Inferno

by Steven Hatch, M. D.

  The mystery deepened. The Sudan outbreak of 1976 would prove to be an Ebolavirus, but although its behavior in humans was roughly similar to that of the Zaire strain—it was, indeed, a little less lethal—its structure was not identical. While the basic internal machinery of the virus was the same, the proteins that coated the surface of the virion were shaped differently. In the laboratory, antibodies that were highly specific for the virus from the Yambuku patients could not latch on to the virus from the Sudanese patients. However, less specific antibodies cross-reacted with both types. Thus, two strains of Ebola had been discovered that year: the Sudan Ebolavirus and the Zaire Ebolavirus. It was the latter that would reappear in Meliandou.

  But in 1976, just as quickly as it had begun, the screaming abruptly halted. In 1979, a small outbreak occurred in the town of Nzara, the same location as the original Sudan outbreak. Nearly three dozen people were infected, and two-thirds of them died. After that, however, human Ebola would not be heard from again for more than fifteen years. Then, starting in the mid-1990s, the virus would burst back in terrifying paroxysms that would affect not only Sudan and the now newly named DRC, but also Gabon, Uganda, and the Republic of the Congo. The outbreaks would return almost yearly up to the present day, and these governments in Central Africa would learn to maintain extreme vigilance against the disease.

  The screaming then took an even more ominous turn. In 1989, an animal quarantine facility in Reston, Virginia, noticed some crab-eating macaques from the Philippine island of Mindanao—more than seven thousand miles away from Sudan or the DRC—had come down with an unexplained serious illness. Under the eyes of the electron microscope, it had the hallmark spaghetti-like appearance of a filovirus, and the nonspecific antibodies against Ebola lit up, which must have come as a serious shock to the scientists involved. Moreover, the disease was spreading inside the facility, as macaques from different shipments began to fall ill. This strongly implicated that the pathogen wasn’t transmitting through direct creature-to-creature contact, as had all previous accounts of Ebola transmission.

  You couldn’t have scripted a more unsettling scenario: Not only had one of the world’s deadliest viruses nestled itself into the United States, it was an airborne strain of the disease. And it was within a half hour’s drive of the nation’s capital. Because of this, several years later, when Richard Preston penned The Hot Zone in 1995, very little needed to be exaggerated for the book to live up to its subtitle: A Terrifying True Story. The core story of the Reston outbreak in the hands of a masterful writer such as Preston quickly turned The Hot Zone into an international best seller, and Ebola captured the popular imagination. At almost the same time, a more comprehensive and scholarly consideration of the subject of emerging infectious diseases (of which Ebola was one small chapter) had come out, and Laurie Garrett’s The Coming Plague also catapulted to fame.

  The only good news from the 1989 Reston outbreak was that it appeared not to cause disease in humans, as a half dozen of the workers involved in the incident were found to have antibody responses to the virus, even though they never became ill. The more sobering news, which wasn’t much emphasized in The Hot Zone, was that the Reston Ebolavirus could be found almost halfway around the world from the previous outbreaks, and in a place where the citizenry travels much farther and with much greater frequency. It indicated there were biological threats out there of which we were only dimly aware, and they were capable of exploiting ways in which humanity was organized in the late twentieth century that might, at its worst, threaten civilization itself.

  The release of The Hot Zone and The Coming Plague in 1995 couldn’t have been more serendipitous, for in that year perhaps the scariest of Ebola outbreaks until then took place, when the virus made its first truly urban appearance in Kikwit, a city of around two hundred thousand people in the country then called Zaire. As with the initial outbreaks, more than three hundred people became infected; the case fatality rate was 80 percent. But the Kikwit outbreak did more than just boost sales and make publishers happy, for it got people thinking about what might happen if Ebola was discovered in a truly large African city—say, of one or two million people. Those cities, of course, have airports with international destinations. And by the late 1990s Africans were traveling more and more, and to every corner of the world.

