by Reid Wilson
At the same time that the DART members arrived, and while burial teams began operating in northern rural counties, the Liberian government was having trouble finding space to bury bodies in Monrovia. About 70 percent of all Ebola transmissions came from contact with dead bodies, which became festering cesspools of virus; finding a safe way to remove those bodies was essential, outbreak specialists knew, to ending the chains of transmission.
But early efforts to create a safe burial space ran into local roadblocks. When the Ministry of Health tried to bury thirty bodies at a site near Monrovia, they had to call in security officers to fend off nearby communities that did not want a cemetery in their backyards. Once the residents were gone, an excavator plowed a mass grave. But the ministry had picked a low-lying area at the peak of the rainy season. As the water table rose, it brought bodies floating back up to the surface. It was a major embarrassment for Sirleaf’s government, which was already straining to prove it could handle the crisis.
The Ministry of Health hit upon a new solution, one Sirleaf brought up to Coons in that early August phone call: they needed to burn the bodies to kill the virus.
But cremation is a foreign concept to most Liberians, for whom the ritual of preparing a body for the afterlife was an important cultural touchstone. The thought of burning bodies was unpopular with many Christian Liberians, and even more so with the significant Muslim population.
“The idea of burning bodies is unpalatable in Liberia,” deVries explained. “It doesn’t happen.”
It was so unusual that Liberia did not even have a crematorium capable of handling the bodies. Instead, they borrowed a facility owned by the Indian Embassy; for Hindus, cremation is a cultural tradition. On August 5, the Liberian government ordered every corpse in Monrovia to be burned.
Even then, the government proved to be unprepared, thanks in large part to woefully inadequate record-keeping. A major part of Liberian funerary tradition revolves around having a place to mourn the dead. At government-run Ebola treatment units in the city, however, ashes were put in barrels, with no record of whose remains were lumped together. Families that had worried about relatives going into an Ebola treatment unit and emerging as corpses now worried that they wouldn’t even have a corpse to bury and mourn. Patients who died at facilities run by Médecins Sans Frontières could count on excellent record-keeping, but it was cold comfort for those whose relatives died lonely, painful, frightening deaths.
The cremations also fed a growing sense that some victims of the Ebola virus were being treated differently than others, exacerbating tensions that had lingered since the nation’s devastating civil war between the governing elites—the descendants of freed American slaves—and the tribes that had lived in Liberia for millennia. Many governing elites continued to bury their dead, even though government policy explicitly called for cremations.
At one meeting of a committee dedicated to dead body management, held in a Ministry of Health conference room and attended by senior officials from MSF, Global Communities, the CDC, and the WHO, the woman who chaired the meeting told the shocked crowd of humanitarian responders she had just come from a funeral herself. The Liberian official in charge of enforcing cremations was violating the rule she was meant to enforce.
Zanzan Kawa, head of the Traditional Council of Chiefs and the highest-ranking tribal leader in Liberia, had tacitly accepted the need for cremations, but he sent a powerful message when he saw the different ways his people and governing elites were being treated: They’re not burning the elites, he said. They’re burning us.
The NGO community was unanimous in warning the Liberian government about the danger it was courting: You’re creating a disconnect between the elites and the poor, they told the government. That disconnect threatened to undermine the careful relationship that NGOs were building with the very poor, those who stood the highest risk of catching Ebola because of their close-quartered living conditions and lack of available hygiene. Without that foundation of trust, the NGOs warned, more people would go into hiding rather than seeking treatment, exacerbating the spread of the deadly disease.
On August 17, about two and a half weeks after the ELWA 2 hospital had collapsed under the weight of the two sick Americans, MSF once again stepped in to fill the breach. It opened a massive new clinic in Monrovia called ELWA 3—at 120 beds the largest Ebola management center ever built. Still, the facility was not big enough, and MSF doctors had to turn away clearly sick Liberians simply because there were no beds to hold them. Those who were sent away were given home protection kits to reduce the risk of infecting their families at home.
“The numbers of patients we are seeing is unlike anything we’ve seen in previous outbreaks,” an overwhelmed Lindis Hurum, MSF’s emergency coordinator in Monrovia, said just a few days later. “Our guidelines were written for an Ebola center with 20 beds, and now we are expanding beyond 120 beds.”7
Like its predecessors, the ELWA 3 facility did not resemble a Western hospital. Instead of brick and mortar, patients rested under a series of tents, donated by various government and nongovernment agencies. Fences made of rebar and door flaps separated red zones, where Ebola patients were quarantined, from safe zones, presumably free of the virus. Patients waiting to be admitted lounged under two tall trees outside the hospital; responders called them the Ebola trees.
Barry Fields arrived at the hospital a few days before it opened. Fields, a microbiologist by training, had been based at CDC’s Kenya office for three years. A few days after Kevin De Cock, head of CDC’s Kenya office, left to head up the agency’s response in Liberia, he called Fields and told him to pack his things. Liberia needed more diagnostic capability, and Fields had the equipment necessary to rapidly build up a laboratory for testing blood samples of potentially infected patients.
