by Reid Wilson
Frieden’s first request of Stokes was to find donors to build new emergency operations centers in each of the three affected countries. The structures would represent a massive and lasting contribution: they would act as data centers, hubs for multidisciplinary teams that could direct resources on the ground to their most efficient targets while analyzing both local and national-level data. Nothing similar existed in Sierra Leone, Guinea, or Liberia; putting everyone under one roof, the thinking went, would dramatically improve the efficiency of operations.
But they were not cheap. Each center would cost an estimated $3 million, so Stokes needed to find $9 million. He spent an early fall weekend calling potential donors, coming up mostly empty—until he reached Paul Allen.
Allen, one of the original founders of Microsoft, has spent hundreds of millions of dollars over the years on philanthropic causes. He told Stokes he was interested in funding the emergency operations centers. Stokes initially misunderstood—he thought Allen wanted to fund one complete center. No, Allen told him, he would write a check to build all three. When costs spiraled, raising the total price by about $3.9 million, Stokes called back to apologize; would Allen like to cover the cost of just two of the emergency centers? Again, Allen told Stokes, he would write a check to cover the higher, total cost.
The finished products were massive, like huge gymnasiums, built by the same prefab contractor the foundation had used in Haiti. When Stokes visited the emergency operations center in Freetown, Sierra Leone, he found more than a hundred people hard at work, divided between critical teams. Some were British military, others CDC staffers or World Health Organization (WHO) officials. Ministry of Health staffers worked side by side with their international partners. British officers and members of Sierra Leone’s army stood shoulder to shoulder in front of maps, flat-screen televisions, and tablet computers. Outside, backup generators hummed. In a nation where just 1 percent of the population has access to the Internet, the emergency operations center, built with a tech billionaire’s money, buzzed with connectivity.
In one corner, a team of operators manned a series of phones. Surveillance teams, armed with some of the cell phones Stokes had purchased from Walmart, would call in to report suspected cases of Ebola or dead bodies that needed to be carefully contained. The operators tapped information into a specially created computer program that prompted all the right questions: Who was the victim? Where, exactly, was the body? Who lives nearby who we can call to learn about the family or the neighborhood? Once answered, the operators would call an ambulance or a hearse to pick up the victim.
Nearby, another team mapped the cases the operators charted. Walls covered in white boards and local maps showed the locations of any suspected or confirmed cases, an effort to plot the spread of the disease and, hopefully, get ahead of it. Every night at 9:00 p.m., the heads of each team met to report on their daily progress.
In Guinea, Stokes visited an emergency operations center in the basement of the only significant Western-style hotel in Conakry that offered reliable Internet access. It seemed like a nice facility. But the power cut out three times; at 11:00 p.m. on the night of his visit, Stokes found himself stuck in an elevator between the first floor and the basement. He was worried he would have to spend the night cooped up between floors.
It was clear that the officials Stokes was helping to pay for had spent many nights in the hotel basement. When he visited in January, a dismal Christmas tree sat neglected in a corner, weeks after the holiday had come and gone. Family photos adorned the walls.
In the field, the foundation funded smaller satellite centers. Stokes visited Bo, a regional capital about three and a half hours east of Freetown, where the CDC had built a lab center in a ramshackle government building. Even here, far from the country’s largest city, the Internet worked, and backup generators thrummed as centrifuges spun. The once run-down building now hosted a high-containment laboratory, where blood samples were processed in metal shipping containers. Stokes was baking in the heat; he could not imagine what the lab technicians, decked in head-to-toe personal protective equipment, must be feeling.
Samples arrived seemingly all the time, flown in by United Nations helicopter and carted in on the backs of motorcycles. Once in the hands of lab technicians, the samples would be sprayed with chlorine, then opened. The paperwork associated with the blood samples would be laid out on the sidewalk, and sprayed with chlorine. Finally, the sample itself would be rushed into one of the containers for processing.
The connection between far-flung villages and the laboratory in Bo, and similar lab outposts across all three countries, largely relied on men on motorcycles. Ranging across three nations with dismally poor road systems, the motorcycles could reach even the most remote and isolated villages, dodging mud pits that would have consumed a car, zipping down forest tracks too narrow even for a small vehicle to navigate. If a sample that reached the lab tested positive—and by the fall of 2014, it seemed there were few samples that were not testing positive—the operations center could dispatch an ambulance to transport the patient, or the body, to an Ebola treatment unit or a morgue.
But Sierra Leone, Guinea, and Liberia are desperately poor countries, with desperately little infrastructure—and desperately few vehicles, motorcycles or not. Frieden told Stokes they needed to shorten the time between a blood sample being taken and a blood sample reaching the lab. That meant more motorcycles, and that meant reaching out to more donors.
Stokes found another set of donors who had made their money in the burgeoning technology industry, and who were now looking to give much of that money away. This time, it was Mark Zuckerberg and Priscilla Chan, the founder of Facebook and his physician wife. The couple wrote a $25 million check—one of the largest individual contributions the foundation had ever received—with shockingly few strings attached. Do what you want with the money, Zuckerberg and Chan told Stokes. Just tell us how you spent it afterward.
