by Reid Wilson
The media was obsessively reporting the story, wondering aloud whether Ebola could be transmitted in the subway, in the meatball sandwich shop, in an Uber. Several outlets reported Spencer’s condition just hours after he was admitted to the hospital, even identifying him by name. It galled Klain that Spencer hadn’t even had the chance to call his own mother to tell her before news outlets reported his illness. It galled him more that outlets reported that Spencer had a temperature of 104.1 degrees—a dangerously high level that would seem to indicate he had been sick, and contagious, for days. Somewhere along the way, two digits had been transposed: Spencer’s actual temperature by that afternoon had risen to 101.4, still high, but nowhere near as dangerous as early reports suggested.
After hanging up with Shorris, Klain met Obama, chief of staff Denis McDonough. and Lisa Monaco, Obama’s chief homeland security adviser, in the White House’s Diplomatic Room. Obama, conscious that a new case of Ebola, after the nurses in Dallas, would create new calls for quarantines and flight restrictions, cracked a wry joke: “Well,” he said, “this isn’t going to help.”
The only way Klain knew the White House could assuage a nervous public would be to ensure that no one else got sick. There were not many appealing ways to satisfy media outlets intent on running ever more shock-inducing headlines on their front pages and in their broadcasts. But there was that third audience Klain needed to satisfy, an audience whose buy-in the government needed in order to create a truly national safety net to detect the first signs of any Ebola outbreak, and one that had its own financial future to consider. These were the hospital administrators, those professionals who ran the major public health institutions in big cities around the country.
The administrators had seen what happened to Texas Presbyterian Hospital in Dallas, when Duncan fell ill. Patients avoided that facility in droves, a situation that grew even worse when nurses Pham and Vinson contracted the disease. Revenue collapsed. Klain needed other hospitals to agree to serve as Ebola treatment centers in the United States, a process that would require them to spend lots of money to build isolation units, train staff, and ultimately gain certification, but one that could also cost them if patients started to wonder whether the virus lurked somewhere in their doctor’s office. Just as Klain needed to prove to the public that no one else in New York would get sick, he needed to prove to other hospitals around the nation that they would be well taken care of if and when a patient with Ebola arrived on their doorstep. And that meant showing support for Bellevue now that Spencer was sick.
The difference between the American medical system and that of the other Western nation most likely to have to deal with Ebola cases, the United Kingdom, illustrated the difficulties the White House faced. In the United Kingdom, the centralized health system meant that the government could designate one hospital to treat any patients who came down with the disease. It was not the hospital’s choice, it was the government’s choice. In the United States, the federal government had no such authority, either over state hospitals or privately run hospitals. It was up to Klain and his team to convince hospitals that it was in their interest to accept any patients who might show up presenting scary symptoms.
If something went wrong at Bellevue, Klain knew that the task of convincing other hospitals to treat Ebola patients would be all the more difficult. On the other hand, if everything went smoothly, Klain thought he could portray the doctors and nurses at Bellevue as heroes, piquing the interest of other hospitals that might want their own doctors and nurses to be seen in a similar light.
Making sure everything went well meant working proactively as much as possible. As Duncan lay in intensive care in Dallas, his blood samples making their way to Austin for testing, the CDC had waited crucial hours before deploying a team to help Texas Presbyterian. The CDC would not make the same mistake again: even before Spencer’s blood samples came back showing he was positive for the Ebola virus, CDC advisers walked through Bellevue’s front door.
Those advisers set about creating a support network around the hospital, training nurses and doctors alike in donning and doffing personal protective equipment and other protective measures. The last thing anyone needed was another sick nurse. The CDC team began running down a checklist of questions they needed to answer quickly: Treating anyone with a contagious disease, especially one like Ebola, generates a lot of waste; where would that waste go? How would it be treated? How would the hospital deal with public anxieties about their nurses and doctors? Landlords who owned apartments where some nurses lived hinted that those nurses could be evicted because of the risk they posed. Every one of those questions had come up in Dallas; in New York, the CDC wanted answers before questions turned to problems.
