by Reid Wilson
Zika broke out of central Africa first in 2007, when it showed up on the island of Yap in Micronesia. Micronesia is remote, but Brazil is not, and by 2015, WHO had reported the first series of cases in South America’s most populous country. Within months, the virus had raced north, through Suriname, across the Panama Canal into El Salvador, Guatemala, and Mexico, and through the Caribbean islands of Martinique, Barbados, and Haiti.
On December 31, 2015, WHO reported its first case on American soil, on the island of Puerto Rico.
The staff inside any White House takes its direction from the tone and tenor set by the president they serve, and under President Obama, officials had maintained their cool during the Ebola outbreak, even when critics called them aloof and out of touch. But Obama had paid the political price for calm when Americans wanted evidence of decisive action, and he would not make the same mistake as Zika-plagued mosquitoes flew north.
“With Zika, we were out very early and very often from here,” Amy Pope said in an interview in the ornate conference room inside the Eisenhower Executive Office Building once reserved for the secretary of war. “Then, we kind of took a back seat and we didn’t see our role as publicizing what was happening on Ebola.… I think in hindsight our better course of action was to be more proactive. With Zika, here’s what it is. Here’s what we’re requesting money for. Here’s where our gaps are. And that’s all in response to Ebola.”
But even with more weapons in the arsenal, the global response has not stopped hundreds of children from suffering Zika’s most horrific effects, like microcephaly, which causes infants to be born with underdeveloped brains. In the United States, Congress refused the Obama administration’s requests to allocate billions of dollars to fight Zika, despite bipartisan support from Florida Senator Marco Rubio, a Republican whose state suffered the lion’s share of infections on the mainland. Instead, Congress forced the White House to reallocate millions of dollars initially intended to fight Ebola, and to bolster the health systems both at home and abroad. Even after the Ebola scare, politics got in the way of the longer-term mission of building the global capacity to stop the next big outbreak.
What every epidemiologist, virologist, and public health expert agrees on is that the question the world faces is not whether the next big outbreak is coming, it is when. And mankind is sowing the seeds that will both speed the next outbreak and probably exacerbate its spread.
“You’ll see other zoonotic diseases. I think you’re going to see them more frequently. The idea that they’re going to be, as they have been in the past, small and rural in nature is, in my view, unlikely. You just have a different level of urban integration and migration now, even in places like Asia and Africa,” the former USAID director Rajiv Shah said.
Technological innovation beginning with jet aircraft has created a world in which almost anyone is only a plane connection away from the nearest hub airport, and from there only a handful of hours from New York or London or Beijing. A growing middle class in Africa, the Middle East, South America, and Asia means that more of us than ever have the financial ability to travel the globe.
At the same time, widespread poverty and the exploding human population means that we are living more densely than ever before and spreading our settlements farther into nature that has never contended with modern human civilization. In equatorial nations, slums abut wilderness, and the expansion of human settlements is decimating rainforests at a torrid pace. Human industrial activity is changing the global climate so much that tropical and subtropical zones are expanding north and south, away from the equator, which means mosquitoes and other creatures that could host new pathogens can now venture ever farther into newly habitable climate. The expansion of human civilization, an interconnected world, and a changing climate all conspire to pave the way for the spread of the fire of the next deadly pathogen.
Scientists fear that next pathogen will be some horrible combination of the worst traits of diseases like Ebola, Zika, and the common flu. A virus with the lethality of Ebola, carried by something as widespread as the common mosquito like Zika, and transmissible between humans like the flu is the stuff of Tom Frieden’s nightmares.
“We always worry about flu. Flu is always the one that could do just terrible things, and that’s something that we need to be continuously” vigilant about, Frieden said. “It spreads readily, and it kills a relatively high proportion of people if you get the wrong strain.” He cited the Spanish influenza as our nearest comparison, a disease that infected as much as a quarter of the world’s population during the early part of the twentieth century, killing 40 million people in the process.2 Devastating though it was, that virus only killed about one in forty victims, or about 2.5 percent of those infected. Even something doubly as lethal, or less than a tenth as deadly as Ebola, would kill hundreds of millions of people today.
The next fire is coming, maybe from Kinshasa, maybe from Karachi, maybe from Kolkata or Kuala Lumpur or Kansas City. Someday in the future, it will leap from its host species into an unsuspecting human, who may then board a plane or infect a neighbor. As it spreads from Patient Zero, the global community will need to race back into the fire, identify the pathogen, identify a treatment and stop it before it spreads out of control.
