by The Pandemic Century- One Hundred Years of Panic, Hysteria
The contrast in the treatment accorded the American missionaries was not lost on Khan’s elder brother, C-Ray, who wondered “if it was good enough for Americans, it should have been good enough for my brother.” Many experts had sympathy for his point of view. Worrying that the better outcomes enjoyed by foreign health workers might further undermine trust in ETUs, they opined that it was important to replace the “stick” of confinement with the “carrot” of treatment. Just as importantly, Khan’s death sent shock waves through Sierra Leone’s medical community that were also felt in Freetown. In a country with one doctor for every 45,000 inhabitants (in the United States, the ratio is one per 410), the government could ill afford to lose the figurehead of its fight against Ebola and a man whom Sierra Leone’s president Dr. Ernest Bai Koroma had described as a “national hero.” The result was that the day after Khan’s death, Koroma declared a state of emergency and established a presidential task force to oversee the country’s response to Ebola.
IT WAS NOT ONLY in Sierra Leone that the free passage of people across the porous borders of the Mano River region ceded an advantage to the virus. In Liberia too, health facilities were completely unprepared for the arrival of Ebola from Guinea, and medics had to learn the lessons of previous outbreaks all over again. A good example came at Foya Borma hospital in Lofa district, the site of what is widely believed to have been Liberia’s index case. CDC epidemiologists traced the introduction of Ebola there to a woman who had arrived in Foya from Guéckédou in the first days of April. At the time, Liberia had no laboratory capable of conducting an ELISA test for Ebola, much less PCR, and because the woman presented with severe diarrhea, the attending physician assumed she had cholera. Even when on the second day she began to display hemorrhagic symptoms, the physician did not consider Ebola, assuming she was coinfected with Lassa. The absence of diagnostic facilities was not the only reason Ebola was able to take hold in Foya. Nursing staff also had limited training in infection control, no rubber gloves or masks, and very limited access to running water—all basic requirements that had been identified by Ebola experts decades earlier but which, due to chronic underinvestment in health care in Liberia, were notably absent. The result was that in a matter of days several health workers and patients had also been infected with the virus. Once it was in Foya, there was little the authorities could do to prevent Ebola from traveling to Liberia’s capital. It is thought the virus was introduced to Monrovia by a patient who traveled by motorcycle taxi to the Firestone treatment center on the outskirts of the city. En route, he infected the taxi driver and others. The result was that by April 7, Liberia was reporting twenty-one cases and ten deaths from Ebola. However, by the end of May, no new cases had been recorded since April 9, and by June the WHO was confident that Liberia was free of Ebola, having gone through two full incubation periods (twenty-one days times two) without any new cases being registered.
As in Guinea, the official case counts would prove misleading. Far from disappearing, Ebola had gone underground. Indeed, retrospective phylogenetic analysis suggests there were now at least three related strains of the virus circulating concurrently in the tri-border region. The first hint of a resurgence in infections in Liberia came in early June when six people in New Kru Town fell ill. Before long other cases were turning up at the John F. Kennedy Medical Center, the country’s only referral hospital. The hospital had been badly damaged during Liberia’s protracted civil war and lacked an isolation ward or personal protection equipment. The result was that, as in Kenema, the virus quickly spread to doctors and nursing staff, prompting the authorities to close the hospital in mid-July. The only other facility in Monrovia equipped to treat Ebola was the Eternal Love Winning Africa Hospital, known as ELWA, operated by the missionary group Samaritan’s Purse. ELWA was rapidly overwhelmed. Then, on July 22, Kent Brantly collapsed, prompting the discussions that would lead to his evacuation to Atlanta at the end of the month together with his Samaritan’s Purse colleague Nancy Writebol. By contrast, Liberians enjoyed no such privileges. So incensed was one Liberian by this disparity in medical treatment that in late July he stormed the government’s Emergency Operations Center and set off a firebomb, destroying computers that were being used to track Ebola cases. By now, Samaritan’s Purse had closed ELWA and had opened a new facility—ELWA 2—next door, but there were still too few beds, prompting patients to camp outside the unit. The pictures of desperately ill people collapsed in the road for want of spaces inside ELWA 2 should have been a game changer, driving home MSF’s earlier warnings that the epidemic in West Africa was out of control. However, it would seem that officials in Geneva were still reluctant to treat the outbreak as anything more than a regional health crisis, albeit a severe one.
