The Pandemic Century

by The Pandemic Century- One Hundred Years of Panic, Hysteria

  Word had got out that we had come from Kinshasa with medicine. I thought it was typhoid fever so I lined them up and collected blood. I was immediately struck by the fact that when I removed the syringe from the site of the puncture wound it bled profusely. My fingers and hands were soiled with blood. I just used water and soap to wash it off.

  The next outbreak Muyembe attended was in 1995 when, after a nearly twenty-year hiatus, Zaire ebolavirus reemerged in Kikwit, a city in the DRC with some 400,000 inhabitants. The outbreak had almost certainly begun in January in a forested area close to the city but had initially been mistaken for typhoid. It was only when a surgical team at Kikwit General Hospital fell ill in March after carrying out a risky operation on a laboratory technician, and Muyembe was sent to investigate, that he realized it was probably Ebola. He forwarded blood samples to the CDC in Atlanta for testing. In all, the Kikwit outbreak resulted in 315 infections and 254 deaths, and might have been much worse had the government not closed the highway to Kinshasa.†

  It was at that outbreak that Muyembe renewed his friendship with David Heymann. The pair had first met at Yambuku when Heymann was a young EIS officer. However, by 1995 Heymann was director of the WHO’s Division of Emerging and Other Communicable Diseases, and it had fallen to him to coordinate the international response in Kikwit. As Heymann dealt with DRC officials and the global media, Muyembe met with local chiefs to try to win the community’s cooperation. “He speaks about those who are infected as being full of evil spirits that cause illness as they attempt to escape,” explained Heymann. “He also discusses with them the reason that there are foreigners with him—because these spirits are stronger than most, and that he needs foreign help. Outbreaks then stop rapidly.”

  Unfortunately, in the crucial early weeks of the West African epidemic these lessons appear to have been forgotten. Instead, the arrival of medical teams in Guinea-forestière sparked violent clashes with communities suspicious of the intentions of foreigners dressed in white biohazard suits. For instance, in April rumors that Ebola had been deliberately introduced to Guinea prompted an angry crowd to storm an MSF facility in Macenta and stone aid workers. In response, MSF was forced to evacuate its staff and close the facility for a week. By July, as anger over Ebola intensified, Kissi-speaking villagers in Guéckédou cut bridges and felled trees to block the path of medical teams offering assistance. Meanwhile, those in the community who were seen to be aiding foreigners were accused of being “traitors” and beaten up. Red Cross burial teams were also a target; the agency reported an average of ten attacks a month across the country. Resistance was particularly intense in Forécariah, where local people objected to burial teams taking blood samples away for testing. Disinfection measures, such as spraying with chlorine, were also subject to misinterpretation, a common rumor being that the sprays were being used to spread Ebola rather than to control it. The most unfortunate incident of all occurred in Womey, in Nzerekore prefecture, where a mixed delegation of medical personnel and government officials was set upon by an angry mob. Eight members of the delegation were captured and killed, their bodies being dumped in a latrine.

  This resistance was not unique to Guinea; it was a feature across the West African Ebola zone. One of the most common rumors was that the virus had been manufactured in a US military facility or that it was a plot by governments to attract foreign aid to the region. People were particularly distrustful of ETUs—hardly surprising given that many of those entering the treatment units were never seen again—fearing that the tented facilities were being used to harvest organs or steal blood. Some of these rumors no doubt reflected people’s interactions with government officials and their experiences of medical programs generally. Others drew on folk memories of the slave trade and colonial histories of exploitation and extraction. Many of the routes used by foreign medical teams were the same as those that had been used by slave raiders in the seventeenth and eighteenth centuries. In the nineteenth century those routes were exploited by colonial administrators to harvest rubber from the forests. Then, during the bloody civil wars that racked Liberia and Sierra Leone in the 1990s and early 2000s, rival militias used the same trails to export diamonds in one direction and import guns in the other. More recently, the demand for natural resources has seen new forms of exploitation as large swaths of the forest have been felled for timber or planted for cash crops, such as cassava. These measures have fallen particularly hard on the rural poor, especially in Guinea, where the inhabitants of forested regions have long resisted assimilation into the country’s Muslim majority. However, it is no less true in Kenema, in eastern Sierra Leone, and Lofa County, in Liberia, where local people are also distrustful of urban political elites and more likely to listen to their local chief than a trouser-suited official from Freetown or Monrovia.