The Ebola virus disease that ravaged Liberia, Guinea, and Sierra Leone was a devastating tragedy that claimed more than 11,000 lives, left three nations in ruins, and exposed a global health system left scrambling to stop its spread. If Ebola leaves a lasting legacy, Shah said, it should be as a wakeup call.
“There are so many much more scary pathogens out there,” he said in his office overlooking Pennsylvania Avenue, just a block from the White House. “The world is still completely unprepared for it.”
Acknowledgments
THIS BOOK WOULD NOT have been possible without the cooperation and support of dozens of people who worked to confront the Ebola outbreak, in Liberia, Guinea, and Sierra Leone, in Geneva at the World Health Organization (WHO), at the White House, the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID).My thanks go to all of them, including—but not limited to—Ron Klain, Anthony Fauci, Tom Frieden, Amy Pope, Gayle Smith, Rajiv Shah, Jeremy Konyndyk, Randy Schoepp, Robert Garry, Senator Chris Coons, Fabian Leendertz, Chris Dye, Julio Frenk, Lieutenant Colonel Ross Lightsey, Colonel Brian Gentile, Captain Jeff Kugelman, and Major General Gary Volesky. I was fortunate enough to speak with Hans Rosling, the Swedish physician and statistician, several months before he passed away in February 2017.
Among the dozens of U.S.-based nongovernmental organizations that mobilized to fight the outbreak, three were particularly generous with their time: the CDC Foundation, and its former president Charlie Stokes; Global Communities, where Piet deVries and Brett Sedgewick sat for long interviews; and World Vision, and the unfailingly gracious David Robinson.
At the CDC, Leisha Nolan, Barry Fields, Peter Kilmarx, John Brooks, David Blackley, Joe Woodring, Kimberly Lindblade, Dan Martin, John Redd, and Blanche Collins endured hours of questions. Benjamin Haynes, Erin Sykes, and Mansi Das helped set up interviews and graciously dealt with a thousand fact-check requests. At USAMRIID, Caree Vander Linden organized an eye-opening visit to Fort Detrick, where Colonel Gentile, Schoepp, Captain Kugelman, David Norwood, Travis Warren, and others patiently explained the science. Captain Michael Schmoyer of the U.S. Public Health Service donated his time as well. At the White House, Peter Boogaard, Ned Price, and Eric Schultz helped with background and arranging interviews. Max Gleischman, who accompanied UN Ambassador Samantha Power on her trip to West Africa, provided insights into the international response at the United Nations. Lieutenant Colonel Lightsey spent hours on the phone answering questions.
I leaned heavily on contemporaneous on-the-ground reporting from journalists including Joshua Hammer, who documented the heartbreaking final days of Sheik Umar Khan; Richard Preston, w
riting in the New Yorker; Bryan Burrough, who reported in Vanity Fair on the response to the outbreak in Dallas; Norimitsu Onishi, who reported from the ground for months for the New York Times; and others. WHO, Médecins Sans Frontières, and the CDC all documented their own work, much of which I used to give the fullest possible picture. Preston himself may have planted the seeds of this book two decades ago with his own book, The Hot Zone, and the subsequent movie version, Outbreak, which I still remember seeing in middle school. I was inspired by authors whose books have covered previous outbreaks, including Laurie Garrett’s The Coming Plague, and David Quammen’s Spillover.
At Brookings Institution Press, my thanks to editorial director William Finan and managing editor Janet Walker for their interest in this story, and for dealing with a nervous first-time author who probably sent them too many drafts. I’m grateful to my colleague Ashley Perks, design director at The Hill, who designed the beautiful map of Liberia, Guinea, and Sierra Leone. Matthew Carnicelli, of Carnicelli Literary Management, provided valuable guidance as this book came into being.
And thanks, as well, to the mentors who have shepherded my career in journalism: Chuck Todd, who gave me my first job and trusted me to help his own book project; Bob Cusack; Steven Ginsberg; and too many more to count. Cynthia Wilson, my mother, taught me how to write as I grew up. Bart Wilson, my father, struck the delicate balance between encouraging me and offering constructive criticism. My wonderful wife Veronica didn’t let me give up when my writing struggled, and our son Max, who joined us as this book was being finalized, is an incredible gift.
