by Reid Wilson
By the end of the year, about $3.3 billion in donations had been sent to West Africa to fight Ebola, and more than one hundred nongovernmental organizations were helping in various capacities. But little of that money went to those who put their lives on the line. Nurses in the Kenema hospital were paid just €80 a week, or about $92. Some had second jobs. Others charged patients under the table for extra care, to supplement their meager incomes.
Medical personnel in Sierra Leone treating Ebola patients directly received €100 a week, the same as burial teams, in hazard pay. Nurses in general wards got an extra €40 for their trouble. Even as health officials arrived from Britain and the United States, Kenema’s hospital still lacked the most basic medical supplies; one doctor from the United States began fashioning medical aprons out of tarpaulins.6
Around all three countries, Ebola treatment units continued opening at a rapid pace. The first facility built by the U.S. military opened on November 18 in Tubmanburg, in Bomi County, west of Monrovia. Three more Army-built facilities opened around Liberia in December. Médecins Sans Frontières opened a laboratory and an emergency management center in Freetown, at the Prince of Wales School, on December 10.
When a new outbreak sprang up in Gbarpolu County, along the border with Sierra Leone, Global Communities once again sent burial teams to squelch it. Though it is only a few dozen miles as the crow flies from Tubmanburg and Monrovia, Gbarpolu County redefines the concept of remoteness; Global Communities had to virtually rent out the only canoe ferry across the Mano River to gain access to the affected villages.
Back in Monrovia, a reversal of fortune had taken place. For decades, it had been the rural communities that harbored resentments toward the governing elite, the descendants of American slaves holed up in the capital who ran a government that favored residents of Monrovia over tribal communities elsewhere. But since August 5, when President Ellen Johnson Sirleaf had ordered bodies in the capital cremated to reduce the risk of Ebola transmissions, it had been those in Monrovia who felt their countrymen in the bush were getting the better deal. Cremation was so foreign to the Liberian concept of death and dying; at least the burial teams up north were washing the deceased and giving them a proper resting place.
Just as traditional tribal leaders became so important in the bush, where they convinced villagers to welcome the burial teams, traditional leaders in Monrovia began taking on a more important role. Cremations had never sat well with Zanzan Kawa, the paramount chief. Sirleaf had mandated cremation not for any nefarious reason; the Ministry of Health was simply running out of places to put dead bodies. Now Kawa appealed to fellow members of the National Traditional Leadership Council to help find a new site for a massive cemetery, one that would give Ebola victims a proper burial, and a proper entrée into the afterlife.
Tribes from around Monrovia offered as many options as they could. Officials from the Ministry of Health, the Ministry of Internal Affairs and the Ministry of Lands, Mines and Energy surveyed each successive site. They examined whether it had enough space, whether it was high enough above the water table to survive the long rainy season, and whether it was accessible to ambulances that would bring in the dead.
By October, they had found a site, one offered by Chief Kawa’s own tribe. The plot of land was called Disco Hill, where a western company used to harvest rubber east of Monrovia in Margibi County. Once the tribe could formally transfer ownership of the land, Global Communities, thanks to a grant from USAID’s Office of Foreign Development Assistance (OFDA), would be able to hire the workers necessary to transform an overgrown forest into a dignified resting place.
But in a country where nothing seems easy, transferring land presented more unexpected hurdles. Land titles had been the source of contention and distrust between the governing elite and tribes since the former African American slaves first landed in what is now Monrovia. And while Chief Kawa’s tribe offered the land for sale for just $50,000—an amount that represented more of a token payment than a serious transaction—the Ministry of Internal Affairs prohibited the sale. Money from the OFDA, a foreign government agency, could not be used to buy Liberian land.
The delay particularly bothered Tolbert Nyenswah. Nyenswah had been driven from his home in 1993, during the beginning of the civil war, when he was forced to spend years in a migrant camp in Côte d’Ivoire. He had returned home after receiving a law degree and a master’s in public health from Johns Hopkins University. When Ebola broke out, Nyenswah had been dispatched from his job as Liberia’s deputy minister of health to become head of the Incident Management System, the agency overseeing Liberia’s response to the outbreak. He told friends he couldn’t believe that such an important step, necessary to stop the cremations that threatened to sow more discord in Monrovia, had been blocked by a government bureaucrat.
After days of torturous back and forth, the Ministry of Internal Affairs decided they would simply buy the land themselves. Workers were already clearing forest and leveling territory; within days, they had created a burial area for Christian victims of Ebola, and one for Muslim victims.
But the ministry’s check had not arrived, and no check meant no bodies. Several times, the landowners had to tell the teams to stop work until the check came through. And while some Liberian customs flummoxed western aid workers, bureaucratic slowdowns and screwups were the same the world over. One check arrived, but it was made out to the wrong person. Another check showed up days later, but for only half the amount necessary to transfer the land.
In December, two months after Chief Kawa’s tribe had identified the site on Disco Hill, Senator Chris Coons arrived in Liberia. The former missionary was the first American elected official to set foot in West Africa during the outbreak, and he had been following the controversy over the cemetery. He brought it up in a meeting with Sirleaf: Why hadn’t this simple act, this cutting of a check, been taken care of? Sirleaf promised to find out.
