On the front line against Ebola
After decades in medical crisis zones, Bangkok-based doctor Erik Fleischman set off for Liberia to face the most dangerous challenge of his career
It was about a month after arriving at the Ebola treatment units in a remote corner of Liberia when Bangkok resident Erik Fleischman felt the early stages of fever. Thoughts of the previous weeks flashed through his mind; of patients writhing in agony as they lay dying in pools of their own vomit and excrement, of the intense heat inside the crowded, non-airconditioned tents which acted as makeshift hospital wards.
“You just think, ‘S**t, here we go’. ”
Dr Fleischman called a friend — the camp manager — and asked him to bring over a thermometer. “ ‘Don’t ask questions,’ I told him. ‘Just bring it’. ”
The friend threw the thermometer into Dr Fleischman’s tent from the outside, wary of getting too close. The result seemingly confirmed the worst: 38.9C.
But there was no immediate panic. He was displaying only one symptom. There was still no headache, hiccups, rash, vomiting, diarrhoea, stomach pains or red eyes.
“You have to put the analytical part of your brain in front of the emotional part,” he said.
Ebola symptoms usually begin to show within four to seven days of infection, although that can stretch out to 21 days.
Dr Fleischman simply had to trace back when he might have been exposed.
“I had to sit there and just count back, and it turned out it had been 26 days [since my last exposure],” he said.
“So I was just going, ‘Thank God I probably just have malaria’. That’s the only time in my life I’ll get to say that.”
Training for battle: Ebola ‘wards’ are set up in tents, with no air conditioning and little ventilation.
FROM CELEBRITIES TO CRISES
Dr Fleischman touched down in Liberia on Dec 5, during the height of the Ebola epidemic that swept across large swathes of West Africa, killing more than 10,000 people by WHO estimates.
He admits to being “scared s**tless” when agreeing to go and set up four remote treatment units. “I knew as much about it [Ebola] as everyone else who read about it on the internet,” he said. That online information painted a grim picture: While no Western medical staff had yet died, Liberia had lost more than a third of its doctors and nurses to Ebola.
“I’d treated a lot of infectious diseases in Africa, so I knew how bad it could get. I knew you were going to be in place where it was the worst-case scenario, with very little resources, with no proper medical staff or hospitals or equipment.”
It was a situation Dr Fleischman was well prepared to handle.
The 50-year-old began his career as a surgeon and cancer specialist in the US, at one point working as a “Hollywood doctor to the stars”, treating Steven Seagal and Mickey Rourke, among other celebrities.
But that career path failed to meet his lust for adventure or desire to make a difference, and he gave it away to turn his attention to HIV/Aids treatment as the disease ran rampant through the US.
In 2003, after numerous charity trips abroad and with HIV mostly under control in the US, he sold his practice and moved to Bangkok, where he still lives with his wife and two children, aged two and eight.
Since then his former role as a senior HIV clinical adviser for the Clinton Foundation has taken him to crisis zones in more than 20 countries in Africa, Southeast Asia and the Caribbean, while a more recent position with Newmont Mining saw him posted for four years to a remote Indonesian island.
Brave face: Dr Fleischman tries to keep his spirits up after contracting malaria in Liberia.
SUPERBUG SUPER BOWL
Despite his decades of experience in high-risk epidemic zones, the threat of Ebola was something entirely new and terrifying. Before the most recent outbreak, the disease’s mortality rate was above 80%, and there was little expertise in how to fight it; strategies until last year had mostly focused on military containment rather than medical treatment.
Dr Fleischman was sent for three days of training with the US Centres for Disease Control before flying out.
“Like everybody else, this was new territory for me,” Dr Fleischman said. “There’s no other disease in history that has had people being world experts after just six months.”
The job in Liberia did not sit well with his family. He said his wife was “not a fan” of the decision. “Nobody was. They thought I was crazy.
“But for a doctor in my field, this is the Super Bowl. When the opportunity to treat the worst disease in the world, in the worst conditions, comes up, no one could fault you for saying no, but it just seemed like a really good opportunity.”
As he touched down in Monrovia, the initial anxiety appeared unfounded. The capital city of more than a million people was bustling with daily life and human interaction; the only visible signs of the epidemic were large tubs of chlorine solution, which is used to kill the virus.
“You go in with the CNN view of things. You go in expecting people expecting to be all biohazard and the streets to be just barren,” Dr Fleischman said. “But by the time we got there, the epidemic had peaked and it was just like business as usual.”
Dr Fleischman likened it to the two most recent coups in Bangkok, both of which he witnessed. “If you watched the news it was bedlam on the streets [when the army moved in]. But if you walked around you just saw business as usual for people,” he said. “People still had to survive. It was exactly the same in Liberia.”
If the mood on the streets was relatively calm, it was perhaps only because the real storm was brewing in the treatment units that Dr Fleischman was responsible for getting up and running.
The clinics themselves were little more than groupings of small tents, erected hastily on dry, dusty fields in areas that were all but inaccessible by road. Securing enough supplies and medical equipment — even basics like food and clean water — proved a constant challenge, part of what Dr Fleischman labelled a “perfect storm of difficulties” confronting the Ebola fight.