So Stokes dramatically increased the number of vehicles tooling around the rural communities of West Africa. The Facebook money bought 206 Toyota pickup trucks, so many that Toyota had to make a special shipment. Before the ship arrived, the foundation arranged to deliver many of the new pickups by airlift. The four-wheel-drive vehicles would allow ambulance teams to get in and out of remote villages, even during the rainy season, when torrential downpours could turn rural roads into frothing mud baths.
Stokes used more of the money to buy four hundred new motorcycles to spread between the affected counties in all three countries. Those motorcycles cut the time between when a patient showed symptoms and when his or her diagnosis came back from a few days to a few hours. “These guys were amazing how quickly they could cover these distances,” Stokes said.
They saved lives, too. Early treatment dramatically improved the survival rate of Ebola patients and, just as important, isolating a patient before they spent several days showing symptoms could save their family members, too, and stop the spread of the disease.
Stokes also visited a small community centered around a palm oil farm, where a once-vibrant market now sat dormant. The CDC Foundation had supplied tents used to quarantine those with Ebola before they could be transported to a proper treatment unit. The market had once been the lifeblood of the community; now, food and water were being trucked in whenever the roads were passable. A CDC staffer manning the quarantine tents pointed to one of the motorcycle riders who helped bring samples in from far-out villages. The motorcyclist had not been paid in two months, the CDC staffer told Stokes; the CDC was giving him as much food as it could, so he could feed his own family.
Zuckerberg and Chan publicized their gift, and therefore the CDC Foundation itself, in a post on Facebook. Allen, the owner of the Seattle Seahawks, flashed advertisements to donate on the Jumbotron during home games. For a foundation used to handling a small number of seven-figure checks from corporate partners and major philanthropies, the huge number of small-dollar gifts that started to roll
in almost overwhelmed their system. Ten dollars here, a hundred dollars there—they had never handled contributions on such a scale. Many of the most prominent charities in the country began sending larger contributions. The Robert Wood Johnson Foundation wrote the first million-dollar check of the campaign. The Bill and Melinda Gates Foundation contributed, then the Silicon Valley Community Foundation, an important gateway to big tech money. Henry Schein, the company that makes personal protective equipment, donated money and gear; the hospital firm HCA wanted to donate beds, so Stokes directed them to the U.S. military. Johnson & Johnson wrote a seven-figure check, too.
Stokes thought that building the foundation’s credibility was key to keeping the money spigot on. In normal circumstances, the CDC Foundation would take a percentage of each contribution to cover its own internal operations, like paying the rent on its Atlanta headquarters or paying the salaries of its employees. With the Ebola outbreak raging, Stokes suspended that overhead charge. Instead, he took $1 million out of the foundation’s reserve fund to handle overhead.
In Africa, the speed with which the foundation could move impressed both government ministers and other nongovernmental organizations alike. The CDC’s central emergency operations center in Atlanta could request money for some specific project. So could leading CDC officials in each of the three West African countries.
When a team of health ministry workers in Sierra Leone planned to mount a massive campaign to conduct door-to-door surveillance in a particularly hard-hit neighborhood, they asked the CDC Foundation for a grant of $160,000 to hire and train 400 staffers. The request hit the foundation’s inbox on a Thursday; within two hours, the money was wired to the appropriate accounts. By Sunday, the 400 newly trained staffers were canvassing the neighborhood.
“A need could arise one day and be approved that day, and we would move funding that week, sometimes that day,” Stokes said. During his January visit, a top CDC aide based in Sierra Leone stopped Stokes to tell him about the door-to-door canvassing effort, and the money that made it possible. “It literally blew our minds,” the official told him.
As a side effect of the foundation’s spending spree, the group was able to funnel some money to residents whose businesses had effectively been shut down by the spread of the disease. Accountants, lawyers, merchants, university instructors, and students, all of whom had seen their livelihoods vanish as society pulled inward on itself, were suddenly put to work driving vehicles or manning phone lines. To speed the purchasing process, the foundation partnered with eHealth Africa, a nongovernmental organization that had built an emergency center to track polio in Nigeria with CDC Foundation money. On the ground, eHealth had the foundation’s permission to buy what it needed to run the operations and lab centers, including everything from generators and fuel to water and toilet paper.
The flexibility in spending brought a measure of order to what had been a chaotic response. Officials with different organizations, whether the CDC or WHO or local health ministries, would wake up each day with a new idea about how and where to spend money. Priorities changed on a daily, sometimes hourly, basis. No government purchasing process would have been able to keep pace. But the foundation, not beholden to any particular set of rules, could dash off a check when a need arose, without marching through a procurement process.
“There are some emergencies for which even a nonprofit with flexibility like us still needs that extra step of unrestricted money. I don’t think there will ever be a way for government to fill that gap,” Stokes said later. “The typical grant-making process would not have worked here. There was no time for that.”
In just a few months, as the U.S. Congress dithered over whether and how to fund the fight against the deadliest disease known to man, the CDC Foundation raised and spent $55 million—eleven times what they had raised to help Haiti recover from its earthquake.
