by The Pandemic Century- One Hundred Years of Panic, Hysteria
Suddenly the entire Monrovia knew Ebola was real—Ebola kills. Ebola’s going to kill me unless I do one or two things differently. There was a huge fear and people didn’t know what this was. They wouldn’t know a virus from a bacteria from whatever, but they knew we had to do something differently. . . . The first thing you do in that kind of overwhelming fear is you retreat, and they changed their behaviors in ways which suddenly slowed down and took the heat out of this thing.
Similar behavioral shifts also occurred spontaneously in Sierra Leone around the same time, particularly in Kailahun and Kenema, the two districts that had been hit earliest and hardest by Ebola. Elsewhere, however, resistance to the Ebola control measures persisted. Noncompliance was a particular problem in the Western District, the area that includes Freetown and its extra urban sprawl, and Port Loko, a 2,000-square-mile district to the north of the capital scored with swamps and rivers. For instance, in March 2015, shortly before Liberia released its last Ebola patient from the hospital, a fisherman infected with Ebola evaded government contact tracers and persuaded three colleagues to ferry him to a remote island in the Rohmbe swamps within sight of Lungi airport. There, he consulted a traditional healer before continuing by sea to Aberdeen, a township on the outskirts of Freetown, where he alighted at Tamba Kula wharf, a stone’s throw from the Radisson Blu Yammy, the city’s premier luxury hotel. By now the fisherman was a walking virus bomb, and on disembarking he made straight for an Oxfam-built toilet block where he vomited hemorrhagic fluids. As a result, twenty villagers in Tamba Kula were infected with Ebola, prompting the authorities to quarantine the Aberdeen community for twenty-one days. In theory that should have been the end of the transmission chain, but despite the best efforts of contact tracers, one of the men who had accompanied the fisherman by boat got away, hitching a ride on a motorcycle to Makeni, three hours’ drive from Freetown, where he infected three more people, including a local healer. All four were eventually traced and taken to a nearby Ebola treatment center. However, once there, they refused medical care, fearing that staff were trying to murder them with what the healer called their “Ebola guns”—a reference to the hand-held electronic thermometers used to measure patients’ temperatures.
In an attempt to eliminate the last hot spots of infection, the government launched a public health campaign under the Krio slogan, “Leh we tap Ebola (Let us stop Ebola).” At the same time, officials met with local paramount chiefs and asked them to use their authority with village headmen to pass on information about suspicious behavior. However, while in many parts of the country this reporting system was successful, in Port Loko there were several cases of village headmen concealing Ebola patients and turning a blind eye to secret burials. The result was that in Sierra Leone, unlike in Liberia, there was no spontaneous behavior change and sudden decline in cases: instead, the outbreak persisted into the summer of 2015.
In the end, what made the difference was the mobilization of additional resources by the international community. On September 19, 2014, in recognition of the security threat posed by the ongoing outbreak, the UN secretary general established the United Nations Mission for Ebola Emergency Response (UNMEER) to scale up the response and coordinate the delivery of logistical and technical support to the Ebola zone. It was only the second time in history that an infectious disease outbreak had been debated on the floor of the UN—the first time had been AIDS in 1987—and it had a similarly galvanizing effect. President Obama pledged to send 3,000 troops to Liberia, and by the end of the year the US Congress had agreed to emergency funding of $5.4 billion for Ebola, more than had previously been allocated for any EID. The result was that by March 2015, Britain, France, and the United States had mobilized significant military assets, and thousands of health workers and contact tracers from more than twenty countries were on their way to West Africa to assist in the “getting to zero” drive. Nevertheless, it would take a further year for the WHO to certify the end of the epidemic. In all, Ebola had sparked nearly 29,000 infections, 11,300 of them fatal. It was the worst outbreak of the disease in history, but while five countries in West Africa had been affected, the Armageddon scenario of a pandemic had been averted.