Initially, Fields and his colleague Heinz Feldmann, chief of an NIH virology lab at the Rocky Mountain Laboratories in tiny Hamilton, Montana, planned to set up their operation in Lofa County, in the rural north. But when they arrived in Monrovia in August, another senior CDC official, Joel Montgomery, told them the plans had changed. The virus was erupting in the slums of Monrovia, and they were needed in the capital.
“We need to control this thing here,” Montgomery told Fields. “It’s going to explode in the city.”
The lab equipment Fields packed up included seven hundred pounds of gear, including generators to keep the delicate and highly technical machines whirring. With it, he could build a level-3 biosafety lab in the field, capable of protecting scientists and technicians from the worst bugs on Earth. But the contractor they had recruited to ferry the gear to Liberia had trouble with the customs paperwork, holding up their mission for three long days.
In the interim, Fields met with staff from Médecins Sans Frontières, to plan where exactly they would set up the lab. The MSF staff had been laboring to get more than a few blood samples tested each day. When Fields told them how many samples his machines could process—about 150 a day—their jaws hit the floor. On the spot, they volunteered to give Fields and his team as many construction workers as they needed. Once construction began, the rudimentary laboratory was completed within twenty-four hours.
Still, the lab was primitive at best. Like the ELWA hospital itself, Fields’s team operated in an open-air tent, stocked with plastic patio furniture they had purchased at a local hardware store. The August monsoons beat down on the roof constantly, and they had to hire a Liberian man to sweep out the rain. They worried constantly about being electrocuted, or that the water would short out their pricey gear. They bought fans, too, in a perpetually losing battle against the tropical heat.
Once the customs paperwork had been fixed and the tent erected, the complicated system of testing blood samples took on a regular order: Fields or one of his colleagues would collect samples from a refrigerator just outside the red zone, walk past patients waiting to be admitted under the Ebola trees, and place the blood in an acrylic box. The blood would be
treated with a buffer solution that extracted RNA, which would prove whether Ebola was present in the blood, while killing 99.9 percent of the virus. They added an ethanol solution to kill what virions remained, turning the blood a rust brown color.
The treated samples would then be moved to two extraction machines, which would amplify a few pieces of RNA so that the computers could tell whether a sample had Ebola present. The two machines were able to diagnose a sample with near-perfect accuracy; to be certain, they ran each sample through both machines. Results were entered into a computer, which would then be sent to the appropriate hospitals.
The tent was situated along the main walking path between the road and the ELWA hospital. As patients walked down the path, they frequently stopped by the lab tent in search of treatment. Fields and his colleagues had to direct them to the hospital itself, though they could tell how sick many were.
“You just knew they were dead,” Fields said later, mist coming to his eyes.
In its first week of operation, the CDC team scanned three hundred samples, a huge improvement over the seemingly interminable waits doctors and patients had to endure before. But the results were as depressingly monotonous as the rain that beat on the roof: Positive. Positive. Positive.
The results were so grim that they had to find solace in any way they could. When the first survivor walked out of ELWA under his own power, having beaten Ebola, Fields, Feldmann, and their colleagues snapped photos with the healed man.
But more patients arrived seemingly by the hour. Taxis carrying the sick would pull up to the ELWA hospital, where a team would help the patient inside while another team sprayed the vehicles down with a chlorine solution to kill whatever virus particles remained behind.
Each day was a brutal slog. A Liberian driver would pick them up at their beachside resort, the same hotel where Randy Schoepp and his team were staying, at 8:00 a.m. They spent most of the day testing samples from patients at ELWA, subsisting on Pringles and cookies for lunch. As the sun set, invariably new samples would arrive from John F. Kennedy Hospital on the other side of town. Well after nightfall, they drove back to the hotel. They took what little pleasure they could in a friendly competition with the U.S. Army Medical Research Institute for Infectious Diseases team, comparing how many samples they had each tested that day. They rarely mentioned how many had come back positive.
Exhaustion set in, and nerves increased. When Fields scraped his arm on some rebar, where patients regularly rested, his colleagues tried to reassure him that he wasn’t at risk, that almost certainly any virus particles that remained had died after being exposed to the air and sun. Fields seethed. “It isn’t your damn arm,” he thought.
A few days after a Western doctor stopped by to see their facility, a sample with the doctor’s name on it came through their lab—and tested positive. The team spent days replaying their meeting in their heads: had they shaken his hand? Every few minutes, it seemed, one of them sneaked off to take his or her own temperature to check for symptoms. (The doctor, whose name was never disclosed, was evacuated to the University of Nebraska, where he was nursed back to health.)
Bleach was everywhere. The person who collected samples from the hospital fridge would bleach his or her hands and boots on the way in, and on the way out. Fields wears a sterling silver wedding band; by the time he returned home, the band was black from constant bleaching.
The ever-present fear of the Ebola virus played out at home, too. A photograph of Fields appeared on the front page of USA Today, above a story about another Western health-care provider who had been exposed. The implication that Fields was the one exposed sent his family into a frenzy, before he could assure them he was okay.
