by Reid Wilson
The suits themselves are cumbersome; the air pumped in from tubes attached to a lab ceiling is loud, and it fills the suit like a balloon, making simple tasks ungainly. Researchers wear earplugs to protect themselves from the noise. Before being allowed to operate in a level-four atmosphere, students train in an unused BSL-4 lab classroom called the Slammer, where they practice building with children’s blocks, or rearranging a deck of playing cards. One room of the Slammer even has the game Operation, which helps test dexterity. The students will eventually operate in laboratories where rats and primates are infected with the planet’s deadliest diseases. One scientist dropped a casual hint about monkeys fighting off the Ebola virus in some back room. The author was not allowed into that back room.
The research conducted at USAMRIID, CDC, and NIH produced results: A decade after the anthrax attacks, NIH scientists had created a possible vaccine, and early trials were conducted among volunteers from the Washington area, and in close American allies in Africa like Mali, Kenya, and Uganda.
It also produced an intriguing scientific mystery. Scientists from USAMRIID, the Army’s chief medical laboratory, had been studying hemorrhagic fever in West Africa for years, led by Dr. Randy Schoepp, aided by a team from Tulane University, headed by Dr. Robert Garry, and a private pharmaceutical company based in San Francisco called Metabiota. They set up shop at a hospital in Kenema, Sierra Leone’s third-largest city, where they built the world’s only ward dedicated to treating Lassa.
Kenema, near the border with Liberia, had long played an important role in scientists’ struggle to understand viral hemorrhagic fevers, specifically Lassa. The CDC had set up an outpost at Kenema Government Hospital in the 1970s, where some of the earliest work on the rodent-borne disease took place. (The first CDC investigator to be deployed to Kenema, Joe McCormick, hadn’t even gotten a chance to unpack his equipment from its shipping containers before he was temporarily diverted to Yambuku, to fight the Ebola outbreak there.7)
But many of the samples of possible Lassa cases Schoepp and Garry were seeing were testing negative. Of the five hundred to seven hundred suspected Lassa cases in Sierra Leone in the years between 2006 and 2008, which Schoepp analyzed, only about 30 to 40 percent were testing positive. The rest of the victims had suffered from something else—some other hemorrhagic disease that was present, albeit on the margins, in the jungles of West Africa. Schoepp’s team isolated the antibodies, a body’s response to the presence of a pathogen: They looked remarkably similar to Ebola antibodies. Garry’s research indicated that similar antibodies had been present in the region for up to a decade.
That did not make sense. Unlike Uganda, Gabon, Congo, and the Democratic Republic of the Congo in Central Africa, West Africa had only ever seen one confirmed case of Ebola, when a Swiss graduate student working on dead chimpanzees in a national park in Côte d’Ivoire fell ill. The student had contracted a new strain of the disease, called the Tai Forest strain, or TAFV; she survived. The TAFV strain has never been documented in another human.
Schoepp’s team initially believed they had found new evidence of the TAFV strain of the virus. But the more they studied the antibodies, the more they concluded they might be looking at the much more deadly EBOV strain. “That was a good indication to us that there was Ebola Zaire circulating in Sierra Leone, Guinea, and Liberia” before the 2014 outbreak, Schoepp said later.
Few believed him, and the rigors of scientific research precluded Schoepp from reaching a definitive conclusion. Though the antibodies were present, scientists could not isolate a strain of the virus itself, meaning they could not prove without a doubt that Ebola Zaire was present. “Nobody believed there was Ebola in West Africa,” Schoepp said. Still, he concluded, it was likely that Ebola had broken out, possibly routinely but never disastrously, long before 2014. Garry believed he had evidence that showed Ebola had started small, infecting just a few people a year, then grown and grown. The question in his mind was not whether one of those minor outbreaks would spread and kill thousands—but when.
By the time the NIH’s vaccine was in phase one tests, gauging the safety and effectiveness, called immunogenicity, in humans, Emile was sick. And unlike earlier outbreaks, Ebola began speeding toward major population centers.
That Ebola would migrate thousands of miles away to those three countries seemed at first to be an almost impossible stroke of bad luck. The colonial powers that departed from West Africa in the 1950s and 1960s left behind two countries—Sierra Leone, once a part of the British Empire, and Guinea, a French colony—in desperately poor shape. Both powers had treated their African subjects terribly; French colonizers forced Guineans to build roads and tap rubber trees, and the British used Sierra Leone and what is now Liberia as the base of operations for the slave trade from the sixteenth to the nineteenth centuries.
Liberia’s own history is even more complex. Established in the nineteenth century as a new home for freed African, African American, and Caribbean slaves, it was the first nation in Africa to formally gain independence, when the United States recognized it in 1862. The freed slaves who returned to Liberia in the nineteenth century did not arrive in an empty land, and occasional battles between indigenous tribes, which make up about 80 percent of the country’s population, and the descendants of former slaves cost hundreds of thousands of lives. Even today, Liberia has two parallel governing structures: a formal government, populated largely by descendants of former slaves centered in Monrovia, and a tribal power structure, consisting of a complex hierarchy of town and provincial chiefs, all the way up to a national level. Lower-level officials on the two sides work closely together; the higher up the ranks, the worse the professional relationship.
