by Hans Rosling
“You must stop wearing your pale blue shirts,” Luke said. “These will make you look like one of us.”
He had a good reason for his gift. Most of the foreign staff employed in the battle against ebola were equipped with T-shirts, vests, and caps bearing the logos or initials of their organizations. My clothes had to show who I was: an official, employed by the Ministry of Health and the government of Liberia.
My role was to work with Luke’s staff to compile the figures and write the text of the daily, ten-page report, which Luke then checked and published.
The problem with the report soon became painfully obvious. The staff relied on a database provided by the CDC. The recording routines had functioned well enough during previous ebola outbreaks. In this outbreak, however, the daily number of confirmed cases was much larger than before.
On my first day, I discovered that not every one of the thirteen Liberian country districts provided daily reports. The reason was the irregularity of contact via email and telephone, and the outcome was that a classic error was introduced: the entry “zero” stood for “no new cases,” but where there was no report at all it was also entered as “zero.” My first intervention was to introduce a “black box” in the table when no report was available, instead of a zero.
Another problem was that getting in touch with the district officials reporting on ebola was done at the personal expense of ministry staff, who had to use their own phones and public phone cards to talk to colleagues in remote regions. The ministerial budget did not stretch to cover all these calls, and the international organizations, with their huge economic resources, had omitted to give telephone cards to key personnel, presumably to “prevent corruption.”
It did not take me long to set up a dedicated funding scheme by way of an agreement between Gapminder and the Liberian Ministry of Health. The aim was to provide free telephone cards for members of staff and there was only one restriction: the cards must be used both to contact colleagues, and to call friends and relations around the country every evening, to gather information and pick up on rumors of new cases. The only other, very strict rule was that anyone caught selling “air time” on the cards would be in deep trouble. The phone card fund was financed by minor donations from Swedish philanthropic sources who wanted to contribute to the fight against ebola, and administered by Gapminder. This highly cost-effective and quickly implemented measure was made possible thanks to my position at the ministry and support from The World We Want Foundation, the Jochnick Foundation, and the Anders Wall Foundation.
* * *
In August and September 2014, in the weeks running up to the publication of the academic article that finally prompted me to take action, the slums in Monrovia had suffered the world’s largest ever outbreak of ebola in a densely populated area. The CDC database had been built to accommodate separate inputs from three sources: first, an examination of the patient at home, second, an examination of the patient on admittance to a treatment facility, and third, the laboratory test results. By the second half of September, a few weeks before I arrived in Monrovia, this system had imploded.
Data collection became impossible because the three-step input requirement presupposed consistent identification of the patient at every stage, by an ID card or similar. One person had to take a note of the examination in the patient’s home; next the clinic staff had to report the admission; and, last but not least, when the patient’s blood sample had been analyzed in a laboratory, the result had to be added to that individual’s data set.
Because Liberians were identified only by name, address, age, and gender, and not by a unique identifying number, minor variations in the spelling of names or errors with house numbers could cause the entire thing to fall apart. It was perfectly possible for the same person to be counted three times. So, of course, no one trusted the figures. That also meant that the laboratories started entering the blood-sample data into their own Excel spreadsheets, which they did not share.
Everyone involved was more or less aware what was going on but no one in an advisory or executive position was prepared to accept the need for drastic change. A simplified reporting system had to be introduced to give the authorities a proper overview of the course of the epidemic. I drew up some new guidelines. As Luke looked through them he appeared worried: “What will the WHO say if we get rid of their format?”
“They will have to put up with it.”
As Luke continued to go through my suggestions, I stressed that we had to get the data in order fast, as we had a crisis on our hands. But what foreign agency could I possibly get to work on the huge backlog of lab data?
“I’m going to ask my boss in Stockholm. His name is Ola Rosling and he is actually my son. He is also a very fast Excel data compiler.”
The suggestion made Luke beam. Within a few hours, all the laboratory Excel files had been transferred to Ola. He got up early in the morning and began to compile all the test data from a total of 6,582 blood samples. First thing the following morning, I checked my email and found the completed and reliable graphic representation of the number of new cases of ebola. And happily, the graph indicated that the number of confirmed cases was already declining.
* * *
“I’ve figured out a good solution, I think,” Moses Massaquoi said one day at the beginning of December. Moses was a jovial man with an incisive mind. He carried the responsibility for all Liberia’s treatment facilities and was one of the country’s six leaders of the fight against ebola. What he had devised was a way to deal with an unexpected and rather irksome problem. That morning, a few Liberians and I had lingered after the end of the coordination meeting. I had just shown the latest graph, which showed that the number of new cases in Monrovia was continuing to fall and was now below ten per day.
Moses had also displayed a data set: the five functional treatment facilities in the capital were almost empty—there were six hundred unoccupied beds. The troubling fact was that several international organizations had been slow off the mark with the promised construction of the additional treatment units and now that they had finally been built, they were no longer needed.
