MONROVIA, Liberia — They were among the only Liberians who could treat Ebola, and in a single morning, it felt as if they were being picked off one by one.
First, before dawn on Thursday, Ebola killed Dr. John Tata. Then, hours later, Dr. Thomas Scotland tested positive for the virus.
With only a few dozen Liberian physicians in a country facing the biggest Ebola outbreak in history, it was a crippling blow. One Ebola treatment center closed its doors. Several of its hygienists and clinicians quit. Others left their shifts early to weep quietly outside.
The United States and other foreign donors are spending hundreds of millions of dollars on infrastructure and medical supplies to stem the tide of Ebola in West Africa. But the biggest constraint is not the lack of hospitals — it is the lack of doctors and nurses to fill them, as key Liberian health-care workers contract the disease or resign out of fear that they will be next.
Even for those medical workers who are used to tragedy, Thursday brought a different kind of pain.
Dr. J. Soka Moses was at the center of it all. Tata was his medical-school professor and a father figure. Scotland was his colleague in the Ebola ward. Suddenly, one was gone and the other was in quarantine.
Moses sat in blue scrubs that afternoon in his makeshift office in a storage room at JFK Hospital, his eyes bloodshot and narrowing with anger. As word spread about the two doctors, three clinicians came to him and quit. Others said they were now afraid to go near patients. He knew he had to close the center, even as demand for treatment soared.
His family had always tended Liberians’ wounds — his mother was a nurse, his father a physician. He had dreamed of working in an emergency room or doing internal medicine. But at age 34, he was now trying to keep one of the capital’s few Ebola treatment centers afloat.
“What can I do? My staff doesn’t think it’s safe to work here anymore,” he said despairingly. “Soon I’ll be here alone, with patients dying in the ward.”
Until mid-August, the Ebola ward at JFK was a cholera clinic. Then, nurses started writing “Ebola treatment unit” on pieces of paper and taping them over old placards.
Now, doctors put on their protective gear in the kitchen. There is no incinerator, so a 10-foot pile of Ebola-laced garbage and excrement sits in the back yard. There is no morgue, so bodies sometimes decay outside, next to where patients sit in white lawn chairs. There are no protective hoods for the full-body medical suits, so the health workers cut theirs out of extra Tyvek material. Moses, the top doctor here, received only one day of Ebola training.
Somewhere amid the disorder, Scotland — short, thin and baby-faced — got a splotch of viral matter on him. When his blood test came back, he called Moses, his voice shaking.
“It’s positive,” Scotland said.
“You’re going to be all right,” Moses replied, not entirely believing the words as he said them.
To be a Liberian doctor working in the country’s Ebola wards means earning around $1,500 a month from the health ministry.
That is, when you are paid — this month, the salaries never arrived.
It means that when you leave the Ebola ward, you are always wondering whether the disinfection process was thorough enough, whether the skin around your mask was exposed, whether you made some other small but potentially lethal misstep. As Scotland apparently did.
“I feel so guilty. I’m his boss,” Moses said. “He worked for me. I feel like I didn’t supervise him enough.”
In fact, more health-care workers have contracted the disease outside the Ebola ward, doing examinations without protective gear or touching friends or colleagues who turned out to have Ebola, according to Frank Mahoney, the head of the U.S. Centers for Disease Control and Prevention’s Ebola response team in Liberia. But fear pervades the wards, now more than ever.
“I’m just wondering if I’m the next one in line,” said Dr. Deazee Saywan, one of three remaining physicians at JFK. “You try to get it off your mind, but you can’t.”
All day, since news of Tata’s death and Scotland’s illness spread, Saywan’s wife had been calling him. His phone rang over and over, but he didn’t answer.
“I know she’s going to tell me to quit,” he said with a sigh.
Being a Liberian doctor has always meant being tasked with the impossible. There were never enough of them to handle the huge number of HIV, tuberculosis and malaria cases. There were never enough to amputate limbs or treat wounds during the civil war that ended in 2003.
But now Liberia’s doctors feel a different kind of powerlessness. Because now their lives are at risk, too.
There’s only one medical school in Liberia, the A.M. Dogliotti College of Medicine. It consists of three faded white buildings, right next to the Atlantic Ocean. Nearly every Liberian doctor in the country’s Ebola wards studied here, in buildings that had no running water until 2008.
According to the Liberia Medical and Dental Council, the country has 173 homegrown doctors. But the number is actually much lower. Most of A.M. Dogliotti’s graduates have gone abroad. Liberia’s ambassador to the United States said the country has closer to 50 doctors — or one for every 90,000 citizens, not counting foreign physicians.