At the same time, Klain, McDonough, Monaco, and their teams kept adjourning to separate meeting spaces across the White House’s sprawling campus to hammer out the administration’s policies on returning health-care workers. How would a returning volunteer like Spencer be monitored, quarantined if necessary? Hundreds of American doctors, nurses, technicians, and others who had volunteered in West Africa would be returning home in the coming months, and debates raged over how strictly those who came home would be monitored. They kept Obama apprised of the internal debate throughout the weekend.
If Spencer’s proactive decision to call public health officials at the first sign of trouble demonstrated the best inclinations of a hyper-aware volunteer cognizant of the danger he or she might pose to others, the way another young returning volunteer was about to be treated demonstrated the worst instincts of politicians eager to show their own leadership, however misguided. And it would illustrate to the White House, once again, the urgency of creating a policy that struck the delicate balance between protecting Americans and protecting individuals, between preventing an outbreak at home and providing the resources necessary to fight the disease in West Africa.
Kaci Hickox had already had a long day, or days, when she arrived at Newark’s Liberty International Airport on Friday, October 24, the day after Spencer checked himself into the hospital. The flight from Freetown required a stopover in Europe, and after a month in the hot zone, the stress of a long trip weighed on her. She had volunteered at an MSF clinic in Sierra Leone, a clinic where staff did not bother to count the number of victims who had died; it was easier to count the smaller number who survived. On Hickox’s first day in the clinic, she had asked one of her patients whether any of her family members had gotten sick; the woman told her that seventeen family members had died within the past two months. On her last night, Hickox gently fed Tylenol and antiseizure medication to a ten-year-old girl whose body shook with violent tremors. Hours before she boarded a plane home, Hickox watched the girl die.4
So Hickox may have had other things on her mind when she told the immigration agent at the airport that she was returning from West Africa. The young man steered her toward a secondary screening room, a windowless facility in the bowels of Newark’s airport. There, over the next four hours, she was questioned by a parade of officials. She got the sense that some were accusing her of an unspoken wrongdoing. Others exhibited at least a modicum of friendliness, introducing themselves and offering weak smiles. Someone brought Hickox a granola bar and a glass of water when she asked. The nurse noticed that one of her interrogators, a man from the CDC, was scribbling notes in the margins of the official-looking form he was filling out; the CDC’s form did not include enough space for all the information the man had to collect.
After four hours, as she grew increasingly frustrated with her detention in the claustrophobic space, a U.S. Customs agent used a forehead scanner to take her temperature, then smirked when the readout showed Hickox had a 101 degree fever. Hickox knew a forehead scanner would be thrown off by her flushed cheeks. The agent seemed as if he didn’t particularly care.
But she had little choice other than to follow the agent to an ambulance, which drove her to University Hospital in Newark. She thought the fuss the agents were making was beyond ove
rkill. Eight police squad cars escorted Hickox the few miles between the airport and a tent, set up outside the hospital as a kind of makeshift isolation unit. The two senior doctors who attended to Hickox were confused—they were told their new patient had a fever. An oral thermometer, far more accurate than the forehead scanner, pegged Hickox’s temperature at exactly 98.6 degrees.
“There’s no way you have a fever,” one of the doctors told her. “Your face is just flushed.”
Hickox was the first person to be subject to new orders issued the day before by New York governor Andrew Cuomo, a Democrat, and New Jersey governor Chris Christie, a Republican. Under those orders, any travelers returning through John F. Kennedy Airport or Newark’s Liberty from West Africa who had contact with an Ebola victim would have to be quarantined for the full twenty-one-day incubation period. If passengers lived in New York or New Jersey, they could be quarantined at home, subject to twice daily check-ins with state medical personnel.