“It wouldn’t have become a problem if these guys had simply accepted the facts and refrained from carrying out their plans,” Moses said and sighed deeply. He turned to Tolbert and explained that, regardless of what we had agreed with the heads of organizations at coordination meetings, foreign ambassadors took it upon themselves to see the president and insist on going ahead with the buildings. Apparently, it was hugely important to have reports of the opening ceremonies shown on television back home.
“It’s true, the president is under pressure. What’s this smart solution you’ve cooked up?” Tolbert asked.
“We arrange a solemn ceremony for them. Military choir and music, someone from the ministry on hand to thank the ambassador in front of the entrance. Staff lined up wearing full protective kit. Great TV, right? But we only let them hand over the units to us, not open them for admissions. Not until we’ve agreed on wider uses for patients with conditions other than ebola.”
Everyone grinned broadly at Moses’s brilliant idea.
“It could work. I’ll have a word with them,” Tolbert said, still laughing.
This exchange must not be misunderstood: the overwhelming majority of the international aid organizations made very valuable contributions. It was only when it came to reporting their work for outside audiences that most of them seemed ready to resort to gross manipulations. I assume the main reason was self-preservation, because they had to ensure financial support from their base, be it government grants or public donations. Or perhaps it could be about a particular charity boss securing their position. Whatever the reasons, from the Liberian perspective their behavior was not helpful.
During November, the number of new ebola cases in Liberia fell quickly. The outbreaks in the countryside were brought under control, one after the other. By the end of November, the graph suggested the epidemic c
ould be over before Christmas.
In order to avoid the illusion that we might soon give the all-clear, I re-plotted the graph with the cases shown on a logarithmic scale on the y-axis. It showed that the outbreak would end as it began—following a slow course with fewer and fewer cases but with sudden flare-ups. The success in the fight against ebola had to a large extent been due to the Liberian public having grasped what was needed, like local shops setting up hand-washing areas, and parents keeping children out of school.
During December, work to control the epidemic was marked by the psychological effects of sheer tiredness on the part of the clinical staff. Patients admitted to the nearly empty units were well cared for but the follow-up and, notably, contact-tracing was far from ideal. Data analyses were incomplete as work became routine for most people. It was very important to reset thought patterns—to re-prioritize. The guiding concept should be a phase-change, as I called it, of our main task: with the “fireman phase” completed, the “detective phase” must begin. It meant, among other things, that we registered cases by name rather than by numbers. The tracing of patient contacts must be perfect if this epidemic was ever going to be stopped.
This was why I decided, in the middle of December, to shift half of my work schedule away from epidemiological surveillance at the ministry to a new base in the office of the capital’s contact-tracing group. I also organized a “war room,” which was used for meetings dealing with the reports that came in every morning to the coordinator of the contact unit. The room was also a workplace for the epidemiologists employed by the international organizations at work in different sectors of the country.
One central task was to mark all cases on a detailed map of the city. Another, equally important one was to indicate on the map where possible contacts lived, as reported by patients. It gave us a citywide overview of the spread of the disease.
As soon as we found out that someone had died from ebola, we would compile a list of all physical contacts that the dead person might have had. During the very first few days after becoming infected, an infected individual was not infectious to others. It was when their symptoms were just becoming noticeable that we needed to isolate them. This was the key to stopping the spread of the virus. We scrutinized the lists and made daily rounds of home visits to find people who might have been close to an ebola patient.
One day, a boy went missing from a family on our list. His mother claimed to have no idea where he was. Actually, she was reluctant to tell us. In cases like this, we turned to Mosoka Fallah, a Liberian with a doctorate in epidemiology, a generous heart, and a sharp brain.
Mosoka went to talk to the woman. She was a single mother because her husband had left her. The boy had been taken away by his dad, she admitted. It happened now and then, and she couldn’t stop it. It is typical of the lot of women in poor communities. For one thing, there is no official help—no emergency services to call.
Gently, Mosoka persuaded her to get the boy back. Because she couldn’t afford the fares for a journey across the city, Mosoka gave her money and she agreed to go the next day.
Then she looked at the notes in her hand: “I can’t use these, such new, crisp notes. It won’t help if I crunch them up—he will see they’re new all the same.”
In the slums, bank notes are worn and tattered because they do the rounds hundreds and hundreds of times. Her former husband would spot straightaway that some wealthy person had given her cash in hand. She was frightened that he would become angry and uncooperative if he thought she was sharing any kind of information about their lives with people he didn’t know. Nothing must give her away.
So Mosoka fixed her up with old notes and she brought the boy home the following day. Not only that: because she now trusted Mosoka, she became a contact-tracer for us. Mosoka Fallah had understood that in the fight against epidemics, your mind must encompass a love of humanity as well as spreadsheets.
