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A Pandemic Tragedy in Guayaquil

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The problem with any story, big or small, is that you’re always starting in the middle. All beginnings are constructions we use to make sense of what is mostly incomprehensible. Of course, there are facts. For example: during one particularly violent twenty-four-hour period in January, eighteen people were murdered in Guayaquil, Ecuador’s largest city and its commercial and industrial capital. That week, there were thirty murders altogether. For the dead, those murders marked the end of their stories. For the city, which just two years ago was battered by one of the world’s most virulent outbreaks of covid-19, the murders were something else: a plot twist in an ongoing narrative of disaster. Guayaquil has a history of violence that stretches back to the days of its founding, in the sixteenth century, but what is happening now is new: January, 2022, ended with seventy-nine murders, nearly three times the number in the same month in 2020, just before the pandemic began.

Last October, I went to Guayaquil to report on the aftereffects of the pandemic, not on the violence there, though I was warned about it, again and again—before travelling, then when I arrived, late on a Sunday, and the following morning, as I walked out the door of my hotel to go to an interview. One day, I spoke with a retired nurse, who told me about friends and colleagues who’d worked through the first, nightmarish wave of covid-19. One had quit nursing. Another had left the country. A third had lost her mind. The neighborhood had changed, too, she told me. Initially, everyone was afraid of contagion; now everyone was afraid of the violence. We were still talking when her sister arrived home, and, in an instant, the conversation turned. As the nurse served me coffee, her sister told me about her son, an inmate at a local prison, Guayas 1. She’d been living in Italy for years, and had flown home in the hope of getting him out. They hadn’t seen each other in three years, but they spoke all the time, had spoken, in fact, just before she boarded the plane. But overnight, while she travelled across the sea, an armed gang overran a section of the prison, killing more than a hundred inmates, including her son. He was stabbed multiple times in the chest and back. Soon after landing, she’d learned that he was dead. “Sometimes I think he wanted his freedom so badly,” she told me, shaking her head, “that in the end he flew away.”

Here’s another beginning. In late December, 2019, Dr. Paola Vélez got a phone call from a friend, asking if she’d been following the news from Wuhan, China. Vélez was on a holiday break at the time, at a beach a couple of hours from Guayaquil, where she lived and practiced as an infectious-disease specialist at a relatively new public hospital called Guasmo Sur. She hadn’t been following the news, she told her friend, but promised to look into it. What Vélez read during the next few days was so alarming that, when she returned to the city, she began drafting a contingency plan for her hospital, based on two logical assumptions: that the novel coronavirus was airborne and that it would eventually make it to Ecuador.

On January 11th, she presented her plan to the hospital’s medical director. A week later, she received the go-ahead to implement it, and began converting a large room at the hospital into a twenty-seven-bed infectious-disease treatment and containment area. She was given no budget, but was offered staff. She trained a group of doctors and nurses in the proper use of P.P.E. and in the protocols for entering and exiting the quarantine area, so as to avoid infection and contamination. When it opened, on January 31, 2020, Dr. Vélez’s unit at Guasmo Sur was perhaps the first public hospital space specifically designed to safely receive and treat Covid patients in Latin America, and certainly the first in Ecuador. “My mistake,” Vélez told me, “was assuming that everyone was preparing just as I was.”

“I can practice a different song.”
Cartoon by Drew Panckeri

Vélez is in her late thirties, with black hair, a broad, friendly smile, and sharp eyes. She and her mother moved to Guayaquil in the nineties, after an earthquake destroyed their home, in the province of Manabí. Everything they owned fit in two suitcases. Now the first thing you see when you enter the two-bedroom apartment that Vélez shares with her mother is a hand-painted Wonder Woman logo adorning the wall that faces the door. Vélez is more than a casual fan. For Halloween in 2020, she dressed up as the superhero, and earlier that year, during the height of the pandemic, she tweeted at Gal Gadot, who played Wonder Woman in the most recent movie, asking that she remember health-care workers. Up a flight of stairs, on the building’s terrace, Vélez keeps a punching bag (to relieve stress, she told me), beside a mountain bike, which she takes out for a ride at dawn every Sunday. Even before the pandemic, she worked long, punishing hours, and was known as a leader at Guasmo Sur. All of which is to say that, by character and by disposition, Vélez was primed for the kind of heroism that the approaching crisis would require.

Ecuador’s first suspected case was reported on January 26th, a few days before Vélez’s covid unit was finished: a forty-nine-year-old Chinese national with flu-like symptoms who had arrived in Quito, the capital, five days earlier. A mucus sample was taken to be tested at Guayaquil’s National Institute of Public Health Research, known as INSPI. The technical director, Alfredo Bruno, a microbiologist who also coördinates Ecuador’s National Influenza Center, had been receiving worrying updates from the World Health Organization about the situation developing in China. The new virus’s genome had been sequenced by early January, and Bruno had ordered reactivating agents from the Pan American Health Organization as soon as they were available, enough to perform a thousand tests or so. To everyone’s great relief, this first sample tested negative, a result that was confirmed by a separate test conducted at the Centers for Disease Control and Prevention. (The patient would later die of complications from hepatitis B and pneumonia.)