  Perhaps because of the hostile reception MSF received in Guinea, it was one of the first to warn of the dangers that the distrust of foreign medical teams presented for the containment of the virus. Speaking at a meeting of disease policy experts in London in May 2014, Armand Sprecher, an MSF emergency physician recently returned from a tour of duty in Conakry, warned that the international health community had “a marketing problem”:

  Our best response . . . is to produce good advocates, survivors who can say and bear witness to what goes on inside the treatment units, to tell everyone that we do have their best interests at heart, that we are trying to save people. The problem is, in order to have survivors, you need patients. In order to get patients, you need survivors. Unfortunately, we’re caught in a catch 22.

  One consequence of this fear of ETUs was to further skew the Ebola case data. Official counts based on people presenting at treatment units in Conakry with either confirmed or probable Ebola reached a new low in mid-April, leading many experts to believe that the world had dodged a bullet. However, at the same time as a dip in cases was observed in Conakry, MSF physicians saw a dramatic spike in the mortality rate in Guéckédou. “All of a sudden we’re having patients who have to come in, they cannot hide their illness, they’re so obviously deathly ill that in their communities they cannot hide from us anymore,” said Sprecher. “That’s not what the end of an outbreak looks like.” Sprecher would subsequently label the dip in cases observed in Conakry in April and May “the dog that didn’t bark.”

  Guinea was not the only country that had an invisible and growing problem. In early March 2014, a young woman named Luisey Kamano had approached a fisherman on the Guinean border with Sierra Leone and asked to be ferried across the river. Kamano had just seen her mother, grandmother, and two of her aunts die of Ebola and was terrified that she was about to be forcibly removed to an ETU. “I was told white people were looking for me, that they wanted to take me to Guéckédou,” she said. “I was told they’d kill me with an injection. So I ran away.”

  Once in Sierra Leone, Luisey easily evaded the authorities who had been alerted by WHO officials that she might be harboring the virus. She was not the only one. By late March other people who had cared for sick relatives had also fled across the border. Many of them made for Koindu, a village set deep in the rolling hills and diamond mines of Kailahun. There they visited a traditional healer, Finda Mendinor, drawn by the belief that she had the powers to expel the evil spirits that were the source of their affliction. It is not known how many people Mendinor treated or how—most likely she gave them herbal medicines and uttered incantations as she touched their foreheads and other parts of their body. One thing is certain, however: her ministrations were no protection against Ebola, and soon she had also contracted the disease. Her death at the end of April sparked a week-long mourning period that brought scores more people to Koindu to attend her funeral. There, local women prepared her for burial by washing and dressing her corpse, while others crowded around the cadaver and showered it with kisses. The result was that within a month of Mendinor’s death, authorities were reporting thirty-five laboratory-confirmed cases of Ebola across Sierra Leone
and at least five active chains of transmission. Nowhere was the impact of this new phase of the outbreak more dramatically felt than at Kenema General Hospital—the same hospital where researchers had detected Ebola antibodies in stored serum samples from Lassa patients a year earlier.

  KENEMA IS LOCATED in the heart of diamond-mining country, and feels like a frontier town. Approached via a new Chinese highway that abruptly turns into a red dirt road just beyond the city limits, the town is a magnet for prospectors en route to the rich alluvial diamond beds that dot the surrounding hills and valleys. In boom times the main square teems with dealers ready to pay hard cash for the right stone, but the city has also seen its fair share of terror. In the early 1990s, Kenema was overrun by the Revolutionary United Front (RUF), a rebel militia led by a former Sierra Leone Army corporal, Foday Sankoh, who specialized in amputations and the abduction of child soldiers. Trading diamonds for arms, Sankoh advanced as far as Freetown, occupying and reoccupying the Sierra Leone capital for several years before finally being repulsed in 2002 by a British-backed force of UN peacekeepers. With the cessation of the civil war, diamond production increased tenfold and good times returned to Kenema. But the conflict had taken its toll on Sierra Leone’s health system, and many doctors fled the country. One of the few to return was Dr. Sheik Humarr Khan.

  Born in 1975 in Lungi, a small town just across the bay from Freetown which also happens to be the site of the country’s international airport, Khan had grown up dirt-poor, the youngest of ten children. Despite these unpromising beginnings, Khan graduated at the top of his class in 1993 and won a place at a prestigious medical school in the capital. He hoped to become a Lassa Fever specialist, but in 1997, as the RUF closed in on Freetown, he was forced to flee to Conakry. His family urged him to apply for a visa to the United States, where several of his siblings had already settled. But in 2004 Khan learned that the director of Kenema’s Lassa program, Dr. Aniru Conteh, had died after accidentally pricking himself with a needle; Khan decided to apply for the position. His application was accepted.