LIKE SARS, the Ebola epidemic drove home the risks that the emergence of novel pathogens in previously remote regions posed in an increasingly interconnected world. The West African outbreak was exactly the sort of scenario that had been envisaged by the Institute of Medicine in the early 1990s when it warned of the dangers that the growth in international air travel and commerce posed for the spread of EIDs. These risks had been brought home to Americans first by the arrival of Patrick Sawyer in Lagos, and secondly, by the presentation in September 2014 of another Liberian national infected with Ebola at a hospital in Texas. Thomas Duncan had walked into the Emergency Department at Dallas Presbyterian Hospital on September 25 complaining of abdominal pain and nausea, but despite his telling staff that he had recently visited Liberia, no one thought to screen him for Ebola and he was sent home with Tylenol and a course of antibiotics. For three days, the forty-two-year-old lay feverishly ill at a friend’s apartment in Dallas, before being picked up by paramedics and returned to the hospital on September 28. It was only then that Duncan was tested for Ebola. Unfortunately, by now he was vomiting copious fluids and was highly contagious. He died ten days later, having infected two nurses.
Like the 9/11 attacks, the Duncan case exposed the porosity of American airspace and the United States’ vulnerability to exotic pathogens which, thanks to commercial air travel, could be in any city on the globe within seventy-two hours. Little surprise then that even before Donald Trump began calling for bans on Ebola patients and health workers returning from abroad, the inquests had started. Most people blamed the WHO. There was a clear lack of direction and “vacuum of leadership” at the highest levels of the UN organization, concluded Christopher Stokes, the general director of the Brussels branch of MSF, a year into the epidemic. “Instead of limiting its role to providing advisory support . . . the WHO should have recognized much earlier that this outbreak required more hands-on deployment.” Dame Barbara Stocking, the chair of the Ebola Interim Assessment Panel, the independent panel of experts tasked by the WHO with examining its response to the crisis, was similarly scathing. Finding that the Ebola epidemic exposed shortcomings in both the WHO’s functioning and the operation of the International Health Regulations, she argued that what had been needed was “independent and courageous decision-making” by the director-general and the WHO Secretariat—qualities that had been notably “absent” in the early months of the crisis.
But if the WHO was at fault, then so were other organizations. For instance, in March 2014 the CDC had dispatched one of its top Ebola experts, Pierre Rollin, to Guinea. The deputy head of the CDC’s Special Pathogens branch, Rollin is a veteran of several Ebola outbreaks and an affable Frenchman with a talent for putting the Science of filoviruses in layman’s terms. Frieden hoped that as a French speaker Rollin would establish a rapport with Guinea’s president Alpha Condé and convince him to extend an invitation to the CDC to assist with surveillance and control efforts. Rollin did not disappoint, quickly persuading Condé he needed the CDC’s help and that it would be counterproductive to close Guinea’s borders. Next, he set up an information management system to log cases and trace contacts who may have been exposed to the virus. For most of the five-and-a-half weeks he was in Guinea, Rollin stayed in Conakry, the better to monitor cases at Donka Hospital, but he also found time to tour prefectures close to the capital and dispatch staff to Guéckédou to report from the epicenter of the outbreak. By the end of April Conakry had not seen a new patient in over a week, and Rollin noted that cases had also slowed to a trickle in Guinea-forestière. Sierra Leone, meanwhile, had yet to report any cases, while Liberia had not seen a case in four weeks. As far as Rollin was concerned, the job was done. Returning to CDC headquarters in Atlanta on May 7, he recalls thinking to himself, “It looks like, smells like, t
astes like regular outbreaks in previous areas.”
However, by the fall of 2014 as Ebola spread to Liberia and Sierra Leone, prompting border closings and the suspension of international flights by panicked airlines, Rollin was desperately backpedaling. “It was an unprecedented outbreak; it never happened before,” he told the New York Times in December. “There were a lot of things we didn’t know at that time. No one could have imagined that it would be what we have now.” Peter Piot, director and professor of global health at the London School of Hygiene & Tropical Medicine and a veteran of the original 1976 Yambuku outbreak, was similarly humbled by the experience. “Together with the Swiss Franc this was probably the Black Swan event of the last 12 months,” Piot informed global health policy makers gathered at the World Economic Forum in Davos on January 21, 2015, two weeks after Switzerland’s surprise announcement that it was abandoning the cap on the franc to allow the Swiss currency to float against the Euro. “It was totally unanticipated and we could not have predicted what would happen based on the experience of the previous thirty-seven years.”