The ELWA hospital struggled to accommodate the demand from patients infected with Ebola. Within ten days of the facility’s opening, MSF technicians were already working to build three new tents, each capable of housing another 40 beds. Ultimately, the facility grew to a capacity of 250 beds; during the course of the outbreak, it treated 1,909 patients, 1,241 of whom tested positive for Ebola. Of those cases, just 541 survived.
The flood of American aid continued through August: On the twenty-fourth, USAID airlifted more than 16 tons of medical and emergency equipment to Monrovia from a forward-staging warehouse in Dubai. The shipment included another 10,000 sets of personal protection equipment, two water treatment systems, two portable water tankers, and 100 rolls of plastic sheeting to construct new Ebola wards. Three days later, Shah authorized another $5 million from USAID’s coffers.
The next day, August 28, 2014, a new WHO count showed a total of 3,052 confirmed Ebola cases in the three West African countries. Liberia had reported a jump of almost 300 cases in just a week. Already, half—1,546 souls—had died.
Sirleaf’s call for help, along with increasingly urgent on-the-ground reports from Pendarvis and others, had spurred a flood of relief from an increasingly attentive American government. But there was little evidence that the early efforts were working; the case count was spiking upward at a faster rate than even the most pessimistic projections. It was fast becoming clear that a more aggressive response was essential to bending that curve downward. What was less clear was just how anyone—the American government or the global health community—could provide that more aggressive response.
TEN
70–30
AFTER A MONTH OF increasingly alarming reports, Jeremy Konyndyk decided he needed to get a firsthand sense of the scale of the outbreak, and Tom Frieden decided it was time to create a more formal structure to respond to the outbreaks. International panic was growing; between the time Konyndyk and Frieden booked their tickets on a British Airways flight through London’s Heathrow Airport, and the day the flight left, the airline had canceled its routes to the three West African nations. Konyndyk and Frieden had to scramble to rebook a Delta flight to Ghana, and to connect from there to Monrovia (British Airways was not alone; of 590 monthly flights to Guinea, Liberia, and Sierra Leone, 216 had been canceled by mid-August, an airline data provider reported).1
When they finally landed, the two Americans were immediately struck by the deeply worried mood they encountered. At one of their first meetings, with Ellen Johnson Sirleaf and her advisers, Konyndyk was struck by how grim the room seemed. Everyone was scared, and everyone was exhausted. They showed him a chart illustrating the virus’s explosive growth in recent weeks, a line that grew exponentially into a mountain of disease and death. There had been more cases reported in a single day earlier that month than during the totality of most previous outbreaks.
Frieden had arrived with the goal of organizing the chaotic response. None of the three West African countries had tapped a single person to oversee the governments and nongovernmental organizations (NGOs) now rushing in to help, and no one seemed to be taking the basic steps necessary to provide the number of beds necessary to quarantine patients, provide them with care, and stop the virus.
“You hit the tipping point when the Ebola treatment units [ETUs] got full. And that was for a few reasons,” Frieden said later. “One, they got unsafe, and health care workers got infected. Two, people couldn’t come there, so they went back to the communities and spread [Ebola] widely. Three, the care in the ETUs was so poor at that point that people said, Why go there? It’s just a place to die.”
In July, Frieden had thought they would need to build facilities capable of housing three hundred patients—one hundred in each country—to stop the virus. But that meant building other infrastructure as well. They would have to organize staff to care for the patients, transportation for those who might be sick, and laboratories to sample blood. It was an enormous logistical undertaking, unlike any even the Centers for Disease Control and Prevention (CDC) had attempted in years past. And as each day passed, the number of beds they would need to control the spread of the virus increased.
“The painful fact was, we knew in July if we could get 300 beds, we could end it. By November, we needed 3,000 beds
,” he recalled later.
Frieden delivered a blunt message to Sirleaf: The world will not come to your aid fast enough. It was not possible for the world to marshal assistance fast enough. You have to mobilize your own communities, spread as much information as possible, while the disjointed international response got its act together.
The first task was to organize a single point person to run the entire response. In Liberia, that person was Tolbert Nyenswah, head of the Incident Management System. The IMS had become the common means by which the CDC handled outbreak responses, and increasingly the way other humanitarian groups organized responses, in the wake of the September 11 terror attacks in the United States. The goal, Frieden explained, was to take what seemed like a dauntingly massive problem—an international outbreak of a deadly virus—and break it down into solvable problems. “Instead of having a fog of war experience with just chaos going on, it’s a way of structuring your emergency response,” he said. “If you have a big problem, break it down to less big problems, and then solve each of those less big problems individually.”
Nyenswah chaired the daily meetings, which took place in a huge conference room in central Monrovia. Government agencies, foreign governments, nongovernmental organizations were all present, and teams tasked with tackling every aspect of the response would deliver daily status updates. Every meeting was heavily structured, to waste as little time as possible. Precision and timeliness were critical: briefing memos laying out decisions ahead had to be delivered on time, and once a decision was made, tasks needed to be tracked. Final decisions rested with Nyenswah, the unflappable deputy minister of health with an education from Johns Hopkins in Baltimore. Everyone else scaffolded, in Frieden’s words, around him. Ordinarily, someone who will run an IMS undergoes months of training. Nyenswah dove in with little more than a briefing from Frieden and his team.