For many graduates, a medical degree is a ticket to a good life outside Liberia.
“The salaries here are bad. There are no incentives. For years, our doctors have left for the glitz and glamour of the First World,“ said Dr. V. Kanda Golakai, the dean of the medical school. “That’s why we have a dysfunctional health-care system.”
Of Moses’s graduating class, more than half are working abroad, he said.
“I can’t even count the number we have working in the U.S. or U.K.,” Moses said.
He stayed for the same reason Scotland and Tata did. Their families were here. Their homes were here. And their country had severe medical problems.
“This is where we’re needed. This is where I feel comfortable,” Moses said. “Sure, I want a big car and a big house, but I want them in Liberia.”
With so few doctors in the country, those still practicing here remained close. Moses went for long runs with Scotland on Monrovia’s beach. Tata came over to his family’s home for meals.
When the Ebola outbreak started, even more doctors left the country. But Moses, Tata and Scotland took jobs at newly created treatment centers. Moses moved out of his home to diminish the risk of infecting his wife and children. Even as some of the world’s most qualified public health experts and logisticians were dispatched to Monrovia, the Liberian doctors remained on the front lines.
“Nothing could be happening without the Liberian health-care team. There’s no way we could solve this with just a bunch of internationals,” said Mahoney, the CDC official. “Without knowing the system, not knowing the community, it couldn’t be done.”
The U.S. military has almost finished a 25-bed field hospital for health workers — Liberian or international — who contract the disease. It is intended to encourage more people to join the fight against Ebola, to serve as reassurance that they will receive top-notch treatment from American doctors if they are infected.
“Obviously there’s pressure to get this thing done,” said Col. Joann Fry, standing in front of the military tents that will make up the center, 30 miles from JFK.
But so far the facility does not appear to have prompted many more foreign doctors to staff the U.S.-built treatment centers.
“What we would like is if we could get international NGOs to man and staff each facility,” Mahoney said. “But we haven’t been successful at getting any to do that.”
Moses hoped Friday would be better. He prepared to see the 21 Ebola victims who remained at JFK. The clinic had closed its doors to new patients, but he decided he would continue to care for the ones already admitted, until they recovered or died.
But as he began putting on his protective gear, five hygienists, in charge of disinfecting the ward and its doctors, stormed out of the building.
“We are risking our lives, and we’re getting paid nothing!” Grace Twaeh screamed as she stalked down the dirt road connecting the hospital to downtown Monrovia. “Everyone is getting infected here. People are dying, dying, dying.”
One of Moses’s assistants chased after her.
“Please, I beg of you, come back!” he shouted.
Twaeh and the other hygienists kept walking.
Moses was near his desk in the storage room. Earlier in the morning, he had spoken with Scotland over the phone. He had told his friend that he would continue treating the patients. But as the hygienists left, he wondered whether that was possible.
“How can I do my job without them?” he asked.
Moses decided to try. He and 11 other JFK employees finished putting on their protective gear. It is a process that requires extraordinary attention to detail, to make sure not only that no skin is exposed but that there are enough layers of protection to survive a charge from a disoriented patient. That happened at JFK last month. The nurse who was attacked contracted the disease and died.
When their gear was on, the men and women gathered in a circle and held hands. A physician’s assistant, Lawrence Kollie, led them in prayer.
“Lord, we are before your tomb of grace,” he began.
When they went into the ward, they saw a familiar scene. The healthier patients sat in the hospital’s fenced-in back yard, next to the massive pile of trash and excrement. Inside, the sickest patients writhed on mattresses or lay unmoving next to pools of vomit. A nurse cradled an infected child whose parents had died.
The patients with the strength to speak asked after Dr. Scotland.
“That man was doing amazing work,” said one middle-aged man. “These guys saved us.”
Across town, a corpse lay inside the morgue at another treatment center. It was Dr. Tata.
The body collection team had parked a white flatbed truck in front of the squat building. Tata’s body, like those of other Ebola victims, was at its most infectious just after death. It needed to be incinerated. The team was waiting.
But some of Tata’s colleagues had pushed back against the protocol. They wanted to make an exception, to bury the doctor’s body, or maybe just his ashes, separately, with some degree of honor.
Mark Korvayan, the head of the body collection team, had spent the past months watching all the ways Ebola does not discriminate between the rich and poor, the educated and the illiterate. He had made up his mind.
“I know he was a doctor, but we can’t take some bodies and leave others,” he said. “They’re all dying of the same virus.”