  *

  Emile Ouamouno fell ill in late December 2013.2 Nobody knows what his precise symptoms were because hardly anyone who cared for him is left alive. He had a fever and may have had a headache. He reportedly had bloody diarrhea. Of course, dozens of diseases can cause bloody diarrhea, all of them considerably more common than Ebola, which had not been seen before in Guinea. This is a book about Ebola, but it is worth pointing out that infectious diarrhea remains among the biggest killers of children under the age of five in this part of the world. Baby Emile was much more likely to have rotavirus, enterohemorrhagic E. coli, non-typhoidal Salmonella, or Campylobacter, among many other organisms, than anything so exotic as Ebola. The global health community has made considerable progress in preventing such deaths, cutting the mortality rate in half over the past fifteen years. It’s actually a great story that should be told to the public. Yet, despite this uplifting advance, more than half a million children annually still die of this largely preventable and treatable condition, which is virtually unheard of in the West.

  Emile, of course, did have Ebola. He died on December 28. The death of a child in this setting is not all that uncommon; on average, nearly one out of every ten children born in sub-Saharan Africa does not live to see their sixth birthday. But the despair of the Ouamouno family would not end there. On New Year’s Day 2014, Emile’s three-year-old sister Philomène became ill and would follow Emile to the grave by January 5. Both were cared for by Sia, who was then seven months pregnant with her third child. The fever hit her the day after Philomène died. Sia had a miscarriage on January 11 and died that same day. Emile and Philomène’s grandmother, Koumba Ouamouno, cared for all of them. Her symptoms started the same day Sia miscarried, which meant that she had been incubating the virus for at least a few days, perhaps more.

  Koumba sought care in a hospital in Guéckédou, and from there the linear chain of the West African outbreak starts to expand in multiple directions. A midwife became ill at the hospital; one of her close relatives traveled north from Guéckédou to a village known as Damdou-Pombo, and a half-dozen people there were killed. Another staff member at the hospital traveled east to Macenta, a city of nearly a hundred thousand people, and a chain of transmission started there. A doctor in Macenta died and was transported back to his ancestral home in Kissidougou, a city of about the same size. His brothers prepared his body for the funeral, and they became infected and started an epidemic there. Another person carried the virus from Guéckédou to a different village called Dawa. By then, several weeks had passed, and the outbreak had quietly begun to creep outward. The virus was edging along, as if to test its boundaries.

  The Zaire Ebolavirus had several advantages in its ability to cause destruction in West Africa that an identical copy of it would have lacked in Central Africa. First, it had never been seen before in any of these countries, so local health officials were slow to recognize what was happening. One of the initial beliefs was that it was cholera, and since cholera was largely a regional concern rather than an international crisis, time was lost in the initial diagnosis.

  Second, there wasn’t much of a health infrastructure in place for local officials to even see the data. To track an outbreak of any kind, from the most feared, like Ebola, to the most mundane, like a diarrheal outbreak in Iowa following a family reunion one August afternoon, cases have to be carefully tracked and recorded. For that to happen, there needs to be someone paid to do this—typically this is a function of government—and there needs to be a centralized bureaucracy to collect and process the information. But Guinea was not only poor; its southeastern corner had felt the ripples from Liberia’s Civil War, as tribal allianc
es brought Guineans into the conflict, with the result that an already impoverished corner of the world had damaged what tenuous infrastructure was in place. Of the three countries of Guinea, Sierra Leone, and Liberia, Guinea might have been in the best shape in this respect, but that wasn’t saying much.