Today, the emergency operations centers in Conakry, Freetown, and Monrovia are still in operation. The once-temporary facility in Freetown is now permanent, and bulked up with a new second story that houses permanent offices for CDC officials, who help train disease detectives to look out for other viruses that plague the populace.
But the emergency operations centers represented just one front in the war on Ebola. In the rural counties well inland from the crowded capitals, another front was opening up, one that would ultimately bend the deadly curve of an out-of-control virus down, for good.
SEVENTEEN
The Burial Teams
IN LIBERIA, GUINEA, AND SIERRA LEONE, the Centers for Disease Control and Prevention (CDC) Foundation had built groundbreaking new facilities to track the spread of Ebola. Médecins Sans Frontières (MSF), the World Health Organization (WHO), and a few other nongovernmental organizations (NGOs) were on the front lines in Ebola treatment units, battling to save the lives of those who dared to seek treatment. But health officials knew they were seeing only a fraction of the real picture. In three nations where Internet access was virtually nonexistent and major highways could be rendered impassable by a monsoon, they knew they were likely missing hundreds of cases, and hundreds of dead bodies that threatened to infect new victims. The CDC estimated that just 18 percent of Ebola patients in Liberia were being cared for in hospitals at the height of the outbreak.1
Those who did not find space in hospitals, or did not seek out treatment, were largely in rural counties far from Monrovia and Freetown and Conakry. They mostly constituted members of rural ethnic groups, still skeptical of central governments hundreds of miles away. They were those least likely to have access to modern hygiene, most likely to continue the traditional burial practices that put them in the closest contact with virus-laden corpses, and the least likely to voluntarily go to a medical facility run by their governments, or foreigners in space suits. Ebola’s race through metropolitan West Africa represented the greatest threat of the virus spreading, but if health officials neglected the outbreak in regional capitals and even small villages, it would live to spread again, like a fire that has found new fuel.
The traditions of the tribes that dominated rural West Africa are replete with superstition and tales of magic. Secret societies carry out rituals deep in the jungles. Villagers believe they can curse a neighboring tribe, or, if some ill wind befalls them, that they have been cursed. It is vitally important that a dead relative be cared for, washed, and dressed for the afterlife once they have passed away.
That tradition in particular put villagers at special risk. Because an Ebola-infected body carries the largest viral load at the time of death, coming into contact with that body is a particularly dangerous endeavor. At the height of the outbreak, the World Health Organization estimated that 70 percent of new Ebola cases came when someone had contact with a dead body, and 20 percent of all deaths were caused by unsafe burial practices.2
Far away from Monrovia, three Liberian counties just south of the border with Guinea had been particularly hard-hit by the outbreak. Piet deVries, the senior country manager for Global Communities, had seen Bong, Nimba, and Lofa Counties up close, during his years in Liberia. They had suffered deeply during the civil war, and now they were suffering again, as equipment and badly needed medical gear piled up in the far-off capital.
After the civil war, Global Communities had been the first nongovernmental organization to venture back into Liberia. Since 2004, the group had been running a program it called IWASH—Improved Water, Sanitation and Hygiene—in the three rural counties, with money from the U.S. Agency for International Development (USAID). The program was meant to halt unnecessary deaths caused by preventable diseases like cholera and typhoid, diseases caused by unsanitary drinking-water supplies.
The Global Communities teams that would show up in small rural villages were always made up of Liberians from nearby areas so they could demonstrate tribal ties. They hoped to spur behavior change by linking actions to health outcomes. If a latrine were situated near a water source, the teams told villagers, they were at
risk for preventable disease. It was up to the community to take responsibility for their own water safety—a message that worked much better than one delivered by an outsider demanding an end to decades or centuries of local custom. The teams had to break the stigma of speaking openly about feces, and about the links between feces and illnesses like diarrhea.
In many villages, before Global Communities arrived, those links just didn’t exist; villagers believed someone got sick because of a curse or because of occult magic.
The partnership between Global Communities and the local villages was forged by environmental health technicians. They were technically employed by county governmental health teams, though Global Communities helped fund the $80 per month they made as they zipped between villages on their motorcycles.
But after a decade, the work of Global Communities was nearing an end. In March 2014, deVries had held his first meeting with the Liberian Ministry of Health about wrapping up his group’s involvement, and handing over control of the IWASH program to the government.
Days later, Ebola’s presence was confirmed in Guinea, and the first cases were trickling over the border into Liberia. DeVries traveled north to Lofa County, where a health official told him to go to the town of Foya, on the border just south of the outbreak’s epicenter. DeVries felt a fear he hadn’t felt before. The atmosphere was scary, he said later.
Instead of handing over the IWASH program, deVries and his partner at Global Communities, Brett Sedgewick, debated another course of action: Global Communities was the only nongovernmental organization with a significant presence in the rural north. Its environmental health technicians were known to the village leaders on the front lines of the fight against Ebola. If the Liberian government or some other NGO couldn’t deliver a credible message about the deadly virus because of deep-seated mistrust, maybe the well-regarded Global Communities teams could. The IWASH program became the Assisting Liberians with Education to Reduce Transmission—ALERT—program. USAID wrote the group another check, for a modest $760,000.3