There is no way to compile the stories of the thousands of people, Liberians, Sierra Leoneans, Guineans, Americans, Brits, and French, who raced toward the fire when others ran away, or to tell the stories of the more than 28,000 people who fell victim to Ebola, and the holes left behind by the 11,000 who died. One can hope that the vaccine finalized in late 2016 will mean there are no more stories of future Ebola outbreaks to tell.
I am incredibly grateful to all who participated in this project.
Notes
Chapter 1
1. Almudena Mari Saéz and others, “Investigating the Zoonotic Origin of the West Africa Ebola Epidemic,” EMBO Molecular Medicine 7, no. 1 (January 2015), pp. 17–23.
2. Sylvain Baize and others, “Emergence of Zaire Ebola Virus Disease in Guinea,” New England Journal of Medicine 371 (2014), pp. 1418–25; Saéz and others, “Investigating the Zoonotic Origin.”
3. Jeffrey E. Stern, “Hell in the Hot Zone,” Vanity Fair, September 11, 2014 (www.vanityfair.com/news/2014/10/ebola-virus-epidemic-containment).
4. See Centers for Disease Control and Prevention, “Lassa Fever” (www.cdc.gov/vhf/lassa/).
5. Stern, “Hell in the Hot Zone.”
6. Pierre Formenty, “Ebola Diaries: First signals—March 2014” (www.who.int/features/2015/ebola-diaries-formenty/en/).
7. Kevin Sack and others, “How Ebola Roared Back,” New York Times, December 30, 2014.
8. Ibid.
9. Formenty, “Ebola Diaries.”
10. Sack and others, “How Ebola Roared Back.”
11. Stern, “Hell in the Hot Zone.”
Chapter 2
1. David Quammen, Spillover: Animal Infections and the Next Human Pandemic (New York: Norton, 2012).
2. Thucydides, History of the Peloponnesian War, book 2, chapter 7.
3. Laurie Garrett, The Coming Plague: Newly Emerging Diseases in a World Out of Balance (New York: Farrar, Straus and Giroux, 1994).
4. For an in-depth history of Ebola outbreaks, see Quammen, Spillover.
5. Jeffrey Taubenberger, “The Origin and Virulence of the 1918 ‘Spanish’ Influenza Virus,” Proceedings of the American Philosophical Society 150 (March 2006), pp. 86–112.
6. Quammen, Spillover.
7. Garrett, The Coming Plague, p. 123.
8. World Bank, OECD statistics (http://data.worldbank.org/indicator/NY.GDP.MKTP.CD http://data.worldbank.org/indicator/SP.DYN.LE00.IN?view=chart).
Chapter 3
1. Rob Fowler, “Ebola Diaries: Fighting an Uphill Battle,” World Health Organization, April 2014 (www.who.int/features/2015/ebola-diaries-fowler/en/).
2. Stéphane Hugonnet, “Hitting the Ground Running,” World Health Organization, March 2015 (www.who.int/features/2015/ebola-diaries-hugonnet/en/).
3. Jeffrey Stern, “Hell in the Hot Zone,” Vanity Fair, September 11, 2014.
4. Quoted in “ ‘Ebola Not in Liberia,’ ” Liberian Observer, March 27, 2014.
5. Quoted in ibid.
6. Stern, “Hell in the Hot Zone.”
7. Quoted in “Liberia Needs US$1.2M to Contain Ebola,” Liberian Observer, March 28, 2014.
8. Fowler, “Ebola Diaries.”
9. “How Ebola Roared Back,” New York Times, December 29, 2014.
10. Cristiana Salvi, “Ebola Diaries: Regaining the People’s Trust,” World Health Organization, April 2014 (www.who.int/features/2015/ebola-diaries-salvi/en/).
Chapter 4
1. As posted on Twitter @HaertlG, April 1, 2014 (https://twitter.com/HaertlG/status/451023126185672704).
2. “How Ebola Roared Back,” New York Times, December 29, 2014.
3. Ibid.
4. Lisa George, “CDC Steps Up Response to Ebola Outbreak in West Africa,” August 13, 2014 (http://news.wabe.org/post/cdc-steps-response-ebola-outbreak-west-africa).
5. “How Ebola Roared Back.”
6. Ibid.
7. Ibid.
8. Richard Preston, “Inside the Ebola Wars,” New Yorker, October 27, 2014.
Chapter 5
1. “How Ebola Roared Back,” New York Times, December 29, 2014.