What was it that had so blinded these experts to the risks posed by the outbreak in Guinea-forestière? And why, even as Ebola spread across the border to Sierra Leone and Liberia, threatening urban outbreaks, were health agencies so slow to respond?
There are several answers to those questions. One is that while Ebola had previously been amplified in hospital settings and, on occasion, had sparked urban outbreaks, those outbreaks had been rapidly contained by the institution of strict barrier nursing controls and the isolation of infectious contacts. Another is that while books like The Hot Zone had reinforced the impression of Ebola as a highly unstable and virulent virus, by the turn of the millennium the concerns that Ebola might mutate into an “Andromeda strain” were diminishing. This was because for all that the reservoir of the virus was unknown, each of the five identified subtypes showed a high degree of genomic stability. Moreover, while the Yambuku outbreak had seen case mortality rates as high as 90 percent, in Kikwit the mortality rate had been 78 percent, while in an outbreak in Gabon the following year the mortality rate had been 57 percent. Clearly, for all the concerns about Ebola’s virulence, infection was not an automatic death sentence. Indeed, in the two dozen outbreaks of Ebola in Africa prior to 2013, the virus had been responsible for a total of just 2,200 infections and no single outbreak had caused more than four hundred deaths. Compared to AIDS or more widely prevalent tropical diseases such as malaria, this made Ebola more of a security risk than an urgent public health threat.
Unfortunately, the experts had forgotten the importance of social behaviors and deeply entrenched cultural practices, such as the consumption of bushmeat and people’s adherence to traditional funerary rituals. Nor had they factored in the mobility of local populations living at the border of three countries or the fact that new highways had greatly reduced travel times to urban areas. Nor had they considered the impact that the widespread distrust of foreigners and government elites might have on the willingness of affected communities to accept that Ebola was real, and not a hoax. No doubt there were other reasons too: in the early days of the epidemic, the absence of laboratories in West Africa capable of testing for Ebola had been critical, as had the Guinean government’s insistence on only counting laboratory-confirmed cases. Nor had medical research agencies and pharmaceutical companies shown much interest in conducting safety studies of Ebola vaccines and drugs that had shown promise in animal models, much less in advancing the medications to license. Instead, ZMapp and other experimental medical products had languished on the shelves of biotech companies.
The absence of doctors and nurses trained and equipped to handle Ebola, plus the fragmentation of health systems due to chronic underinvestment and civil war, also played a role. But perhaps the biggest lesson of the West African Ebola epidemic was that Zaire ebolavirus had most likely been circulating undetected in the tri-border zone for years. Indeed, the strain that sparked the outbreak—known as the Makona variant—was all but identical to strains isolated in previous outbreaks in Central Africa (in the language of viral genomics, the subtypes were 97 percent homogenous). Moreover, phylogenetic analysis suggested that the outbreak had been triggered by a single spillover event, a finding consistent with the epidemiological evidence and reports that the index case had originated in Meliandou in December 2013. There was one other intriguing finding: the Makona variant had diverged from other Zaire ebolavirus variants only about a decade earlier. This suggested that it was a relatively recent introduction to West Africa. Little wonder then that when medical researchers discovered that some local people presenting for Lassa also carried antibodies to Ebola, no one gave the report much attention.
The question is, how did Zaire ebolavirus get all the way to Guinea and why Guéckédou? Introduction from a human traveler seems unlikely: there is little regular travel or trade between Central Africa and Guéckédou, and the town is a twelve-hour drive from the nearest international airport at either Conakry, Freetown, or Monrovia. The more likely culprit is a fruit bat. Besides the hammer-headed fruit bat, Hypsignathus monstrosus, the leading candidates are Franquet’s epauletted fruit bat, Epomops franqueti, and the little collared fruit bat, Myoncyteris torquata. These bats are common across sub-Saharan Africa, including Guinea, and some are thought to be capable of migrating long distances. Perhaps a wayward fruit bat introduced the virus to Guinea-forestière, from where it spread to local bat populations, including the colony of Mops condylurus sheltering in the tree stump in Meliandou. As for why Guéckédou, one need look no further than the clearance of formerly forested areas by loggers and farmers. Clear-cutting in particular has had a devastating impact, driving bats from their roosts and forcing them ever closer to human habitations.