Inside the tents, green army cots were set up in tidy rows of up to 25. With no air conditioning and little ventilation, these “wards” would easily top 40C in the intense midday heat.
That heat was exacerbated by the full-body PBE, or biohazard suit, which workers were required to wear when entering the units’ “red zones”.
“First of all you can’t see anything, because you’ve got the goggles on,” Dr Fleischman said. “You’ve got the mask over your face, so no one can hear what you’re saying, plus the goggles are all foggy.”
As Dr Fleischman went over to talk to his first patient, his initial apprehension about treating Ebola gave way to a vague feeling of optimism. The patient felt good, was not displaying any symptoms, and had not recorded a fever for two days.
“Then we turn to walk away and we hear a loud thud. And we go over and he’s having a full-on seizure,” Dr Fleischman said. “He’s pulled his IV out so he’s got blood pouring down his arm, and he’s bitten his tongue so he has bloody saliva dripping all down the side of his face, and he’s already lying in vomit.”
The first priority was to use a Valium injection to stop the seizure, while being careful to ensure the patient didn’t react violently and rip off anyone’s protective gear.
“It took him a while, but he stopped having a seizure, but there’s just blood everywhere. There’s blood on us, on our aprons, on our gloves. It was closer than you ever want to get to something that infectious.”
Even after the patient was under control, the danger remained for the medical team. They had to move to a decontamination area, where they were doused in chlorine solution.
Everyone was required to wear two pairs of latex gloves inside the red zone. As Dr Fleischman removed the blood-soaked outer pair, the replacement proved too small and both layers split, exposing his skin to the contaminated environment.
“All I’m thinking about is my wife and kids, and thinking, ‘What am I doing? This is so stupid’, you know?” he said.
“There were a lot of places where things could have gone wrong. These were uncontrolled environments with the most infectious thing known to man right now.”
The next day proved a powerful reminder of that fact. Dr Fleischman’s first patient had not survived the night.
“It’s impossible to talk about it without getting emotional. But this is the worst death a person can die, as far as I’ve seen, and I’ve worked in some really horrible places,” Dr Fleischman said.
“You couldn’t even put someone in a bed with a sheet, because there was so much vomit and diarrhoea and fluids that it would just soak through everything immediately.
“People would just vomit and [have] diarrhoea until they went unconscious.”
The burden of helplessly watching patients die was broken by Dr Fleischman’s primary job, which was to train local staff members and improve the safety of operations at the treatment units.
“The number one goal was to make sure that everybody you trained stayed alive. We didn’t want to lose anyone to anything stupid,” he said.
The training regimen was rigorous, with more than 500 people passing through the five-day programme. Mostly, they worked on didactics and scenarios, and how to put on and take off the PBE suits.
The largest team were hygienists, comprised mostly of locals with no medical experience whose jobs were essentially to mop up bodily fluids all day. Wages were low, yet for many it was the only work available in an economy ravaged by the epidemic.
But the horrific conditions helped breed an intense camaraderie among the multinational team of workers, which Dr Fleischman said was “probably similar to what people in war experience, without the bullets”.
“Everyone was treated as though they were doing something that was extremely brave, and extremely stupid,” he said.
“You make incredible tight, fast friendships. And afterwards you come back and you just think nobody can understand what you just went through.
“Whatever you read or whatever pictures you see, you can’t imagine how intense it was at any given moment there, and how bad it could go so quickly.”
Dr Fleischman battled through his bout of malaria and continued working in Liberia for a total of two months, returning to Thailand in February.
While many health workers in his native US have been treated as outcasts upon their return, Dr Fleischman said he was overwhelmed by his homecoming.
The infectious disease department officer at Suvarnabhumi airport was “very excited” to greet him, he said. He called over his manager, who gave the doctor a hug and took photos together before organising someone to drive him home.
Dr Fleischman received daily phone calls from the department for the next 21 days, as well as twice-weekly visits to his house to have his temperature taken. His movements were not restricted, but Dr Fleischman mostly kept to himself and avoided public places as he was still suffering from the lingering effects of malaria.
“They handled it really well. It was a real credit to the Thai public health system,” he said. “I think this is the best place you could have gone back to.”
Early this month, Liberia dismantled a crematorium and removed drums containing the ashes of more than 3,000 Ebola victims, as the government says the danger had now passed.
For Dr Fleischman, the news was bittersweet. He’s concerned about the country’s ability to recover financially, and is worried there is still no effective medical prevention available to halt the spread of the disease if it returns.
But while the experiences with Ebola continue to haunt him, he hoped they could be used to improve responses to future epidemics.
“If you ask me would I do it again, I probably would. But it’s one of those things that you do that’s just always going to stay with you,” he said.
“Whatever profession you’re in, if you don’t get in it for the challenge and the excitement, then I think you’re missing a lot … I wanted to see what I could handle, and what I couldn’t handle.”
For the time being, at least, Dr Fleischman seems to have answered that question. He is putting his globe-trotting adventures on hold as he takes up a less dangerous job at Bumrungrad International Hospital, a role he hopes will give him time to spend with his young family.
“It’s time to be a father now, too,” he said. n