In mid-February, there was a new suspected case: an Ecuadorian woman in her seventies who was living in Madrid and had come to Guayaquil to see her family. Her visit, before she fell seriously ill, had been a whirlwind of family gatherings, festivals, and celebrations; as many as eighty close contacts had potentially been exposed. At the time, Bruno and his lab colleagues were the only four people in the country able to conduct a test for the novel coronavirus. The woman’s symptoms, and the fact that the Spanish capital was already suffering through its first wave of infections, put the medical authorities on edge. “We placed the sample in the machine and basically made the sign of the cross,” Bruno told me. As he and his team waited for the results, his cell phone rang. It was the Minister of Health, Catalina Andramuño. He should tell no one of the results except her, she said. An hour later, he called her back with the news they had all been dreading: the test was positive. Andramuño made the official announcement on February 29, 2020. (Brazil had announced its first case three days before.) By then, there were at least twenty-four other people in Ecuador with Covid-19 symptoms; within days, there were twenty confirmed cases.

January and February are vacation and travel season on Ecuador’s Pacific coast: schools are out, and the weather is humid and oppressively hot. It’s the time of year for graduation parties and family trips to the beach, foreign travel for those who can afford it, and homecomings for the large Ecuadorian diaspora, scattered across Europe and the United States. Guayaquil, the country’s economic engine, is at the center of it all, as it has been for much of the nation’s history. During the cacao boom of the late nineteenth century, when Ecuador exported more than twenty per cent of the world’s processed cacao, nearly all of it left via the port of Guayaquil. The city grew as most Latin American cities have grown: in fits and starts, with little regard for the natural world, through periods of prosperity interrupted by the occasional calamity. In the case of Guayaquil, the most common disasters were pirate attacks and fires; in 1896, a fire wiped out nearly a third of the houses in the city, leaving more than half the residents homeless. Guayaquil sits at sea level, on the largest estuary ecosystem on the Pacific coast of South America, a concatenation of wetlands, saltwater marshes, creeks, and islands, less than fifty miles from where the enormous, muddy Guayas River flows into the sea. In the aftermath of the worst fires, the local government drained wetlands to build neighborhoods (which were later susceptible to flooding), redrew maps, and straightened roads, preparing for the next stage of the city’s growth. Today, Guayaquil is a sprawling metropolis of more than three million residents. The port handles ninety per cent of Ecuador’s imports and half of its exports, and the airport is the country’s second busiest, after Quito’s. The wealthy live in a satellite city called Samborondón, a lush enclave of shopping malls and gated communities with names like Rio Sol Towers, Ibiza, and Camino del Rio. Rafael Correa, a Socialist President, who was in office from 2007 to 2017, often referred to élites like these as “pelucones,” a mocking reference to the wigs, or pelucas, that the European aristocracy once wore.

More than one and a half million Ecuadorians live abroad, mostly in the U.S., Italy, and Spain, and many, like the first Covid-19 patient, returned to visit family just as the virus was taking hold in Europe. More than two hundred thousand people arrived at Guayaquil’s airport between January 1st and March 16th, the day the government closed its borders to international arrivals. Dozens of clusters were likely seeded in those first months of 2020—at parties and weddings and gatherings throughout the region. In early March, after some confusing back-and-forth among different government entities, the Minister of Government, María Paula Romo, announced the authorization of mass gatherings, including a soccer match between Barcelona, Guayaquil’s most popular team, and its rival from outside of Quito, Independiente del Valle. Pedro Pablo Duart, who was then the governor of the state of Guayas, encouraged the public to attend, tweeting, “The most dangerous virus is fear.” Some twenty thousand people showed up. (“That was crude. It was a mistake,” he told me, while denying that anyone had been infected at the game.) A week later, even after the outbreak had begun to spread and social-distancing and quarantine rules were in effect, lavish parties were still taking place in Samborondón. According to Duart, police shut down more than fifteen illegal gatherings there during the weekend of March 14th.

The first patient was being treated at a private clinic when she tested positive, but she was soon transferred to Paola Vélez’s unit at Guasmo Sur. Vélez didn’t tell her mother for almost a week—she didn’t want to worry her—but in fact, Vélez admitted, it was exciting. She showed me photos from those heady early days: she and her colleagues in P.P.E. In some pictures, the masks have been removed, and they’re beaming. “From a professional standpoint, you feel that this is your moment, that you have to show that this is what you’ve trained for,” she told me. “Afterward, I was sorry and asked God for forgiveness for being so selfish. I had no idea what was coming.”