2. Helene Sandbu Ryeng, “Harisson Sakilla: Liberia’s First Ebola Survivor,” medium.com, April 15, 2015 (https://medium.com/ebola-stories/harisson-sakilla-liberia-s-first-ebola-survivor-881309013a61).
3. Richard Preston, “Inside the Ebola Wars,” New Yorker, October 27, 2014.
4. Madeline Drexler, “On The Ground: Alumnus Battles the Nightmare in Liberia,” Harvard Public Health Magazine, December 16, 2014 (www.hsph.harvard.edu/magazine/magazine_article/the-ebola-response/).
Chapter 6
1. Joshua Hammer, “My Nurses Are Dead and I Don’t Know If I’m Already Infected,” medium.com, January 12, 2015 (https://medium.com/matter/did-sierra-leones-hero-doctor-have-to-die-1c1de004941e).
2. Quoted in “Interview: Sierra Leone’s Ebola Doctor Feared for His Life,” Politico SL, May 8, 2014 (http://freemediasl.com/articles/interview-sierra-leones-ebola-doctor-feared-his-life).
3. Erika Check Hayden, “Infectious Disease: Ebola’s Lost Ward,” Nature, September 24, 2014.
4. Ibid.
5. Quoted in “Interview: Sierra Leone’s Ebola Doctor.”
6. Hayden, “Infectious Disease.”
7. Denise Grady and Sheri Fink, “Tracing Ebola’s Outbreak to an African 2-Year-Old,” New York Times, August 10, 2014.
8. Hayden, “Infectious Disease.”
9. Hammer, “My Nurses Are Dead.”
10. Ibid.
11. Ibid.
Chapter 7
1. Folasade Ogunsola, “How Nigeria Beat the Ebola Virus in Three Months,” theconversation.com, May 13, 2015 (http://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372).
2. World Health Organization, “Nigeria Is Now Free of Ebola Virus Transmission,” press release, October 20, 2014 (http://who.int/mediacentre/news/ebola/20-october-2014/en/).
3. Michael Daly, “How Bureaucrats Let Ebola Spread to Nigeria,” DailyBeast.com, August 14, 2014.
4. Ibid.
5. Katherine Harmon Courage, “How Did Nigeria Quash Its Ebola Out
break So Quickly?” Scientific American, October 18, 2014.
6. Daly, “How Bureaucrats Let Ebola Spread.”
7. Will Ross, “Ebola Crisis: How Nigeria’s Dr. Adadevoh Fought the Virus,” BBC News, October 20, 2014 (www.bbc.com/news/world-africa-29696011).
8. Courage, “How Did Nigeria Quash Its Ebola Outbreak?”
9. F. O. Fasina and others, “Transmission Dynamics and Control of Ebola Virus Disease Outbreak in Nigeria, July to September 2014,” Eurosurveillance 19, no. 4 (October 9, 2014) (http://eurosurveillance.org/images/dynamic/EE/V19N40/art20920.pdf).
10. Daly, “How Bureaucrats Let Ebola Spread.”
11. Courage, “How Did Nigeria Quash Its Ebola Outbreak?”
12. Fasina and others, “Transmission Dynamics and Control of Ebola Virus.”
Chapter 8
1. Lisa Abbott, “Notable Alumni: Dr. Kent Brantly,” Heritage Christian School (www.heritagechristian.net/discover/notable-alumnni/post/~board/notable-alumni/post/kent-brantly).
2. Brenda Goodman, “The Race to Save Dr. Brantly: The Inside Story,” WebMD.com, September 12, 2014 (www.webmd.com/a-to-z-guides/news/20140912/saving-kent-brantly#1).
3. “Ebola Survivor Nancy Writebol: All Doctors Could Say Was ‘We Are So Sorry,’ ” NBC News, September 3, 2014 (www.nbcnews.com/storyline/ebola-virus-outbreak/ebola-survivor-nancy-writebol-all-doctors-could-say-was-we-n194361).
4. Alexandra Zavis, “Ebola Doctor’s Dilemma: Two Patients, and Drugs Enough for One,” Los Angeles Times, December 24, 2014.
5. Goodman, “The Race to Save Dr. Brantly.”
6. Richard Preston, “Inside the Ebola Wars,” New Yorker, October 27, 2014.