by Reid Wilson
EPIDEMIC
Ebola and the Global Scramble to Prevent the Next Killer Outbreak
REID WILSON
BROOKINGS INSTITUTION PRESS
Washington, D.C.
Copyright © 2018
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Library of Congress Cataloging-in-Publication data are available.
ISBN 978-0-8157-3135-1 (cloth : alk. paper)
ISBN 978-0-8157-3136-8 (ebook)
9 8 7 6 5 4 3 2 1
Typeset in Electra
Composition by Westchester Publishing Services
For Veronica and Max
my two inspirations
Contents
Cast of Characters
Preface
Introduction
1 Emile
2 A Mysterious Killer
3 Into the Fight
4 A Turning Point
5 Roaring Back
6 Death of a Hero
7 Lagos
8 The Samaritans
9 A Call for Help
10 70–30
Photo Section
11 Darkest Days
12 Deployment
13 Dallas
14 The Ebola Czar
15 Panic and Quarantine
16 The Obama Phones
17 The Burial Teams
18 A Waning Tide
19 Medicine without Borders
20 The Next Outbreak
Acknowledgments
Notes
Index
Cast of Characters
In Washington
Barack Obama President of the United States
Chris Coons Senator from Delaware; member of the Senate Committee on Foreign Relations
Anthony Fauci Director of the National Institute of Allergy and Infectious Diseases
Ron Klain U.S. ebola response coordinator; former chief of staff to Vice President Biden
Jeremy Konyndyk Director, Office of U.S. Foreign Disaster Assistance, U.S. Agency for International Development
Amy Pope Deputy homeland security adviser, National Security Council
Samantha Power Ambassador to the United Nations
Susan Rice National security adviser
Rajiv Shah Administrator, U.S. Agency for International Development
Gayle Smith Senior director for development and democracy, National Security Council
In West Africa
Ellen Johnson Sirleaf President of Liberia
Alpha Conde President of Guinea
Ernest Bai Koroma President of Sierra Leone
Tolbert Nyenswah Assistant minister of health, Liberia; head of Incident Management System
Tamba Boima Director, Community Health Services Division, Ministry of Health, Liberia
Mosaka Fallah Epidemiologist and immunologist
Hans Rosling International health expert, Karolinska Institute
Sheik Umar Khan Head of Lassa Fever Program, Kenema Government Hospital
Robert Garry Professor of Microbiology and Immunology, Tulane University
Piet deVries Country director for Liberia, Global Communities
Brett Sedgewick Director of development services, Global Communities
George Woryonwon Global Communities
David Robinson Senior adviser for operations, World Vision International
Craig Spencer Médecins Sans Frontières (Doctors Without Borders)
Kent Brantly Samaritan’s Purse
Nancy Writebol Serving in Mission
David Blackley Epidemiologist, U.S. Centers for Disease Control and Prevention
Barry Fields Microbiologist, U.S. Centers for Disease Control and Prevention
Peter Kilmarx Ebola response team leader, U.S. Centers for Disease Control and Prevention, Sierra Leone; deputy team leader, U.S. Centers for Disease Control and Prevention, Guinea
Kim Lindblade Epidemiologist, U.S. Centers for Disease Control and Prevention
Joe Woodring Senior medical officer, National Center for Health Statistics, U.S. Centers for Disease Control and Prevention
Dan Martin Public health adviser, U.S. Centers for Disease Control and Prevention
Leisha Nolen Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention
Deborah Malac U.S. ambassador to Liberia
Darryl Williams Major general, commander, United States Army Africa
Gary Volesky Major general, commander, 101st Airborne Division
Ross Lightsey Lieutenant colonel, 101st Airborne Division
Tony Costello Major, 36th Engineer Brigade
Jeff Kugelman Captain, U.S. Army Medical Research Institute for Infectious Diseases
Michael Schmoyer Captain, U.S. Public Health Service
Fabian Leendertz Epidemiologist, Robert Koch Institute
In Atlanta
Tom Frieden Director, U.S. Centers for Disease Control and Prevention
Charlie Stokes President and chief executive officer, U.S. Centers for Disease Control and Prevention Foundation
At the U.S. Army Medical Research Institute for Infectious Diseases, Fort Detrick, Maryland
John Dye Chief of Viral Immunology
Brian Gentile Colonel, director of administration
David Norwood Chief of Diagnostic Systems Division
Randy Schoepp Virologist
Travis Warren Principal investigator, Division of Molecular and Translational Sciences
In Geneva
Margaret Chan Director-general, World Health Organization
Christopher Dye Director of strategy, Office of the Director-General, World Health Organization
Gregory Hartl Spokesman, World Health Organization
In Miami
Julio Frenk President, University of Miami; member, World Health Organization Ebola Interim Assessment Panel
Preface
THE OUTBREAK OF EBOLA Virus Disease began in 2013 in a small town in rural Guinea. From there, it spread to Liberia, then Sierra Leone, then across borders into Nigeria, Mali, Europe, and the United States. In the end, more than 28,000 people were infected, and 11,325 lost their lives. Dozens of organizations fought the disease, from global organizations like the United Nations and governments like that of the United States to nongovernmental groups like Médecins Sans Frontières, the Red Crescent/Red Cross, and Global Communities. Together, thousands of responders poured into
West Africa to aid the thousands more Guineans, Liberians, and Sierra Leoneans who took it upon themselves to save their own countries.
All those who helped save lives deserve recognition, but it is not possible to tell their stories in one place. Instead, my aim is to relate the broader story of the global response to the outbreak, with a special focus on the United States government’s work to combat Ebola, while shining a spotlight on the weak state of global health preparedness. While this volume’s goal is to be as comprehensive as possible, I am aware, regretfully, that many heroes of that period will be left out.
Dozens of sources were interviewed for this work over hundreds of hours, beginning even before the outbreak formally ended. The vast majority of those sources spoke on the record. In the few instances where those sources asked for anonymity to discuss sensitive topics, I have sought to provide as much contextual information about their identities as those sources would allow.
Introduction
TOM FRIEDEN FELT THE sweat dripping down his face in the oppressive humidity of equatorial Africa. Dressed in head-to-toe protective gear, peering through the plastic face mask, he struggled to come to terms with the scene of desperation as he walked through a hospital ward in the slums of Monrovia, Liberia’s capital. All around him, he gazed into the faces of the dying, dozens of patients suffering from a terrifying virus that melted their bodies from the inside.
As Frieden walked the aisles, he came to a fourteen-year-old boy sitting on a rickety wooden chair. The young man was barely conscious, a state that so often accompanies the end stages of this particular pathogen. It was clear he had just days, maybe only hours, to live. A bottle of liquid, rehydration solution, sat next to the boy. Frieden begged him to drink as much as he could.
A few beds down the row, Frieden met a young woman who had lived through her ordeal with the virus. She had cared for her husband when he got sick, cared for his body when he died, and she had survived the worst hell on earth after she came down with the virus herself. But the woman had a vacant stare that the lone doctor on the ward, Armand Sprecher, told Frieden had become a common trait among those who survived. It was not clear to doctors and scientists studying this deadly disease whether the stare was from shock, from fluid build-up that caused brain swelling, or from something else entirely. In previous outbreaks, so few people had actually survived that no one had a chance to study the aftereffects. “We see this in survivors and we don’t know what it is,” Sprecher told Frieden.
Amid the heat, the humidity, the moans of human suffering, Frieden saw another woman lying facedown on her cot. He was struck by her hair, woven into beautiful braids that must have taken hours of careful, loving work. Then Frieden noticed the flies on the woman’s legs. He realized she had died during the night, but her body had not yet been moved. A man next to the dead woman complained that the body was a risk to the rest of the patients struggling to survive. Sprecher explained to the man that they needed four staffers to move a body. Patients were dying too fast for the few remaining staffers to cart them off. Throughout the ward, sixty corpses lay among the living and the dying, waiting to be transferred to a crematorium that was working overtime to burn infected bodies. There was no one to remove the bodies, no one to clean the mess of blood and vomit and diarrhea that coated beds and floors. So many were ill that Sprecher and his dwindling team of nurses did not have time to put IVs into the patients’ arms.
Frieden and Sprecher are no strangers to human suffering. Sprecher works with Médecins Sans Frontières, known in the United States as Doctors Without Borders, where he spent a career fighting viruses in Uganda, Angola, and the Democratic Republic of the Congo before being deployed to Liberia. Frieden, the director of the Centers for Disease Control and Prevention in Atlanta, had responded to some of the deadliest disasters in the remotest parts of the world.
“I’ve worked in earthquakes, hurricanes, tornadoes. I’ve seen famine, I’ve worked in war zones,” Frieden said later, recalling his visit to the hospital in Monrovia. “I’ve never seen anything like that. I mean, it was a scene out of Dante.”
When Frieden returned to the United States a few days later, he called the White House, where he was patched through to President Obama. Frieden, agitated after a long transoceanic flight, told Obama what he had seen: the grisly makeshift hospital, three West African nations, already the poorest in the world, decimated by a virus that had claimed the lives of hundreds of health care workers and now left adrift without the help they so desperately needed to fight back. The World Health Organization, ostensibly the agency that was supposed to head the response, was so woefully overmatched for the task, Frieden told Obama, that a global spread of a deadly virus was possible, if not probable. The American government was the only actor with the capacity to stop what could become a global pandemic of an incurable disease.
The virus that raged from remote forest villages to crowded slums of major capitals is one of the most deadly pathogens ever discovered; in previous outbreaks, nine out of every ten people infected had died, often in gruesome ways. It is named for a small subtributary of the mighty Congo River, near the site where four decades ago villagers came down with a hemorrhagic fever that terrified the first Westerners to see it. That small subtributary is called the Ebola River.
By the time Frieden returned to the United States after his eye-opening trip, five months had passed since the World Health Organization had confirmed the presence of the Ebola virus in Guinea. Scientists would later discover it had actually been about eight months since the first victim, known in epidemiological parlance as Patient Zero, fell ill. Just weeks after Patient Zero died, Ebola had spread across the border to Liberia. After a brief moment of cautious optimism that the disease was under control, it appeared in Sierra Leone. Like a horrible feedback loop, the virus was now amplifying itself, and those few epidemiologists brave enough to put themselves in harm’s way were beginning to warn that the situation was spinning out of control.
In the forty years since scientists first identified the virus, Ebola had never reached a city of significant size. Now, Frieden and his counterparts in the global health community watched as Ebola reached three major cities at the same time—Conakry, Monrovia, and Freetown, capitals with populations reaching a million people packed tightly into poor and crowded slums. Those slums were ideal incubators for the highly contagious virus. More worrisome, that meant the virus had, for the first time in recorded history, reached cities served by daily direct flights to Europe and the Middle East. All the epidemic needed to become a pandemic was for the right person to buy a plane ticket.
Two realizations hit Frieden and his counterparts, Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, and Rajiv Shah, the director of the U.S. Agency for International Development. The first was that a combination of factors—dense populations and crushing poverty in massive slums, and the cultural funerary traditions that put family members in close contact with their deceased relatives—meant this outbreak, already the worst in recorded history, was unlike any they had ever seen. The second was that the global health community was woefully unprepared to respond and incapable of marshaling the resources necessary to stop it.
In West Africa alone, thousands, if not hundreds of thousands, of lives were at stake. Globally, millions could be at risk.
The days of an isolated outbreak of a contagious disease are over. Every city of any size, in the modern globalized world, is one connection away from Washington or New York or Beijing or Jakarta. Today’s outbreak in West Africa, if left unchecked, is tomorrow’s global pandemic. Someone had to fight Ebola in West Africa, to prevent a global outbreak that could threaten millions of lives.
Every fire starts with a spark. Every spark, under the right circumstances, can become a conflagration burning out of control, consuming everything within its path—a house, a forest, a people, a country.
The spark that landed in the unique tinderbox of West Africa was made of a f
ew strands of ribonucleic acid, a set of genetic code that, when it comes into contact with human cells, begins rapidly multiplying, searching voraciously for anything that can fuel its growth. The impacts on the human body can be horrifying to witness: bleeding, vomiting, diarrhea, a slow, painful, and violent death. All the while, the small flame is searching for its next host, and the fire spreads.
The Ebola outbreak that killed 11,325 people in West Africa over more than a year and a half was unlike any other epidemic the global health community had seen. Many of the dozens of people interviewed for this book use the same phrase to describe the conditions that contributed to its appearance and spread: the perfect storm.
The circumstances were seemingly tailor-made for a humanitarian disaster of epic proportions: the disease showed up in an area where it had never before appeared, where conditions for its rapid spread were aided by a combination of ancient traditions and modern transportation, all colliding in three desperately poor countries where the medical infrastructure was already teetering on the brink of collapse.
At the same time, the outbreak exposed a woefully inadequate global response network that was ostensibly supposed to find and fight deadly pathogens. After decades of bloat, international organizations had become so overburdened by bureaucracy and corruption that they could not possibly handle a disease of Ebola’s magnitude.
The story of the Ebola outbreak in West Africa is one of incredible lows and incredible highs, of terrible luck and unbelievably good fortunes. It is a story of countries consumed by terror, of politicians taking advantage of fear, and of heroes who ran toward the unfolding disaster, many of whom lost their own lives. It is a story of the past, with deep roots in colonial history, and of the future, with ramifications for the next time the world faces a deadly pathogen. And it is a story of dramatic innovation across the globe—ingenuity and creativity that saved tens of thousands, maybe hundreds of thousands of lives.
“When this is a movie,” said Gayle Smith, who oversaw the American response at the National Security Council, “people will say you overdid it.”