  In those days, there was no Chinese highway and it took eight hours to reach Kenema from Freetown, a grueling drive along untarred dirt roads. On arrival, Khan was pleased to find that the public hospital was no longer a scientific backwater but had a state-of-the-art laboratory courtesy of a partnership with Tulane University. Researchers could now screen patients for Lassa and treat them on the spot. Dividing his time between the laboratory and the maternity ward, Khan quickly won the respect of nursing staff and was soon also a well-known figure about town, particularly on the nights when his favorite soccer team, A. C. Milan, was playing in the European Champions League and he could be heard cheering them loudly from his regular spot in a local bar.

  When Khan learned about the outbreak in Guinea, he warned nurses they should be prepared in case Ebola came to Kenema. At the very least there was a good possibility that suspected Ebola bloods would be sent to the hospital for testing since the Tulane laboratory was the only one in the country with PCR equipment. Unfortunately, by the time he verified the first positive blood sample on May 24 from a nurse who had attended Mendinor’s funeral, it was too late: staff had already admitted a pregnant woman to the maternity ward unaware that she was infected with Ebola. A few days later the woman miscarried, spreading the virus to other patients.

  In response, Khan set up a triage zone in front of the hospital and tried to impress upon the staff the importance of avoiding contact with blood, vomit, and other fluids whenever they entered the red zone—the area of the hospital reserved for Ebola patients. When a Tulane research colleague arrived with surgical gloves and personal protection kits, Khan demonstrated the correct procedures for disrobing and disinfecting the suits and gloves with chlorine. Unfortunately, within weeks the hospital was overrun with new Ebola cases—many of them people who had attended Menindor’s funeral—and nurses were under so much pressure that many disregarded the protocols. In the hope of stemming the outbreak, Khan traveled to Kailahun, where he met with village headmen and tried to convey the dangers Ebola presented to the local population. However, many community leaders were in denial and resisted Khan’s entreaties to evacuate suspect cases to Kenema for testing. On one occasion, a local chief seized Khan’s government-issued Toyota and held it overnight, warning him to stay out of Kailahun. Opposition was fiercest of all in Koindu, where the population erected roadblocks and threw stones, shattering the windshield of Khan’s car. “There were rumors that we were coming to give them the disease,” recalled Robert Garry, the Tulane researcher who had traveled to Kenema to assist Khan. “They said we would take people away and never come back. The attitude was, ‘Leave us alone.’ ”

  The news that Ebola had crossed the border sent government officials in Freetown into a spin. Over the next few days Khan fielded increasingly frantic calls from the president’s office and the Ministry of Health. By now, a Seattle-based nonprofit, Metabiota, one of whose members shared the Kenema laboratory, had also confirmed the presence of Ebola in Sierra Leone and was being asked to send a representative to Monrovia where there were reports of suspected Ebola cases in New Kru Town. However, WHO officials on the ground were in denial, telling members of local NGOs, “Ebola doesn’t cause urban outbreaks” and that there was no danger of the virus reaching Freetown. Judging by a series of memos and emails between senior WHO officials in Geneva that were obtained by Associated Press, this denial went all the way to the top of the UN organization. Treating Ebola as an international emergency “could be seen as a hostile act . . . and may hamper collaboration between WHO and affected countries,” warned Keiji Fukuda, the WHO’s Assistant Director-General for Health, Security and Environment, in an internal briefing note to WHO Director-General Margaret Chan on June 2. “This outbreak must be considered as a sub-regional public health issue.” Sylvie Briand, the director of WHO’s Pandemic and Epidemic Diseases Department, concurred. “I don’t think declaring a pheic [public health emergency of international concern] will help fight the epidemic at this stage,” she emailed a colleague on June 4. “The problem with declaring a pheic is that one has to make recommendations and these risk hurting the country without helping public health. . . . I see [it] as a last resort.” As a result, it was not until late July that Chan upgraded the emergency to Grade 3 and it was not until August 8 that, bowing to international pressure and concerns that, in the words of MSF, the outbreak was “totally out of . . . control,” Chan finally declared Ebola a pheic.‡