The event that arguably changed this was the arrival of a Liberian-American lawyer in Lagos, one of the most populous cities in Africa. Patrick Sawyer had boarded a flight to the Nigerian capital on July 20. An employee of the mining company ArcelorMittal, he was en route to a conference in Calabar, in southern Nigeria, as a representative of the Liberian ministry of finance. At least, that was the story Sawyer gave officials on arrival at Murtala Mohammed International Airport in Lagos. In fact, Sawyer, who had been caring for his sick sister in Monrovia a few days earlier, was already infected with Ebola. One theory is that he was desperate to get to Nigeria, calculating he would have a better chance of receiving high quality care there. Unfortunately, on the flight to Lagos, Sawyer started vomiting and passing bloody stools, endangering other passengers. Taken on landing to the First Consultant Hospital in Lagos, Sawyer at first denied having had any infectious contacts and insisted on being discharged so he could continue his journey to Calabar. Initially, the nursing staff thought he might have malaria, but as his symptoms worsened, one of the consultants grew suspicious and decided to test him for Ebola. When his blood test came back positive, she quickly instituted barrier nursing controls and alerted the authorities to trace other passengers on the flight. In all, Sawyer infected nineteen people and it was only thanks to the consultant’s quick thinking that the outbreak spread no further. However, she could do nothing to stop the infection running its course, and five days later Sawyer died. Then in August she also fell ill and died, adding another health worker to Ebola’s tragic toll.
The Sawyer case was a wake-up call. In response, Liberia’s president Ellen Johnson Sirleaf ordered the country’s borders sealed and banned diplomats from traveling abroad. The United States followed suit, issuing a travel warning advising its citizens to stay away from the former American-freed slave colony. Meanwhile, prompted by the news that the Samaritan’s Purse missionaries had arrived in Atlanta, Donald Trump, then a New York property developer, tweeted, “Stop the EBOLA patients from entering the U.S.” and “The U.S. cannot allow EBOLA infected people back. People that go to far away places to help out are great—but must suffer the consequences!” As panic spread, several major carriers, including British Airways and Air France, canceled their services to Liberia, Guinea, and Sierra Leone, leaving just two operators, Brussels Air and Air Maroc, to continue flying health workers and vital aid in and out of West Africa. “Let’s face it,” lamented Peter Piot, “there is an epidemic of Ebola in West Africa, then there is a second epidemic, an epidemic of mass hysteria.”
Through all of this, Margaret Chan held steadfast to her belief that the outbreak did not warrant an escalation in the WHO’s response. However, by now it was clear to everyone that Ebola was spreading faster and further than the WHO had anticipated, and when on August 6 Sirleaf announced a national state of emergency, the pressure on Chan became irresistible. The result was that on August 8 she finally bowed to international pressure and declared Ebola a pheic. Joanne Liu, the international president of MSF, would later comment acidly that Chan’s decision had less to do with the growing humanitarian crisis in Africa than the fear that Ebola was just a plane ride away from a major American or European metropolis. “The lack of international political will was
no longer an option when the realisation dawned that Ebola could cross the ocean,” she says. “When Ebola became an international security threat . . . finally the world began to wake up.”
Unfortunately, by now the epidemic was also testing the limits of MSF’s medical and humanitarian capacity. At the onset of the epidemic in March, MSF had a handful of Ebola veterans it could call on. Since then, it had called up all its hemorrhagic fever experts, plus experienced medical and logistical staff, and put an additional 1,000 volunteers on crash courses in Ebola management. At the same time, the agency had begun construction of the ELWA 3 center in Monrovia, which would become, when it was fully operational in late September, the largest Ebola treatment center in the world. However, the immediate impact of the evacuation of the American missionaries was paralysis. Samaritan’s Purse quickly suspended operations at its two Ebola management centers in Monrovia and Foya—the only centers in the country at that time—leaving MSF to absorb the full brunt of the crisis. Nor did WHO’s declaration of a public health emergency trigger a direct intervention from other humanitarian aid organizations on the scale witnessed during natural disasters such as the 2010 Haiti earthquake or Typhoon Haiyan in the Philippines in 2013. On the contrary, in the short term, it worsened matters. “We didn’t want to say it but everybody was dragging their feet to come and play a role,” said Liu.
One reason for this paralysis was fear. Ever since the publication of The Hot Zone, the best-selling 1994 book by New Yorker journalist Richard Preston, Ebola had occupied a terrifying place in the public imagination. Drawing on the outbreak at the Reston primate facility in Virginia in 1989 and interviews with survivors of the Yambuku outbreak, Preston’s account focused on the most lurid and visually shocking symptoms of Ebola, such as the way that in the last stage of illness patients sometimes “bled out,” leaking blood and hemorrhagic fluids from their eyes, noses, and intestines. Even though such symptoms are mercifully rare, they helped fix in the public’s mind the idea that Ebola was, as Preston put it, a “molecular shark.” Through the imaginative use of flypapers marked with biosafety hazard warnings and extensive passages devoted to the Reston incident, Preston also reinforced the impression of Ebola as a potential biowarfare agent, one that could emerge from the jungles of Africa, or the laboratory of a deranged terrorist, at any time, spreading panic and threatening the future of humankind. “A tiny change in its genetic code,” he warned, “and it might turn into a cough and zoom through the human race.” Experts subsequently concluded that concerns of Ebola becoming a viable aerosol were overblown. Nevertheless, the proximity of the Reston outbreak to the US capital underlined Ebola’s potential as a biosecurity threat, resulting in its selection for a war game exercise at a meeting of the American Society of Tropical Medicine and Hygiene in Honolulu.§ More significantly, the Reston incident contributed to Ebola appearing alongside AIDS in the Institute of Medicine’s iconic 1992 list of EIDs.