Two days later, on December 23, the check—made out to the right recipient, for the right amount—was signed. Sirleaf issued a declaration formally ending the national policy that all dead bodies must be cremated that same day. On December 24, the first Ebola victim was buried at Disco Hill.
For the next several months, the dead found a resting place at the cemetery, albeit one that was far more regimented than a normal burial site. Burial teams similar to those who roamed the northern counties met every arriving ambulance. Every body bag, every grave was completely sprayed down by a disinfection team, dressed in full protective gear, wearing backpacks equipped with chlorine sprayers. The entire facility was separated by orange plastic fences, demarcating red zones where Ebola might be present, and blue zones where protective gear was not required.
From an ambulance, a body would be carried to a temporary morgue. Three identification cards traveled with the body at all times, to ensure that families knew where their loved ones rested. Grave-diggers, who worked in teams of four, could excavate a final resting place in about five hours; once a location was ready, the six members of the burial team would lower the deceased, body bag and all, carefully into the ground. The chlorine sprayer stayed behind to disinfect everything that might have come into contact with the body.
A year after the Disco Hill cemetery opened, Global Communities formally transferred control of the site to the Liberian Ministry of Health. On January 19, 2015, Matt Ward, the group’s site director, handed an oversized key to a Ministry of Health official in an elaborate ceremony. Three thousand Ebola victims rested beneath their feet. The ashes of thousands more who had been cremated between August 5 and December 23, transferred to a newly built mausoleum, had found their resting place, too.
In Sierra Leone, not one of the 58,000 sponsored children involved in World Vision’s programs contracted the Ebola virus.
EIGHTEEN
A Waning Tide
WHEN LEISHA NOLEN RETURNED to Sierra Leone in November, she felt as if she were visiting a different country from the one she le
ft in August. After her last deployment, the normally active Centers for Disease Control and Prevention (CDC) Epidemic Intelligence Service officer had been so depressed about the spiraling virus that she sat, moribund, on her couch for weeks on end. During that deployment, the daily case counts were growing by the dozens—on some days, by the hundreds. Nolen and some of her colleagues spent their time in Sierra Leone and Liberia wondering whether they, or anyone, could actually get a handle on the growing crisis. The looks on the faces of the Sierra Leoneans she worked with were grim; unlike Nolen, they were not going to rotate home for a break. Their home was the one on fire.
But a few months later, Nolen found a different situation entirely. Her third deployment took her to Kambia, in northern Sierra Leone, a town of about 40,000 inhabitants about halfway between Freetown and Conakry. The number of reported, suspected, and probable cases of Ebola in West Africa continued to rise, from about 4,800 at the beginning of November to 7,100 by the beginning of December, but Nolen detected a notable change in the country’s mood.
Employees working for the CDC, Médecins Sans Frontières (MSF), Global Communities, and others detected the same change in the last few months of the year. The case curve, which just a few months before had been growing exponentially, was starting to level off. Elders in villages facing the virus for the first time were no longer skeptical that Ebola existed; instead, they started asking questions about how to stop the spread of the danger in their midst, a credit to the national education programs airing on radio stations around all three countries. The international response had finally caught up with the severity of the outbreak, to the extent that even smaller countries were contributing what they could. The Dutch government spent more than €18,000 for a Stop Ebola card game, modeled on the game Memory.1
In his morning meetings, Major General Gary Volesky began to see a downward trend in new case counts. Every day, Volesky would review the “heartbeat chart,” a graph that showed weeklong averages of new cases and projections of cases in the future, which gave responders a sense of which regions needed urgent attention. The upward curve that resembled a hockey stick when he arrived had begun to bend slowly downward through November.
“By December, you’re saying, wow, there’s less than 30 cases reported total a day,” Volesky said. But he remained leery: A single person had started the initial outbreak in Guinea. A single person had spread the virus over the border into Liberia. A single person had brought Ebola to the heart of Monrovia, sparking an outbreak in densely packed urban slums. “It only took one person to start this before,” he said later.
A new cluster of Ebola cases in Cape Mount County, on Liberia’s northern border with Sierra Leone, showed just how much progress the nation had made. Even before the first cases popped up, burial teams trained by Global Communities were patrolling villages in Cape Mount. The first bodies those teams were called to pick up showed that the villagers still did not fully buy into the virus’s lethality—the bodies had been washed and dressed for the afterlife.
But where education efforts directed by Monrovia’s government had not worked, the nongovernmental organizations (NGOs) working in Cape Mount turned to their second line of attack: traditional leaders.
Cape Mount is a predominantly Muslim county, one of the few in Liberia. So Global Communities found the highest-ranking Muslim traditional leader they could: Musa Kamara, who headed the Paramount Chiefs Council, a group of traditional elders, in neighboring Lofa County. Chief Kamara had seen the toll Ebola took on villages in his Quardu Gboni District, and he knew how urgent it was for Cape Mount to take action quickly. A day after receiving a call asking him to visit, he was in the car.