Finally, why did the outbreak occur in 2014 and not earlier? Without further ecological investigations and a better understanding of Ebola transmission patterns and where the virus goes between outbreaks, it is difficult to say. However, several observers noted that the outbreak coincided with the beginning of the dry season in Guinea-forestière, prompting speculation that the drier conditions may somehow have influenced the number or the proportion of infected bats in the region—presuming, of course, that bats are the reservoir of Ebola—and the frequency of their contact with humans. Or perhaps Emile and his friends had a knack for extracting the lolibelo and were simply unlucky.
* Filoviruses belong to the family Filoviridae and take their name from the Latin word filum, meaning filamentous, a reference to their elongated filamentous structure.
† Unfortunately, the order did not extend to the airport, resulting in the boarding of a plane to the Congolese capital by a thirty-one-year-old female patient. Once there, it was only her rapid isolation in a private clinic and strong disease surveillance measures that prevented the virus from spreading to other parts of Kinshasa.
‡ The term is commonly pronounced “pike” or “fake.”
§ The war game exercise uncannily presaged the 2013–2016 Ebola epidemic, imagining an outbreak at the border of three fictitious equatorial countries where civil war had led to a dangerous concentration of refugees living in unsanitary border encampments.
CHAPTER IX
Z IS FOR ZIKA
“The ideal is to think globally and to act locally.”
—RENÉ DUBOS, “The Despairing Optimist,” American Scholar (1977)
Recife in northeastern Brazil is a city of contrasts. Take a stroll along the grand Haussmann-style boulevards that radiate from Recife’s renovated harbor area and you could be in Paris. The sense of dislocation increases as you board a catamaran on the Rio Beberibe and sail past the brightly painted baroque buildings that line the waterfront of Santo Antonio, the city’s historic center. With its network of canals and ornate churches and monasteries dating back to the colonial period, Recife rightly calls itself the “Venice of the South.” Built with the profits of the seventeenth-century sugar trade, it is
a monument to the ingenuity and vision of the original Portuguese and Dutch settlers. However, first impressions can be misleading, and as you turn your back on the lavishly gilded Capela Dorada and head west toward Boa Vista, you enter a world of modern apartment buildings and outsized shopping malls, and, in the gaps and crevices between, the places the poor call home.
Like other cities in Brazil, Recife (pronounced “her-see-fey”) is infamous for its favelas and urban slums. They hug the highways running parallel to the coast and encroach on the canals that feed into the Beberibe and other tributaries that drain from what used to be a massive mangrove swamp. One of the largest, Jaboatão dos Guararapes, lies south of the seaside resort of Boa Viagem, a five-mile stretch of prime beachfront lined with international hotels and luxury condominiums.
It was here that in 2015 Brazilians awoke to a disturbing new reality. In August of that year several women from Jaboatão dos Guararapes and adjacent communities gave birth to babies with an unusual congenital syndrome. The infants had normal faces up to the eyebrows, but virtually no foreheads, and when pediatricians ran a tape measure around their heads they found they were far smaller than normal, less than 32 centimeters, and in some case as small as 26 cm (a typical newborn’s head measures 35 cm). Many of the babies cried continually, as if they were in constant pain, and could only be comforted by being bathed in warm water or by resting their stomachs on pilate balls. Others had trouble focusing on their mothers’ faces, while the worst affected were racked by seizures and spasms and had grotesquely twisted limbs and clubfeet.
One of the first physicians to recognize the new syndrome was Vanessa van der Linden, a neuropediatrician of Dutch descent who practices at Hospital Barão de Lucena, a public hospital in the northeast of the city. In early August, van der Linden examined a pair of twins. One of the boys had a severe case of congenital microcephaly, and when van der Linden ordered a CT scan she was alarmed to see that instead of having the usual walnut formation, the child’s brain was smooth and white, with calcified patches marring the cortex. “I’d never seen anything like it,” she said. The boy’s mother recalled that in the first month of pregnancy she had developed a rash, but nothing that was overly concerning. Puzzled, van der Linden ordered tests for rubella, syphilis, and toxoplasmosis, a parasite harbored by cats that is extremely common in Brazil and which, like rubella and syphilis, is known to be associated with congenital birth defects, but all the tests were negative. Next, she looked for genetic mutations, such as Down’s syndrome, but again the tests were negative.