  Third, there was a new technology that permitted the virus to travel vast distances in a fairly short time. It wasn’t cars or airplanes, which were luxuries far too costly for poor agrarian communities in this part of the world. But it was at some level the underprivileged person’s solution to achieving mobility: the motorcycle. Cheap, relatively easy to maintain, far more gas efficient than cars, and much more versatile in narrow and muddy country jungle roads than buses, motorcycles provided the perfect answer for remote villagers needing cheap transportation to sell their wares and engage in trade. One or two generations before, travel from a place like Meliandou to Guinea’s capital of Conakry could take many days and be exorbitant. With motorcycles, one could travel not only to Conakry but to Sierra Leone’s capital of Freetown or Liberia’s capital of Monrovia in less than a day. Whole fleets of motorcycles could be found in the regional centers, and ferrying passengers around became an important part of the local economy. Riding on a motorcycle also requires close contact with the driver, which provided another chance for the virus to spread beyond normal traditional family or tribal routes.

  In short, it was an ideal place for a killer virus that moved at a Goldilocks pace—not too fast for people to recognize immediately that something was dangerously amiss, and not too slow for it to easily hitch a ride on its human host to make more copies of itself, but just the right speed to stay out of reach of local, regional, and eventually, world health authorities.

  Touch was how the virus spread. Any direct, skin-to-skin contact with an infected person, or the virus-filled fluids that issued from them, provided a chance for spread. Fortuitously for the virus, West Africans, whether Christian or Muslim, observe a funereal custom by which acquaintances pay their respects to the dead by touching the body directly and handling it as part of the burial rites. To decline to perform this action—something that public health authorities would soon advise—was tantamount to refusing to shake someone’s hand in the West for no apparent reason. It would have been regarded as obnoxious in the extreme, an affront to traditional values. The more funerals that took place, the farther the virus would spread.

  The recognition that this was an Ebola epidemic would not come until nearly the end of March 2014. At that time, blood samples had been taken by staff members of Médecins Sans Frontières, or MSF, the group known better to Americans as Doctors Without Borders, and were sent to Europe for testing. MSF had an inkling that something wasn’t right in the weeks before, and eventually the blood samples proved it. The WHO was informed and sounded the alarm.

  But other events were taking place in the world that had stretched the WHO thin. At the time, a virus known as MERS-CoV—the Middle Eastern Respiratory Syndrome Coronavirus—had generated a fair amount of alarm and was occupying the efforts of WHO officials day and night. And that was only the beginning. Dr. Robert Fowler, a physician working with the WHO at the time, said that the discovery of an Ebola outbreak in West Africa with everything else happening at that time was like “a plane crashes in the Hudson in the morning, and there’s a snowstorm in the afternoon and floods in the subways in the evening, and then you have two planes hit the World Trade Center in the middle of the night.” Moreover, the cash-strapped WHO was tasked with responding to the outbreak with a regional staff whose budget had been cut in half over the span of several years. To expand Fowler’s analogy, it was as if the calamities befalling New York were met with a response from a police and fire department working something very close to a skeleton crew.

  To make matters worse, politics got in the way. Ebola experts from the CDC and WHO’s headquarters in Geneva were initially stiff-armed by local African WHO officials, who wanted to “prove they could handle this one without help.” As guiding principles, self-sufficiency and self-reliance were the recipe for Africa’s future success. In an Ebola outbreak, however, that strategy backfired, and although no media reports can explain exactly how much of a delay these back-channel arguments caused, precious time may well have been lost in the early days.

  Then came what almost any impartial observer would regard as a moment of pure farce, perhaps the most darkly comic moment of the entire epidemic: A Twitter war broke out between public health organizations, as if one group had just dissed the other’s wardrobe. The WHO administrators appeared to regard the outbreak relatively lightly. “There has never been an #Ebola outbreak larger than a couple hundred cases,” wrote WHO spokesperson Gregory Härtl in the days following the announcement of the outbreak, later saying Ebola “has always remained a very localised event.” By this time, about fifty cases had been documented, in keeping with the size of many of the outbreaks that occurred during the 2000s.

  But MSF, whose ground intel was reporting a different story, reacted with incredulity, noting in a press release that “we are facing an epidemic of a magnitude never before seen in terms of the distribution of cases in the country.”