For Hickox, who lived in Maine, that meant an extended time in the tent, which had only a portable toilet and no shower. When she asked to be allowed to take a shower, after two days traveling from the other side of the world and seven hours in an unpleasant airport quarantine room, hospital staff gave her a bucket and a sponge. Instead of a clean change of clothes, Hickox was given thin paper scrubs. Even her cell phone barely got reception. Her situation did not change when her blood work came back the next day: she had tested negative for Ebola.
Christie, a bombastic figure known more for yelling at anyone and everyone who opposes him than for any actual policy achievements during his two terms as governor, maintained that quarantine was the right approach, even as he repeated a number of incorrect statements. At a press conference on Saturday, Hickox’s first full day of quarantine, while campaigning for the Republican governor of Florida, Christie said the nurse was “obviously ill.” (Not known for backing down or admitting fault in the face of facts, Christie repeated his misinformation over the following years, including in a nationally televised debate just days before ending his quixotic presidential campaign in 2016.)
The next day, a second test of her blood came back, this one also negative.5
Hickox had the presence of mind to mount a public relations campaign, with help from a few well-placed friends. “I am scared about how health care workers will be treated at airports when they declare that they have been fighting Ebola in West Africa. I am scared that, like me, they will arrive and see a frenzy of disorganization, fear and, most frightening, quarantine,” she wrote in an op-ed for the Dallas Morning News,6 placed through a friend who worked at the paper.
On Sunday, Hickox’s cell phone worked well enough to call in to CNN, where she castigated Christie’s diagnosis from afar. “First of all, I don’t think he’s a doctor,” Hickox said of the governor. “Secondly, he’s never laid eyes on me. And thirdly, I’ve been asymptomatic since I’ve been here.”7
After hanging up with CNN, Hickox told hospital staff she wanted to see her lawyer. She had not shown any symptoms since arriving back in the United States, though it still took hours of wrangling and negotiations before she was allowed to speak with an attorney. By Monday, eighty hours after arriving at Newark, she was freed, allowed to return home to Maine. Some of the hospital staff, who agreed with Hickox about the danger of blanket quarantine policies, made a show of shaking her hand without wearing protective gloves.
Still, Christie and Cuomo had put even more pressure on the White House. On Sunday, Obama met with his Ebola team and senior administration officials—twenty-six people in all, including Vice President Joe Biden, the secretaries of Health and Human Services, Defense, and Homeland Security, Attorney General Eric Holder, and others. They had to walk the thin line between acknowledging the obvious threat and allowing scientists to do the work that would actually stop the disease’s spread.
“The President underscored that the steps we take must be guided by the best medical science, as informed by our most knowledgeable public health experts,” the White House said in a statement that day.
He also emphasized that these measures must recognize that healthcare workers are an indispensable element of our effort to lead the international community to contain and ultimately end this outbreak at its source, and should be crafted so as not to unnecessarily discourage those workers from serving. He directed his team to formulate policies based on these principles in order to offer the highest level of protection to the American people.
In plainer English: the White House did not want to take the steps Cuomo and Christie wanted to pursue. They would have to find a way to convince Americans that returning health-care workers would not start their own Ebola outbreak once they got home—without locking them in a tent outside a hospital in Newark.
Christie’s office tried to spin Hickox’s departure as a political victory. She would return home by private transport, Christie’s office said, not by train or plane. Another Republican governor facing a tough reelection fight in November, Maine’s Paul LePage, said his state would work with Hickox to quarantine her at home; Hickox had no interest in such an arrangement. After just a few days, a state court refused to grant LePage an order forcing the nurse to stay home. She took pride in going for a bike ride with her partner the next day. She never came down with the Ebola virus.
Still, underscoring just how much the American public feared the Ebola virus, polling showed that a vast majority of voters sided with Christie over Hickox. Eighty percent of Americans told CBS News pollsters they wanted anyone returning from West Africa to be quarantined. In New Jersey, just 37 percent of voters said they believed the federal government was handling the outbreak well,8 and two-thirds said they approved of Christie’s decision to quarantine the young nurse.9
Just two days after Spencer was admitted to the hospital, Samantha Power and her team boarded an Air Force jet, a modified 737, at Andrews Air Force Base just outside the Capitol Beltway. Power hoped to raise global awareness by showing up in West Africa. And her presence would be notable: she would be the first member of President Obama’s Cabinet to set foot in the hot zone. She brought along reporters from NBC News, the Reuters United Nations bureau chief, and Evan Osnos, a staff writer at the New Yorker, to shed some light on what she saw as an undercovered crisis.