Cartoon by Roz Chast

In truth, no one did. If there was one thing that characterized the outbreak in Guayaquil, it was the velocity with which the contagion spread across the city, whose public-health and funerary infrastructure was woefully unprepared. Although there were several relatively new hospitals in Guayaquil, most of them were understaffed even before the pandemic decimated the medical ranks. Some hadn’t been finished in time. I toured one, Monte Sinaí, with a young doctor named Heinert Gonzabay Campos, who proudly showed me a new modern intensive-care unit. When I asked him to describe what it had looked like at the height of the 2020 covid surge, he admitted that it hadn’t been in use then, and took me to a makeshift emergency area on a lower floor, where he explained how the beds had been crammed in, and the bodies had lain, and a wall had been hastily constructed, in an attempt to contain the spread of the disease. “Many people showed a lot of courage, a powerful desire to save lives,” he said. “But that wore off over time. The mothers and fathers of hospital employees died in our arms.” Gonzabay Campos’s father died of covid on the other side of the country.

In a forthcoming study, Dr. Esteban Ortiz, at Quito’s Universidad de las Américas, concludes that Guayaquil likely had the world’s most lethal outbreak of covid-19 per capita. “One day, there were no patients,” he told me. “The next, there were five thousand looking for beds in intensive-care units.” Ortiz estimates that about sixty-five per cent of the city’s residents were infected during March and April of 2020, and, judging by the number of excess deaths, by the end of April the death rate was nine times what it would normally be. Within a few weeks of the first confirmed case, Guayaquil’s hospitals were on a wartime footing, in an exhausting and relentless state of triage that would last for the better part of a month. The twenty-seven beds that Vélez had prepared were soon filled, so she added another room. Eventually, she had four rooms, and they weren’t nearly enough.

Vélez hardly left Guasmo Sur, and she describes those weeks as the worst of her professional life. Hospital morgues, designed for only a few cadavers, were overwhelmed almost immediately, with corpses piling up in spare rooms and even on the sidewalks in front of the hospitals. Hundreds of people died in their homes, and with mortuary services paralyzed—funerary workers were scared of getting infected—many grieving families were forced to live for days with the decaying bodies of their loved ones. Duart, who spent those weeks visiting hospitals and coördinating food deliveries in Guayaquil, told me that the scenes were horrifying. “You’d see a woman standing in line just fall over—pum!—and die.” Ecuador’s emergency phone service was so inundated with calls that it collapsed, not just in Guayaquil but nationwide. In the midst of this crisis, hundreds of bodies were lost, misplaced, or buried without proper identification. One family was mourning a dead aunt when she suddenly called, having awoken from a three-week coma. Somehow, in the confusion of the teeming hospital, she’d been mistaken for someone else. It was unclear whose ashes the family had been given, or how to return them.

The shock of what took place in Guayaquil helped alert Ecuador and the entire region to the potential severity of the illness. “We took steps that the rest of the world took later,” Otto Sonnenholzner, Ecuador’s Vice-President at the time, told me. “And this worked in twenty-three of our twenty-four provinces.”

Before the pandemic, Roberto Farías worked as an unlicensed cabdriver, seven days a week, taking home about fifteen dollars on a good day. He lived with his niece, Madeline, a graphic designer, and his mother, Norma, in a modest three-bedroom home in a working-class district of Guayaquil known as El Suburbio. When I met him, last fall, he was still struggling to understand what had happened to him and his family.

Though Ecuador’s first confirmed case was announced at the end of February, 2020, the danger felt remote at that point. Roberto drove his taxi, just as he normally would, until Sunday, March 15th, the day before President Lenín Moreno issued a nationwide stay-at-home order. Roberto wasn’t feeling particularly well, and though his sister, who’d moved to Madrid more than a decade earlier, was worried that it might be covid, he wasn’t too concerned. He called a friend who worked at a hospital and described what he was experiencing—high fever and chills—and to his relief was told that it was most likely dengue fever, whose symptoms are easily mistaken for covid. (An outbreak of dengue in 2019 was one of the worst in Ecuador’s history, and stretched into the early months of the New Year.) At the time, despite the rising number of positive covid cases, authorities were assuring residents that there was no community spread. Still, Roberto stayed in his room, taking the medicine he’d been prescribed for dengue and urging his mother and niece to keep their distance, just to be safe. He didn’t improve. Roberto didn’t know that one of the symptoms of the novel coronavirus was a loss of taste or smell, and he playfully chided his mother for forgetting to salt the food, or to add sugar to the milkshakes she made for him.

Paola Vélez in a Guasmo Sur hospital room that she designed for COVID patients.Photograph by Fabiola Cedillo for The New Yorker

On March 18th, the day before his sixty-seventh birthday, President Moreno released a video urging all Ecuadorians to stay home, while assuring them that he was working from his office. In one shot, he chats with his Finance Minister on Zoom. In another, Moreno, who was paralyzed in a 1998 robbery attempt, sits in his wheelchair on the balcony of the Presidential Palace, looking out over Quito’s deserted central square. “The streets are empty,” he says, before adding confidently, “In a few days, we’ll see this plaza buzzing again.”

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