Liberia (where, as I type this, I am right now).

Needless to say, it has been a bit of a weird day.

At the risk of boring everyone to tears, I present the uncut version, which I knew was never going to make it into the Times based on length. But if you are interested in going into some greater depth, feel free to read on. Apologies for the redundant parts; they made very few changes from my original chopped version. But I did want some readers to know about Phil Ireland, and to remind everyone again about Sean Collier.

Why I Go

In nearly every medical school applicant interview, candidates are asked why they want to pursue medicine as a career. Invariably, the answer takes some form of a simple idea: I want to help other people. It is almost impossible to make this answer sound new or genuine or creative, and yet for most applicants it is an honest response. 

I’ve been thinking about this of late because, years after I had to answer that question, I’m being asked a similar kind of question from colleagues and friends. You see, I am going to be headed to Liberia shortly to participate in the efforts to control the Ebola outbreak, and—in addition to being asked whether or not I am insane—people want to know why I would willingly seek out such an assignment.

It is a legitimate question. Although I think many Americans have magnified the danger that a person like me faces heading into the current chaos of West Africa, it is nonetheless a risky thing to do, and there is the real possibility that something terrible will befall me while I am deployed. Becoming infected with Ebola is only one of a laundry list of hazards I will face. It is the rainy season in Liberia, which means that I am at risk of catching malaria (even though there are pills that can help prevent it, but it’s not 100 percent protective); I could acquire Typhoid fever, a common problem in sub-Saharan Africa; and there are a host of other infections, less well known but also capable of causing serious illness or even death, such as dengue and Lassa fever. 

But all of these hazards, even including Ebola, are a secondary concern to my primary fear, which is that of violence. As I type this, the media reports coming out of the region are abuzz with the news that eight health care workers trying to aid in Ebola education in a rural village in Guinea were murdered by locals and had their bodies hidden away. One cannot know precisely what was going through the minds of the locals as they committed this atrocity, but I am reasonably sure it was a mix of terror, rage, and helplessness that fueled the violence. Especially in the epicenter of the outbreak where the three most hard-hit countries of Guinea, Liberia, and Sierra Leone all border one another, whole communities are being decimated, and they do not trust anyone, to the point that they will act in ways that make matters only worse as they did in Nzedekore. There’s at least a 19th-century romantic gloriousness at the prospect of catching Ebola as an image of personal sacrifice, but there’s nothing appealing about having one’s body stuffed into a septic tank. I would really, really prefer that not happen to me.

So why do such a rash thing?

In trying to answer this question, a part of me wants to speak for all of the doctors and nurses and water sanitation engineers and all the other consultants who have been scrambling to get ourselves over there. So part of “why I go” is “why we go.” I cannot pretend to speak for everyone, but I am confident that it is this fundamental desire to alleviate human suffering that is driving us toward the Hot Zone. Many of the people on the ground or headed there soon are specialists in disaster relief: they are so committed to aiding people in the most dire circumstances that they have centered their careers around providing services in the most chaotic situations imaginable. They are experts at this sort of thing, and they endure great hardship to bring stability to these kinds of places, so that the people there can have something resembling a life that those of us in more comfortable circumstances would recognize: a chance to live, love and thrive in a reasonably safe environment. We go because we consider that a sacred obligation.

But I am not the kind of professional who made disaster relief my career path, and so while the suffering seen in, for instance, Iraq and Syria right now are no less troubling to me, I never thought to volunteer to go there, or any other number of places where human suffering can’t be quantified. But this outbreak, and the location of this outbreak, has a special resonance for me, and hopefully I can bring some particular skills to the situation.

I am an infectious disease physician. Our subspecialty is an odd lot, not generally highly pursued by ambitious internal medicine residents, who prefer the more lucrative and procedure-oriented specialties of cardiology, gastroenterology, or critical care. Many of those who join the ranks of infectious disease do so for the reason that I did, which is a passion for epidemics, and the awareness of the impact of human behavior and development on disease. Until we had adequate treatment for it, HIV was a disease that proved deadly not only because of the molecular mechanisms by which it chipped away at the immune system, but also because it was transmitted through sex, about which humans have both intense desire as well as deep ambivalence, and which led to policies and attitudes that only made the epidemic worse. 