  Härtl’s tweet in response was nonchalant: “No need to overblow something which is already bad enough.”

  MSF took another turn, pointing out that it was hard to “overblow” the Zaire Ebolavirus, as it had now been identified: “This is the most deadly strain of the Ebola virus. It kills 9 out of 10 patients.”

  Almost immediately Härtl shot back, tweeting, “Don’t exaggerate. #Ebola can kill up to 90% of those infected and in this particular outbreak fatality rate is less than 67%.”

  MSF’s view of the matter would ultimately prove to be the more prescient of the two. However, Härtl’s final statistic of the case fatality rate for the West African outbreak did basically hold, which must have provided him some comfort in retrospect.

  What MSF had sensed, and what at least some of the people at WHO were oblivious to, was that this particular outbreak found itself in the perfect storm of destitute local governments, shoddy surveillance infrastructures, byzantine international bureaucracies, and societal observances such that it could be silently moving through the countryside unbeknownst to these groups, waiting for its chance to deliver a blow with crushing force. Yet that isn’t how it played out initially. March turned into April, and with it came a decline in cases. Guinea, which hit a peak in the first weeks of April, started to trend down. Liberia, which had seen a case or two in a village called Foya in the northwestern corner of Lofa County, could find nothing else. Sierra Leone still hadn’t registered a case at all. Härtl was on his way to being vindicated.

  Then came May, and Ebola did indeed roar back. The second wave, which would continue on through the next several months, was on a trajectory that had never been seen before. In a way, Härtl’s original statement was, strictly speaking, still correct: There never had been an outbreak larger than a couple hundred cases. What was happening in West Africa would be an n of 1.

  This was unprecedented. Sierra Leone saw its first case, and almost immediately those cases multiplied with frightening speed. Liberia’s previous flirtation with Ebola in March and April looked like a tremor before the real earthquake. And, of course, Guinea’s tally increased at the same rate. Ebola always had remained a localized event, but now it threatened to engulf three countries with a total population of about twenty-two million people simultaneously, with cases breaking out hundreds of miles from one another. This was no longer a single outbreak by previous definitions but had instead become a meta-outbreak where dozens of local outbreaks were taking place, and all in one of the least-prepared areas that could be imagined. Yet hardly anyone in the outside world was fully aware of this, even by late May. By contrast, the Kikwit outbreak of 1995, primed as it was by the popularity of Preston’s and Garrett’s books, had become front-page news much more rapidly.

  *

  Emile’s father, E
tienne Ouamouno, bore witness to the loss of his family, never having been infected despite having lived and breathed and slept right next to the virus for days on end, only belatedly aware of the danger it had posed to him. Whether the fact that he escaped its clutches makes him feel lucky or the opposite is a question I suspect he ponders often. A few brave souls from the international media came to Meliandou in the midst of the outbreak to interview him, and he spoke of how the events of the previous year had affected his outlook. “When I think about them, I feel very sad,” he said to the BBC in a video recorded in late 2014. “The pain is too much. I just can’t bear it. But then, I have to say to myself, ‘they’ve gone.’ I just have to accept it and move on.” He says this and then quickly looks away into the distance.

  Even before Ebola roared back, the villagers of Meliandou had realized that their neighboring communities looked at them, however unjustly, as the source of this scourge. The same effect that had been seen two generations ago in Lassa was again playing out in West Africa, as the farmers of Meliandou were unable to sell their produce on account of hailing from the outbreak’s Ground Zero. In an attempt to exorcise the evil they believed was in their midst, and perhaps to make some kind of a symbolic atonement for a wrong they didn’t commit, on March 24, 2014, they took torches to the tree in and around which Emile Ouamouno had joyfully played only a few months before. The tree, a living, being creature that would also become collateral damage just the same as Etienne Ouamouno and his fellow villagers, finally caught fire.