“It was an opportunity to demystify Ebola,” Max Gleischman, Power’s spokesman, recalled in an interview later.
Still, Spencer’s illness scared the team, and as Christie and Cuomo implemented new quarantine requirements in New Jersey and New York, the team members questioned whether they should go. They were supposed to return home to New York, where Power had to go to work at the United Nations. What would it look like if America’s ambassador to Turtle Bay were stuck in a quarantine tent the way Kaci Hickox had been? Ultimately, Susan Rice, Power’s predecessor and now the president’s national security adviser, signed off on the trip.
Power stopped first in Conakry, Guinea, then in Monrovia, Liberia, and Freetown, Sierra Leone. As she whisked between government ministries and American embassies, Power and her team were subjected to the same rigorous cleaning processes as an everyday West African: bleach baths for their shoes, guards armed with forehead thermometers, constant hand-washing. At one point, Gleischman asked Power to slow down, so the NBC cameras could capture her undergoing the screening process.
In Liberia, Power saw firsthand just how vast the scope of the outbreak had become. There were signs everywhere, advertising the emergency number residents should call if they found a dead body, or if they suspected a friend or family member was ill. Inside the giant emergency operations center in Monrovia, detailed maps of the city covered the walls. Blue pushpins represented the locations of those who might be infected. Red pushpins represented bodies that needed to be picked up. Gleischman was struck by the sea of blue and the islands of red, scenes of death and disease in a tightly crowded city of a million residents.
After a quick trip back to Monrovia’s
airport, then across the country in an Osprey, Power visited a mobile testing lab run by the U.S. Navy in rural Bong County, near the heart of the initial outbreak. They visited an Ebola treatment unit—though they stayed far away from any potentially infected patients, cognizant that Cuomo and Christie still had quarantine orders ready to be imposed.
A day later, in Freetown, the magnitude of the outbreak appeared most evident—the city was a ghost town. At a soccer stadium the British military had taken over to build their own operations center, Power watched new medical trainees, about to be deployed into the field, dress in full personal protective equipment and jog around a track under the tropical sun, preparing for the intensity of treating patients in a hot zone.
Power made a final stop in West Africa, in Ghana, where she met with Anthony Banbury, the American who had been placed in charge of the United Nations Mission for Ebola Emergency Response, or UNMEER, at the new group’s makeshift headquarters in an industrial park near Accra’s main airport.
Banbury had been in charge of field support for UN missions across the world before taking over as head of the Ebola response. And despite his thirty years’ experience at the UN, he made clear to Power and her team that he was frustrated. Amid piles of gear stacked to the ceiling, like some kind of Costco for public health, Banbury told Power he had been frustrated by the logistical hurdles he faced, and the pace with which help was arriving.
“The U.N. just isn’t equipped to do these things quickly,” Gleischman said later, summing up the consensus view among the U.S. delegation. “It’s just not fast, and this was a time where speed was literally a matter of life or death.”
Frustration with UNMEER’s slow start soon trickled down to American and other international responders on the ground. Within weeks, high staff turnover at the UN agency convinced many that the new mission was doomed to irrelevance.
Power’s last stop came in Brussels, where her U.S. Air Force plane parked at the far end of the tarmac for half an hour while medical personnel were summoned to check the Americans for signs of infection. Once cleared, Power hosted about twenty European ambassadors at the American embassy to the European Union. She was there to shake the cup, to ask for international assistance, and to deliver a message. Get engaged in the fight in West Africa now, she told the assembled ambassadors, before you have to deal with Ebola in Europe.