An infectious disease doctor thinks about what occupations and exposures might cause a disease: where you’ve traveled, what kind of pets you have, what you just ate for lunch. Knowing the details of a disease’s “pathophysiology,” to use a fancy medical word, is only part of what makes infectologists good at their jobs: we simply have a habit of thinking about other factors that impact disease that other professions are less concerned with. I find that intellectual process continually fascinating, and is why I knew I wanted to pursue this specialty from my early days in medical school.

In particular, many infectious disease doctors are driven toward international health, and in particular settings where resources are most limited. Even before Ebola came, West Africa was a place where infections were still the leading cause of mortality, much like it was in the US and Europe 100 years ago. Global health groups often refer to the “big three” diseases that constitute the major causes of suffering: HIV, malaria, and tuberculosis. But that is only the beginning in West Africa. There is Yellow Fever, pneumococcal disease, meningitis, rickettsial infection, streptococcus, and a host of other maladies that can shorten lives and bring general misery to a place. 

Trying to provide long-term solutions to such places is why I became passionate about infectious disease. I read Laurie Garret’s book The Coming Plague (an exhaustive and thoroughly well-researched account of the many infections that threaten our lives) prior to medical school almost 20 years ago, and it changed my life. I agreed with her premise that the rapid technological changes to our world may create a host of unintended consequences that viruses and bacteria will be only too happy to exploit for their own purposes.

And this Ebola outbreak is the infection of my professional lifetime, as seminal an event as AIDS was in the 1980s when nobody knew how far the epidemic would spread or when there would be treatment and how effective it would be. This is as big an event as the Spanish Flu of 1918, which killed perhaps one percent of the entire world’s population in less than a year. And the particular dimensions of this outbreak—its ability to unleash paranoia and cause huge economic disruption on a regional scale—haven’t really been seen since 1665, the time of the last great episode of Plague in London. As an international calamity, the last episode of what we may be witnessing now happened in 1348, when the Black Death killed off about a third of Europe’s population and destabilized the entire structure of medieval European life.

As someone who chose this particular profession for the reasons why I did, how could I not want to help out? Why do the police put their lives on the line on a daily basis? To preserve order. Why do our soldiers don their gear and deploy all over the world, never questioning their orders even when they have personal reservations about their mission? To defend their country. Why do firefighters run headlong to the fire? To put it out, of course. Ebola is not really different, and it is my fire; along with many other colleagues, I go to put it out.

The vast majority of people who pursue these callings do not make the ultimate sacrifice, but they are willing to do so because they believe in something higher than their own lives. As I prepare for my deployment, I have been thinking a lot about Sean Collier, the young officer who served as cop at MIT as he began a career in law enforcement. Sean got a bullet through his heart because a few assholes thought they were making some kind of profound political statement by maiming a bunch of people with a bomb at the finish line of the Boston Marathon. His plans were to transition from his work at MIT to become an officer in a suburban town where he grew up north of Boston. Surely he must have thought that the most dicey moments of his work at MIT would consist of busting up a few frat parties or perhaps handling some rowdy people at a student protest. Yet he wore the uniform, prepared at least in theory to face more serious threats, and then the moment was upon him. His life—and more to the point, his death—serves as a reminder of the meaning of service. I go with a different agenda, but have similar notions.

I go also for more personal reasons. I am a medical educator: my professional joy is not only to care for my patients, but also to train the next generation of physicians. I love to teach and somebody pays me for it, and for that reason I ended up in Monrovia last year to help kick-start a residency program in Internal Medicine for the Liberian Ministry of Health. I was mainly based at John F. Kennedy Hospital, and gave lectures to a core of seven medicine residents, the first class of advanced trainees as Liberia tried to rebuild its medical infrastructure. I came to know these trainees and thought of them no differently than I think of my own residents where I work. 

Among those residents was a young man named Phil Ireland. He was the kind of resident that any faculty member would instantly recognize as a leader: he had a hunger to know more, a drive to take care of his patients, and a charming and warm personal manner. I was excited to see what would come of his career, and before I left Monrovia I asked him to think about whether or not he would consider coming to the US for further training, as Liberia would be able to benefit from his knowledge in the years to come upon his return. 

