This is the first of a series of dispatches.
Here is a picture of my friend Dr. Darin Portnoy.
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 non-profit organization. It’s the same group Doctor 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 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 ten 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). However, even though he’d never worked on a hemorrhagic fever, Portnoy did not find much of the practical instruction surprising. What was shocking was the re-orientation 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 five 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 he 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 skip them.
Portnoy made excellent “horse kicks,” as the instructor encouraged, to free his booted feet from the PPE. On that he was 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 are 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 exceed 90-100 degrees F. 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 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 lay on a cot.
There wasn’t much time for chit-chat or reflection at the end of the second day. Like most at MSF, he understood the pre-occupation 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. 16 have died. (Nearly all of those were locals on MSF payrolls, which is why the MSF 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—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 Congo. And its mobilization in Guinea had nearly 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, he is en route to Liberia.