In the ebola epidemic, it was even more important than usual to empathize with people’s needs as well as to think in numbers. Identifying exactly where the numbers of new cases were increasing or decreasing was one of our hardest tasks, and burials created special problems in this regard. We could not understand why, in these extreme conditions, it was still essential to transport a corpse to the home village to be buried.
I remember one such case very well. A grandmother had contracted ebola, quickly became very ill and died. Her family had promised to fulfill her wish to be buried next to her husband. They kept their promise: they washed her body, clothed it in a nice dress and loaded it into a run-down taxi. The cab driver was paid risk money for the trip to the grandmother’s home village and the family jumped in next to the body. Granny was buried and ebola was spread to another village. We tried to communicate the precautionary message but often in vain.
It was hard to grasp why it should be so. How could people be so thoughtless? But it was not a matter of being clever or stupid. In the example above, it was all about love for a mother or a grandmother, the heroic woman who had helped her family all her life, perhaps also during the civil war. Was the most important duty to her or to the authorities? For most people, such choices were hard.
We knew we should be offering grants toward burials, and managed to do this toward the end of the epidemic for some cases. People were allowed to decide where to bury their dead but were given a shroud by the Red Cross, a body wrap that left the face exposed. The actual ceremony was conducted with the help of “funeral assistants” in protective clothing, who placed the body in the grave. It worked well as long as the assistants were humane as well as technically well-informed.
* * *
“Can I come in?”
There was a gentle knock and a woman put her head round the office door. Her black hair had been plaited into two beautiful, long, thin plaits that framed her face and flowed over her shoulders. I recognized her: Miatta Gbanya, the head of finance in the Ministry of Health who had been appointed deputy leader of the countrywide response to ebola. I invited her in and said that she was always welcome.
“I actually need to have a word with Luke. Do you know where he is?”
I didn’t, but expected him back soon because we had the daily report to go through.
This was near the end of November. Because the number of new confirmed cases was definitely shrinking, our days had become less hectic.
“Have a seat, you surely need a few minutes’ rest,” I said and pulled out a chair for her.
We had discussed official issues on several occasions but it was a privilege to spend a few minutes with the busiest civil servant in charge of ebola control. I knew that Miatta Gbanya grew up during the civil war, trained in nursing, and had joined the work of humanitarian organizations in the Congo and South Sudan. She later went off to Bangladesh to study at its best university and acquired a master’s degree in public health.
I admired her a great deal and also had a question for her that I so far had not dared to ask. She seemed in a good mood, so this might be the right moment to satisfy my curiosity.
“I have gathered that the worst time was the month before I arrived at the end of October. What was it like for you then? What was the most difficult thing you had to deal with?”
She looked thoughtful. So many bad things had happened then.
“Perhaps the very worst moment was at the beginning of October. I was on the phone to the States. They had been persuaded to donate extra generously to ebola control measures, but I had to tell them that they were about to make their funding conditional on the wrong things. I had my work mobile in my left hand…” She clapped her hand to her left ear. “Then my private mobile rang. It was my cousin, who sounded upset, and I asked the US negotiator to hold for just half a minute to let me take this other call. Fine, he said, but keep it short, our decision has to be made within a few minutes.”
She raised her other hand to the right ear: “My cousin was in tears. Her mother had become ill with fever and diar
rhea. My cousin had taken her to an ebola clinic but they couldn’t admit anyone, there was a queue already. ‘Please, can you help?’ So, there I was, with the responsibility for the nation on my left and for my dear aunt on my right,” Miatta said.
She fell silent. Her eyes were looking past me with her hands still covering her ears.
I whispered after a while: “What did you choose, your nation or your family?”
Now Miatta looked me in the eye.
“I chose the nation, just as all of us in leadership positions did that autumn. As we did here in the Ministry of Health every single day. During the day, we never stopped working. But at night we wept for the dead, for our friends and colleagues and relatives. Then, slowly, we got the support we needed and began to win against the virus.”
I asked the final, necessary question: “What happened to your aunt?”
“She died. It was ebola,” Miatta said, as if it had been inevitable.
We were silent for a long while and then I spoke again: “I have been extremely impressed by the work you are all doing. Before I came here, I had accepted what the European media was saying—that the situation was chaotic before international epidemiologists took control.”
“Sure. I realize that’s how we are portrayed. They are all so crazy about their own organizations. Some of them are great and bring lots of very fine people here to help us. But they want to be praised, the more the better.”
She was laughing rather cynically when Luke came in.
“What, are you laughing at me when my back is turned?” he said jokingly.
“No way, we’re laughing at the sharks who love being praised,” Miatta said happily.
I had already noted that when the leading Liberians felt irritated and exhausted, they used this term for international organizations: “the sharks.”