Then Ebola came, and Phil became infected in the course of his duties. The only good news about this is that Phil survived, although I do not know his condition as I write this. Surviving Ebola is not a matter of going back to work in a week, as survivors cope with a variety of ailments, some of which are quite debilitating. Moreover, they must cope with the psychological trauma of survivor’s guilt, and the post-traumatic stress of having lived through the nightmarish conditions they must have seen and experienced during the illness. I go with the hope that I will see Phil in Monrovia, as well as his classmates, and be able to resume my duties as their teacher. I have an obligation to them.

Finally, I go to honor the work of a colleague who was not as fortunate as Phil. My host in Liberia was the Chief of Internal Medicine at JFK Hospital, a man named Abraham Borbor. I liked him from the moment I met him. He was kind and intelligent and compassionate, and clearly had inspired fierce loyalty among his staff. But what drew me most to him was his sense of humor. We spent hours in conversation about the myriad challenges of living in a place like Liberia and the sorrows that his people have had to endure, and yet despite chewing on such weighty and depressing matters, he still was able to be amused at the world around him. He could joke about the fickleness of American and Liberian politicians as much as he found the idea of pouring some warm coke into his glass of warm beer a source of great amusement—“well, going the same place anyway,” he observed. He had a rich cackling laugh that had the effect of making you laugh along with him—a contagion of a different sort than what has befallen West Africa of late. 

Now, because of Ebola, the world will not hear that laugh again.

When Abraham Borbor saw this plague upon him, he did not flinch and he did not run. He did what he has always done, which is take care of patients. Putting himself in danger to do his job was not new to him. Liberia experienced a brutal civil war during the most productive years of his career. Nobody would have harshly judged his decision to flee the country with his skill set. He had done some training in Britain, and he could probably have managed to find a way to stay there and finish out his career. 

But he returned to JFK and, along with a handful of nurses, basically was the medical staff for years in Monrovia. He had few or no supplies, limited electricity if any, and the specter of real violence at his doorstep every day. Basically he had his wits, and what must have been a fierce determination to man his post. This was his life for years on end. The Liberia that I visited in 2013 must have seemed like a Garden of Eden compared to that. As he neared the end of his professional work, there must have been some satisfaction in that, along with the knowledge that he saw it through. 

Then Ebola came, and he met his end, along with his colleague Doctor Samuel Brisbane, who formed the internal medicine senior faculty at JFK. Not only has their loss been devastating to Liberian medicine in the present, as there are fewer doctors to direct medical care, but it will ripple into the future through the loss of their years of wisdom as a new generation of doctors and nurses learn medicine. There is a crisis upon us now, but after the storm, education will need to resume. I went there as an educator and was treated with kindness and deference. Now, especially with Borbor gone, I go to honor that commitment that he made to his profession and to the next generation. He took me into his world and placed a small part of Liberia in me; how could I not go after the disease felled him?

We live in a cynical age, where a term like brotherhood can only be uttered sardonically, tossed out as part of a joke making fun of Victorian idealism. But Dr. Borbor became—at least in some meaningful although small way—my brother when I went over there. I go because I owe him something.
In addition to thinking about the sacrifice of Sean Collier as I prepare to leave, I’ve also spent a lot of time calling up Beethoven’s Ninth Symphony in my mind. I am not the first to observe what a remarkable piece of music it is. But it is the lyrics that keep running through my head, for Beethoven set his music to a poem, the Ode to Joy, about brotherhood—pure, unadulterated and unironic. We have enshrined the Ode to Joy around the world: we play it as part of opening Olympic ceremonies, we sing it on New Year’s Eve, we listen to it in Symphony halls across the country on a perpetual basis.

Is the Ode to Joy just pretty music, or do we heed its message of a universal brotherhood? Do we find it a useful concept when all is going well but abandon it when chaos descends? Do we in the academic world, who hold graduation ceremonies bathed in lofty rhetoric, and allude to cultural touchstones like Beethoven’s Ninth as being the pinnacle of civilized achievement, really believe in the principles these words would imply? Or is it just cultural window-dressing, used for a carefully arranged photo op for the school’s website?

I go because I do believe in these words. I go because if I do not, after where I have been and the people I have met, those words would mean very little. I would very much prefer to return whole, but if I do not, it will be because I could not see any other way forward.