  Unfortunately, that declaration came too late for Khan. In the hope of containing the outbreak, the Ministry of Health had decided to refer all suspected cases from Freetown to Kenema—a grueling four-hour journey by road in overheated ambulances. On one level, the policy made sense: Kenema was one of the few hospitals in the country whose staff had previous experience treating hemorrhagic fever, albeit Lassa. However, Kenema was also a stronghold of the opposition Sierra Leone People’s Party. The result was that when ambulances carrying Ebola patients began arriving at the hospital, rumors spread that the epidemic was a plot by the ruling All People’s Congress Party and that nurses on the wards were deliberately infecting patients with Ebola in order to attract foreign aid for the benefit of the political elite in Freetown. In early July these tensions reached a boiling point when a woman set up a makeshift pulpit in Kenema’s market area. Claiming that she was a former nurse and had seen Khan poisoning patients with her own eyes, she incited an angry mob to march on the hospital. In response Khan barred the gates and ordered his staff to evacuate while police fired tear gas to disperse the crowd.

  The claims were nonsense, of course. The people who were in most danger of getting Ebola were not other patients but Khan and his staff. As Will Pooley, a newly qualified British nurse who volunteered to work on the Ebola ward in June, recalled, conditions inside the hospital were “chaotic.” Arriving for duty in the morning, it was common to find five or more corpses lying sprawled in the toilets surrounded by
pools of vomit and bloody diarrhea. There were maggots and flies everywhere, and the heat inside the PPE suits was oppressive. To Pooley’s horror, many nurses were unable to bear it and removed their suits when they got too hot. Others would perform cursory decontaminations, then splash water on their faces. Most alarming of all, he frequently saw staff eating from shared bowls of rice, oblivious to the fact that someone who had just emerged from the Ebola unit may have dipped their hands into the same bowl. “For that reason I always left the hospital to eat,” said Pooley.

  The first member of the medical team to fall ill was Khan’s colleague, Alex Moigboi. In a rare breach of protocol for the usually meticulous doctor, Khan reached for Moigboi’s face to examine his pupils. In doing so, he inadvertently touched Moigboi’s skin. Moigboi was diagnosed with Ebola soon after, and died on July 19. By now Mbalu J. Fonnie, the hospital’s much-loved matron, was also feverish. Refusing to believe she had Ebola, Khan allowed her to stay in the annex reserved for “suspect” cases long after her bloods also tested positive. Fonnie was given antimalarials and IV fluids but there was little Khan could do, and on July 22 she died. By now, Khan was also feeling unwell and kept his distance from colleagues as a precaution. When his blood tested positive for Ebola it was decided that rather than remaining in Kenema, where his sickness might panic patients and staff, he should be moved to an MSF facility in Kailahun. It would prove a fateful decision. In Kenema, the treatment protocol was to give patients fluids intravenously, but MSF took the view that the risk of death from bleeding was greater than the potential benefits so placed Khan on the standard regimen of oral treatments—paracetamol for pain relief, antibiotics for diarrhea, and rehydration salts. In addition, MSF considered giving Khan an experimental drug called ZMapp that had shown great promise in monkeys but had never been tested in humans. In June a researcher from Canada’s public health agency had brought three treatment courses to Kailahun to test the drug’s viability in a tropical environment, depositing the vials in a freezer adjacent to Khan’s ward. MSF agonized over whether it should give Khan the drug. On the one hand the ZMapp might save his life; on the other, if he died, people might accuse MSF of hastening his death, or worse, poisoning him, thereby further eroding trust in its medical staff. In the event, MSF decided not to give Khan the drug. Critically ill, Khan was apparently never told about the ZMapp. As his white blood cell count dropped, there was talk of evacuating him in an air ambulance, but there were no protocols in place for managing such a risky procedure, and many doubted that in his fragile condition Khan would survive the arduous journey to Lungi airport where, in the shadow of the town where he grew up, a plane was waiting to fly him to Europe. The debate proved moot; Khan died on July 29 before a final decision could be made. However, his case focused attention on the need for procedures for airlifting other health workers to safety, particularly foreign nationals working for NGOs or under contract to the WHO. The result was that when Will Pooley fell ill in August after handling a baby whose parents had died of Ebola but that had initially tested negative for the virus, he was airlifted to London in a Royal Air Force ambulance. Removed to a high level isolation unit at the Royal Free Hospital, London, Pooley was sealed in a pressurized tent and treated with ZMapp. He survived. Around the same time, two American missionaries who had been caring for patients at Samaritan’s Purse’s Eternal Love Winning Africa (ELWA) treatment center in Monrovia, also fell ill. After a debate about what to do, the decision was taken to airlift Kent Brantly and Nancy Writebol to Georgia for emergency treatment at Emory Hospital, Atlanta; they were first given ZMapp to stabilize their condition. They also survived.