Once he arrived, Chief Kamara and a local grand mufti organized a meeting with traditional leaders in Cape Mount, especially those who were skeptical about the virus. The disease is real, they told their counterparts. After the meeting broke up, the chief visited nearby villages to spread his message beyond the traditional leadership. Ebola, Kamara said, was survivable, but only if those who were ill sought treatment in time. Save Cape Mount, he urged villagers, from the horror Lofa went through.
Within days, those who had fallen ill started showing up at newly built Ebola treatment units. Where the government in Monrovia had little credibility, Kamara had served as an important validator of the point they were trying to get across. The mistrust between traditional leaders and the central government might still exist, but the two sides knew when they needed to work together.
As the infection curve bent downward and as virus hunters started believing they could strangle the disease, a new batch of scientists began arriving, a group more accustomed to dealing with the microscopic, rather than the human, element of an outbreak.
Just as virus hunters had arrived in West Africa sensing the opportunity of a lifetime, their best chance to practice their craft under the highest possible pressure, so too did microbiologists see an opportunity in the Ebola outbreak.
Before 2014, only a relatively small number of people had ever come into contact with the Zaire strain of the virus, dubbed EBOV—and even fewer had caught any of the three relatives that have been shown to harm humans. Only 1,383 known cases of the EBOV, or Zaire, strain had been diagnosed before the outbreak in West Africa; just 778 cases of the Sudan strain (SUDV) had been diagnosed. Over the course of just two known outbreaks, 185 people had come down with the Bundibugyo (BDBV) strain. And the Tai Forest virus had been found only a single time in that one unfortunate Swiss graduate student, working in the nature preserve in Côte d’Ivoire in 1994.2 In almost every outbreak, the Ebola virus burned through a population so fast that the disease had disappeared before microbiologists arrived to study it.
Put another way, before the outbreak in West Africa, scientists knew little about one of the scariest viruses on the planet—which meant that their efforts to create new treatments and vaccines had not progressed as fast as with other, better understood diseases. Lab tests at places like the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) and the CDC could only go so far. Seeing the virus in the wild, understanding how it morphed and mutated between patients, would give scientists an invaluable leg up in the war against such a deadly pathogen.
Captain Jeff Kugelman was among the first genetics experts deployed to Liberia to slice open Ebola virions in hopes of finding new ways to prevent the next wave of infections. Trained as a viral geneticist at the University of Texas at El Paso, Kugelman, bespectacled and with the shaved head of a career Army man, is serious about his work at USAMRIID. He arrived in Monrovia on November 17, 2014, armed with an Illumina MiSeq, a high-tech gene sequencer about the size of an office printer.
The MiSeq is an extremely expensive, extremely delicate machine, designed to sequence the genetics of any given specimen. Sequencing any Ebola virion, isolating the base pairs of A, T, C, and G proteins that make up RNA, would take between three and seven days; Kugelman’s mission was to sequence as many samples as possible, to understand the various threads of infection that had radiated out from Meliandou nearly a year beforehand. Diagramming those infection chains would help virologists understand how Ebola spread, and how it had mutated along the way.
The company that produced the machine knew it would not be able to send engineers to the hot zone to conduct repairs in case something went wrong, so Kugelman took a two-week course to become a certified engineer qualified to fix the MiSeq. Illumina bent over backward to help, maintaining a twenty-four-hour rotation of technicians based in London and the United States to advise Kugelman if he needed help. The technicians and the course came in handy immediately. The day Kugelman arrived, the local contractor hauling the sequencer to his makeshift laboratory dropped the box. The machine broke, but Kugelman had the skills to repair it using only the tools at his disposal.
“It survived a pretty close to worst-case scenario,” Kugelman chuckled later, nervously eyeing his delicate machine as it sat on his desk at Fort Detrick.
From the start, Kugelman and his small team had to cart in virtually everything they needed to do their work. Their lab had no clean water, no fuel for generators that kept the machines whirring. They were working on a biosafety level-4 (BSL-4) pathogen in what amounted to BSL-2 conditions, with far fewer safety precautions than they might have liked. Kugelman kept three backup battery packs, each with about seven hours of life, on standby to make sure the MiSeq and their computers would not shut off in the middle of hours-long sequencing processes, so they wouldn’t lose their work. Power spikes kept blowing out converters as surges coursed through the system. The results they generated would lead to a better understanding of how Ebola worked—and later, the virus’s lasting effects on someone who had survived its initial, devastating onslaught.
As Kugelman worked, the first Army-built Ebola treatment units began opening in Liberia. But by then, the infection curve had begun to level off from its exponential growth in September, October, and the early part of November. That meant the demand for beds to treat Ebola patients dropped, and the Army had to decide whether to continue building the facilities already under construction. It was becoming clear that the military had planned to build more facilities than would actually be needed—a conundrum that led to some criticism back home, but Army officials thought it was a better problem than the one they would have faced had they built fewer than the number of facilities required.3