BY THE MIDDLE OF August, as dead bodies piled up in the streets of Monrovia, Sirleaf was becoming desperate. In a moment of panic she ordered Ebola patients to be moved to a temporary holding center in a converted school in West Point, a slum area of Monrovia that is home to some 50,000 people, most of them desperately poor. In response, West Pointers ransacked the center, and seventeen Ebola patients fled into the slum. Four days later, on August 20, Sirleaf ordered police and soldiers to block all the exit roads and placed the entire community under quarantine.
West Point is an opposition stronghold, and soon rumors were rife that Ebola was a hoax and that Sirleaf’s real motivation was to quash an armed rebellion. As food prices soared, the imprisoned slum dwellers took to the streets in protest. Then, when the government-appointed commissioner tried to escort her family out of West Point under armed guard, an angry crowd stormed the barricades. Police and armed soldiers drove them back with their batons and shields, but when the rioters began throwing stones they opened fire, wounding two young men. Tragically, one of them, a fifteen-year-old called Shakie Kamara, died. Incredibly, Kamara’s death brought Sirleaf to her senses, and ten days later she lifted the quarantine, but the damage had been done and public distrust of the health measures deepened.
In late August, shocked by the scenes of police brutality, CDC director Tom Frieden traveled to West Africa to assess the situation, meeting with Sirleaf and other West African leaders. Although he was no stranger to explosive outbreaks of infectious disease, Frieden found the conditions in Liberia “beyond belief.” Stopping at a hastily constructed MSF treatment unit in Monrovia, he was appalled to find just one doctor for 120 patients.
There were people . . . struggling for their lives, right next to people that had died . . . but to remove someone who’s died you have to have six people come in in full body suits and they didn’t have enough staff to do it. . . . I particularly remember one tent I went into, there were eight beds, or eight mattresses on the ground, and there was one woman lying face down with beautiful cornrow braided hair, and as I looked more closely I realized that she was dead. There were flies on her legs and she was one of the ones that couldn’t be removed. So to have so many deaths that you can’t even keep up with burying the dead is just a horrific situation.
Frieden warned Sirleaf that bad as the situation was it was “going to get worse very quickly” and that if she wanted to get to grips with the epidemic she needed to put Ebola management on a professional footing. He also advised her to engage with communities, as there was no possibility that extra bed capacity could be provided quickly enough. On his return to the United States, Frieden briefed President Obama, telling him that the epidemic was even worse than he had feared. He then issued a statement to reporters in which he compared the WHO’s lackluster response to Ebola to the foot-dragging he’d witnessed during the early years of AIDS. By now, Liu had also decided to up the ante. In an emotional address to the UN in New York on September 2, she decried the “coalition of inaction” and warned that severing links with the affected countries in the hope that the epidemic would burn itself out was not a solution.
To curb the epidemic, it is imperative that states immediately deploy civilian and military assets with expertise in biohazard containment. . . . To put out this fire, we must run into the burning building.
At this point, there had been nearly 1,400 probable and confirmed cases of Ebola in Liberia and nearly seven hundred deaths. However, with new infections doubling in Liberia every fifteen to twenty days, and Sierra Leone not far behind, CDC disease modelers were predicting the two countries could see as many as 16,000 cases by the end of September. In the absence of additional interventions, and extrapolating from existing behavioral patterns, by the new year the situation could be catastrophic, according to the CDC, with as many as 550,000 cases across Liberia and Sierra Leone, or 1.4 million when corrected for underreporting. “Something is different in Monrovia,” MSF’s Armand Sprecher told a reporter from the New York Times in August. “We’ve never seen this kind of explosion in an urban environment before.”
Just at the point when it seemed the situation in Liberia could not get any worse, it did. August is monsoon season, and as the rains fell on the graves of hastily buried Ebola victims, the dead began floating to the surface. The sight of the decomposed corpses sparked outrage, prompting Sirleaf to institute mandatory cremations. Although cremations are deeply offensive in Liberian culture, this time Liberians acquiesced. “People accepted it and it didn’t cause any riots,” said Kevin De Cock, the head of the CDC’s mission to Liberia. “There was some resistance, but basically it was done.”
Then came another surprise: people stopped touching one another. At first this sudden behavioral change astonished De Cock and other Western observers, but when they thought about it later it made sense. As Bruce Aylward, assistant director-general for polio and emergencies, argued, it was precisely because in Monrovia the crisis had been so extreme and the WHO’s failure so marked that the behavior change happened there earliest: