by Reid Wilson
The team asked about hollowed out trees, where a colony of bats might live. Grudgingly, villagers told them about one such tree, a few meters from the outer ring of homes. They had burned it just days before, when Guinea’s government told villagers that bush meat was to be avoided.
The tree had been home to a colony of bats, and after Emile got sick, it had become a source of suspicion. Both of those facts were important clues to Leendertz’s team. While no one has ever isolated live Ebola virus in bats, scientists strongly suspect certain species of the flying mammals are Ebola’s reservoir host. They cannot say it without rigorous scientific proof, but few virologists and epidemiologists think something other than a bat might be harboring Ebola in between human outbreaks.
After burning the tree, villagers had collected enough dead animals to fill an entire rice bag with corpses. And while the animals were gone, Leendertz was able to collect soil from nearby, which contained enough genetic material to allow him to identify the species of bat that inhabited the tree—Angolan free-tailed bats, Mops condylurus, an animal with a massive range stretching from Liberia to Somalia all the way to South Africa. It was not enough to prove that the insect- and fruit-eating bats were responsible for Emile’s illness, but their presence was a telling clue.
About an hour outside of Monrovia, Randy Schoepp began thinking about home. After almost a decade spent traveling between his home in Frederick, Maryland, and Sierra Leone to study Lassa fever, Schoepp’s team had redeployed to a small HIV clinic, where they converted several rooms into a highly secure testing lab. To stay clear of the technicians in the rest of the clinic, Schoepp took over a four-room suite on the second floor, in the very back, far enough away, he hoped, to avoid exposing anyone to blood samples that might be teeming with the virus.
In those early days, few organizations had the capability to test blood samples for the Ebola virus; Schoepp, using a hugely expensive device about the size and shape of a large coffee machine, could. Carefully, Schoepp’s team trained five Liberians in the delicate art of operating in level-four conditions, burdened by hefty space suits that rang with the deafening tone of air being pumped in. Encumbered as they were, the technicians learned to process a potentially infected blood sample, pulling out and isolating RNA, then binding it to one of the assays that would allow the coffee pot machine to show whether Ebola was present.
But by the time he had arrived, Schoepp wondered if he was too late. After a month in the hot zone, Schoepp’s team had received thirteen samples to test. They were all negative, free of the virus.
“Maybe we missed it. Maybe this was the end of it,” Schoepp thought.
Schoepp boarded a commercial airliner, connected in Europe, and landed at Washington’s Dulles International Airport, still about an hour from his home near Fort Detrick. He had barely cleared customs when a text message made his phone vibrate. It was one of the Liberian technicians with an urgent message: You need to come back. Something has happened.
The bad luck of the early phase of the outbreak was that the Ebola virus had jumped an international border, from Guinea to Liberia. The miracle was that it had not jumped other borders, into Sierra Leone or Côte d’Ivoire, two neighboring nations where tribal connections were thicker than any relationship with far-off national governments.
But on May 23, just a day after Liberia had been deemed free of the virus, a pregnant woman arrived at the government-run hospital in Kenema, Sierra Leone, the very hospital where Schoepp’s team and Garry’s team had conducted their Lassa tests. She showed signs of being sick.
Robert Garry had been traveling to Sierra Leone for ten years, ever since Tulane won an NIH grant to work on Lassa fever in 2005. Over that time, the trip from Freetown to Kenema had been cut from a grueling twelve-hour slog over roads no wider than an alley to a relatively easy three-hour trip, over more modern roads built by Chinese and Italian investors. Garry’s hunch had been that previous work he had done, developing tests to seek out the HIV virus, would apply to Lassa. In Kenema, the heart of Lassa’s endemic territory, Garry’s tests had been so successful that they had branched out and begun testing assays that would identify another hemorrhagic fever, Ebola.
When the young pregnant woman with flu-like symptoms showed up, the head of Kenema’s Lassa unit, Dr. Sheik Umar Khan, knew he might be looking at his country’s first Ebola case; after all, the hospital is just a few miles from the border with Liberia, where the disease had only just been stamped out, and a short drive from the border with Guinea, where cases were still present. Khan had years of experience with hemorrhagic fevers himself, and he knew what to do. He donned a full-body protective suit, a head covering made of strong white Tyvek fabric, a breathing mask, a face shield, goggles, and two pairs of surgical gloves. Over that, he added a pair of rubber gloves, high rubber boots, and a plastic apron.
Khan drew the woman’s blood, then sent it to Schoepp’s old lab for testing. When the results came back positive the next day, he placed the woman in isolation. Though she lost the baby, miraculously, Sierra Leone’s first Ebola victim recovered.
Virus trackers raced to the scene to interview the woman. They had to know: Where had she come from? Where might she have contracted the virus? What they learned was shocking. The patient had attended a funeral for a local healer, a woman who said her traditional remedies and incantations, and the snakes she placed on the bodies of the sick, could cure the mystery disease raging through the Forest Region. The healer had tended to many Ebola patients, and after so much contact, she too fell ill. On April 8, the healer died.
Hundreds of mourners had participated in her funeral across the border, in a predominantly Muslim district of Liberia. The village where she had died was just a few hours from Kenema, over bumpy roads, but close enough that doctors knew they could expect a wave of new cases. A subsequent investigation traced an incredible 365 deaths from Ebola to the faith healer’s funeral; the first 13 Ebola victims in Sierra Leone had all attended her funeral.8
But the doctors were optimistic that they could stem the tide, if they worked quickly and aggressively to track new cases. Garry sent his two teams of four investigators each north to the Kailahun District, and the town of Koindu, just across the border from the outbreak’s epicenter, in their old but rugged vehicles.
The reports those teams sent back quickly deprived Garry of any hope that the virus had been contained. The investigators found whole villages that looked like something out of a zombie movie. The villages were decimated, bodies lying in the streets, the sick and dying were everywhere. One team found a home containing six dead bodies.
Soon, some of those infected followed the pregnant woman to Kenema. Their instincts were right; the hospital was the only facility in West Africa with a dedicated isolation ward, albeit one initially designed to treat patients with Lassa fever.
“The cases just started to come. It was apparent there had been a lot more cases up there,” Garry said.
But a hospital in West Africa, even one equipped with a hemorrhagic fever isolation ward, is hardly what Westerners would consider a suitable medical facility. “We wouldn’t even call it a hospital,” Schoepp recalled of his old office. “We would call it a group of sheds that happen to have some very poor medical equipment.”
Kenema’s hospital had enough beds to handle about two hundred patients. It was made up of low cinderblock buildings, all of which were just one-story tall. The various wards—a maternity ward, separate wards for treating men and women, a converted administrative building that served as the Lassa ward—were spread out across the small campus, fenced in on all sides. Construction was begun on a new, more modern Lassa ward, which would house forty-four beds, three times the size of the current unit. That current unit was tiny; it held only seven beds, enough space for fourteen patients, if they shared beds.
Almost immediately, the hospital was overwhelmed. WHO statistics tell the sterilized story: A report on May 27 shows one confirmed case of Ebola, the pregnant
woman. A report from the next day, May 28, shows sixteen cases—more than the total outbreak so far in Liberia. Five days later, there were fifty cases, then eighty-one in another three days, most of them at Kenema. The numbers do nothing to convey the sorrow, the horror, of a hospital ill-equipped to handle the onslaught. Patients soon lined the hallways, moaning in pain and delirium into the night. Without the same protective measures Khan had taken, nurses began to fall ill. Within just a few weeks, twelve had died.
Cases soon popped up in Kailahun, a district capital near the intersection of Sierra Leone, Guinea, and Liberia. Then the first resident of Freetown, Sierra Leone’s capital city, population nearly a million, showed symptoms. Across the border, new patients were falling ill in Guinea, and then in Liberia. In the final week of May, the number of cases in Guinea shot from 258 to 281. By the first week of June, the case count rose to 344.
In Liberia, cases began rising, too. A few weeks after he had returned to Monrovia, deVries received a call from Tamba Boima, a Liberian Ministry of Health official he counted as a close friend. Boima had traveled north, to Lofa County, on the border with Guinea. Ebola had reemerged in Voinjama, Lofa’s capital, a city of 270,000.
“You’ve got to come back,” Boima told deVries. “We need to do another [public education] program.”
The neat bell curve that was supposed to map out Ebola’s decline was suddenly trending back upward. Something had happened; even as Liberia was declared virus-free, even as Guinea’s trajectory looked so promising, someone—more accurately, everyone—had missed a sign. The virus hunters who had gone home in early May now turned around, packed their bags once again, and boarded flights back to a much more complicated situation than they had left behind.
Ebola had found new fuel.
FIVE
Roaring Back
THE FAMILIAR CURVE THAT showed the Ebola outbreak subsiding in May 2014 allowed epidemiologists and virologists the chance to breathe, to rotate home and see families after a harrowing month. It allowed the world to turn its attention to the seemingly endless crises elsewhere: the annexation of Crimea by Russian forces, the perilous debt crisis that threatened Greece, and with it the future of the eurozone, the devastating civil war in Syria, and the growing threat of a particularly aggressive jihadist group that, by the end of June, would declare itself the Islamic State, all vying for space among the headlines.
But the health workers who had been closest to their colleagues and friends in Guinea, Liberia, and Sierra Leone began to hear reports in increasing numbers that the downward trend in Ebola cases was reversing itself. The disease was once again on the march.
Soon, doctors who had remained behind or rotated in to take their own shifts were overwhelmed. It was like being in a giant whack-a-mole game, where the moles popped up too fast. In late May and early June, new cases emerged in Conakry, Guinea’s capital; in Telimele, in central Guinea; and in the tiny town of Boffa, along one of Guinea’s main highways north of the capital. In the Forest Region, fifteen new cases emerged in the final week of May.
“There was an impression that [Ebola] had been contained,” said Amy Pope, President Obama’s deputy national security adviser who would be intimately involved in the American response. “So then when it became clear that there was a pretty significant outbreak in the Forest Region, it kind of caught everybody by surprise.”
On his way home to New Orleans in early June, Robert Garry stopped in Washington to raise the alarm. A soft-spoken man with a bushy mustache, Garry hunches over; he has a tendency to chuckle in uncomfortable situations. This situation was less uncomfortable than it was urgent: the outbreak was rebounding.
Garry found a receptive audience at the National Institutes of Health (NIH), where several of his longtime colleagues shared his anxiety. But his reception at other federal departments—the Department of Health and Human Services, the State Department, the United States Agency for International Development (USAID)—was less accommodating. The humanitarian experts Garry met with were polite, though they made clear they did not share his urgency. Several of those experts told him that the World Health Organization (WHO) was insisting everything was still under control.
Garry wondered where WHO was getting its information. In June, a single WHO doctor, Tom Fletcher, had showed up at the Kenema hospital. He told Garry he had taken the initiative to travel to West Africa on his own; his agency had not sent him.
The challenge health workers faced was evident hundreds of miles to the east, where Harisson Sakilla worked as a principal at a mission school in Liberia’s Foya district, at the crossroads where all three countries meet. In late May, according to a UNICEF diary, the thirty-nine-year-old got word that his mother had fallen ill at her home in Kpondu, across the border in Sierra Leone. Assuming she had malaria or some other common disease, he walked two hours down a dirt path to care for her. Finding her too weak to seek treatment on her own, Sakilla took a canoe across the Makona River into Guinea to another village where he could buy drugs. Within a single day, one man had set foot in all three countries, without once encountering anything resembling a border control operation.
Sakilla cared for his mother for three more days, as she alternately writhed in delirium or sat, glassy-eyed and nearly comatose. As she lay close to death, Sakilla returned to his own village in Liberia to buy the material in which she would be buried. At her funeral, Sakilla watched as his mother’s body was washed, clothed, and wrapped for burial. He may have been one of the dozens who kissed her body, a traditional lament in West African funerals. For three more days, he and his relatives grieved over their loss.
On the fourth day, on his walk home, he felt ill. His joints were weak, his body wracked by fever. He had diarrhea, and a walk that ordinarily took two hours stretched to an agonizing four. Days later, Sakilla went to a new Ebola Treatment Center in Foya, run by Médecins Sans Frontières (MSF), where he was the first patient to be admitted. After more than a month of treatment, at times teetering between life and death, watching those around him carted in on stretchers and out in body bags, Sakilla walked out with a certificate issued by Samaritan’s Purse showing he was free of the disease. As he walked back to his home, his wife ran down the dirt path outside their house, shrieking with joy. Harisson embraced his six children; their father had survived.1
But Sakilla’s story was rare. After his mother died and as he lay fighting for his own life in the treatment center in Foya, Harisson had lost his father, his sister, his older brother, a niece, and the niece’s daughter.2 The pattern repeated again and again across all three countries, while the world was otherwise distracted.
By the time Randy Schoepp arrived back at the HIV diagnostics clinic outside Monrovia, he could plainly see that the atmosphere was different. After the Liberian technician had texted him to ask him to return, Schoepp had spent only a week back home, before reboarding a flight bound first for Europe, then for Monrovia.
On his first deployment to Liberia, the 13 samples Schoepp had tested had come back negative. When he returned, almost all tested positive. And at the rate at which samples were arriving at the lab, the team began working furiously, around the clock, just to keep pace. First they were processing 15 to 20 samples a day, then 30 or 45. By the late summer, they reached a capacity of 120 or more every day. The samples arrived at all hours of the day and night, in boxes packed in delivery trucks or on the backs of motorcycles. They were handed off to a technician on the ground floor of the two-story facility, then taken upstairs to the windowless, oppressively hot four-room suite where diagnostics tests could be run, as far away from everyone else in the building as the technicians could hide themselves.
The technicians, dressed in head-to-toe personal protection equipment, would carefully unwrap the package in what virus hunters call a “gray” room, a space where one had to assume that Ebola was present, and therefore had to take precautions when entering and exiting. The technicians would remove any paper that had come along with the s
ample—patient details like names, ages, genders, treatment center locations—and disinfect the paper. The sample itself was taken next door, to an extraction room, the dirtiest room, where one was most likely to encounter Ebola, in the suite. Transferred to a glass tube, the sample would then proceed to a third room, where it would be combined with the assay, the chemical compound designed to show whether Ebola was present. The assay had come from another room, the fourth and cleanest—most likely to be Ebola-free—in the suite.
In the third room, Schoepp stared at the computer screen for hours on end, waiting for each result to come back. Seemingly every sample revealed the same answer: Positive. Positive. Positive.
As so many cases emerged, virtual death sentences for those infected, Schoepp thought back to an episode of MASH, in which one of the American doctors serving in Korea is asked whether he sees the faces of the men he treats. No, the doctor replies, he just sees a blur. Anything more would be too much for one soul to take. Schoepp searched for his own coping mechanisms.
Even then, relief was scarce. In many instances, a well-organized medical response will code patients, assigning them numbers to avoid confusion that might come with keeping track of often-similar names. But in Liberia, the samples that crossed Schoepp’s desk were attached to actual names and the villages where they were being treated. In the course of those chaotic weeks, from his vantage point sometimes hundreds of miles away, Schoepp watched entire families, entire clans, entire villages come down with Ebola. One family in particular stuck with him: it was a family of seven, from a predominantly Muslim village in northern Liberia, that had attended a funeral. Their samples arrived together: six of the seven tested positive. The only one that turned up negative was the youngest child, five years old, who had been too young to take part in the funeral rites.