Formed from the ashes of the Western slave trade, struggling to recover from decades of internal strife and tribal conflict, the three nations are impoverished even by African standards. They are tied together by history, thanks to Western meddling and centuries of tribal ties, and by geography. On a map, Guinea seems to enfold the other two nations, the artificial borders drawn by European hands, the results of an agreement formalized in 1895, thousands of miles away at a signing ceremony attended by colonial British and French diplomats in Paris. Guinea’s capital, Conakry, is the northernmost of the three; Guinea wraps east into the interior, then around its two neighbors. Sierra Leone lies south of Guinea, its own southern border shared with Liberia. All three capitals, Conakry, Freetown, and Monrovia, founded by Europeans and Americans centuries ago, face the Atlantic Ocean.
Death is no stranger to West Africa. All three countries have been torn apart by civil wars and ruthless dictators. All three have supported insurgencies in their neighbors. Up to half a million Liberians died in civil wars between 1989 and 1997, then again between 2000 and 2003, in which rebels funded by Sierra Leone and Guinea clashed with the government run by the brutal Charles Taylor. About 50,000 Sierra Leoneans died in a decade-long civil war that ended in 2001; United Nations peacekeeping troops spent the following five years disarming rebel groups, before leaving in 2005. Guinea’s president Ahmed Sekou Toure funded wars across the region.
On a continent with a long and deadly history of colonial rule, the three West African nations are unique, both for their dependence and independence. Portuguese traders first explored the coast of West Africa in the late fifteenth century. The explorer Pedro da Cintra was the first to name the mountains near the coast, which he called the Lion Mountains, or Serra Lyoa in his native tongue. Other colonizers would eventually exert their own spheres of influence. The first British settlements were established in Sierra Leone in the mid-1600s, from which raiders kidnapped Africans to send to the new world. The first African slaves arrived in North America in the middle of the seventeenth century. French troops established themselves in what is now Guinea about a century and a half later, marauding through the interior attacking the Malinke tribe.
Early movements to find new homes for freed black slaves in Britain and the United States gave bi
rth to modern Sierra Leone and Liberia. In 1792, the Committee for the Relief of the Black Poor sent 1,200 free blacks on 15 ships from British-controlled Nova Scotia to establish a colony christened Free Town. In 1822, the first ship carrying 37 settlers and 10 liberated slaves from the Virginia colony arrived on Cape Montserado, which had been purchased from a local tribal chief by the American Colonization Society. Within the next decade, another 2,600 freed blacks moved from America to the new town, first called Christopolis, then renamed Monrovia—the only capital of a foreign country to be named after an American president, James Monroe, who helped secure a $100,000 congressional appropriation to establish the settlement. (The movement to send freed blacks back to Africa represented a duality of purpose in both Britain and the United States. On one hand, there was a growing population of abolitionists committed to ending slavery and freeing African slaves. On the other, those same abolitionists preferred that the newly freed blacks leave America or Britain, rather than staying and living among their white neighbors.)
The American Colonization Society struggled to pay the bills for the new colonies they established around Monrovia. By 1847, they urged the colonies, since joined together, to declare themselves the independent nation of Liberia. Though the United States continued to keep a close eye on the tiny country, Liberia was the only nation in Africa not to be colonized by a European power.
Still, the so-called repatriation of freed African slaves was nothing of the sort. Those who left America to return to Africa were culturally, ethnically, and linguistically distinct from the tribesmen who had called Liberia their home for millennia. After establishing the new nation, the colonists, repressed for generations themselves, denied the indigenous population the right to vote unless they converted to Christianity. After a century of rampant embezzlement of foreign funds, three decades of violence began in 1980 with the violent overthrow of President William Tolbert. Civil war raged, pitting tribes against the class of descendants of American slaves, and tribes against tribes; almost every effort at peace failed until 2005, when a former World Bank economist named Ellen Johnson Sirleaf won election, promising national reconciliation.
Sierra Leone declared its independence from the United Kingdom in 1961. Guinea emerged from the ashes of France’s Fourth Republic in 1958, when new prime minister Charles de Gaulle made clear to French colonies they could declare independence. Both nations struggled: Sierra Leone’s government was toppled three times in a period of two years in the late 1960s. The one-party rule of President Toure sent 200,000 Guineans fleeing into exile. After Toure’s death in 1984, a military coup landed another strongman, Lansana Conte, in power until his death in 2008. His elected successor, Alpha Conde—a former opposition leader who fled into exile after Lansana Conte jailed him for eight months in 2001—has delayed parliamentary elections since taking office in 2010.
Even though other African nations suffered under colonial rule, the decades—centuries—of violence in the three West African nations left their populations among the poorest in the world. Dry statistics only hint at the poverty that strangles West Africa. In 2013, Guinea’s per capita gross domestic product (GDP) was only $521; Sierra Leone’s was $797; and Liberia’s was just $453. The same year, the per capita GDP of the United States was $52,980, according to the World Bank.8 Just over 30 percent of Guineans and 35 percent of Sierra Leoneans are literate, among the lowest rates in the world. The life expectancy in Sierra Leone, forty-six years, is ranked 194th on a list of 194 countries studied by the World Bank; Guineans can expect to live fifty-eight years on average, 172nd on the list. Liberians live to be sixty-two, on average, seventeen years less than the average American. Just 1 percent of the population of all three countries has access to the Internet.
To the ethnic groups that dominate the three West African nations, the new borders, artificially drawn based on European whims, meant little—other than that rivals with centuries of antagonistic history were thrown together in one country, and that allied tribes with deep familial ties were divided by some faceless French or British cartographer. Civil wars erupted once colonizers left. And even today, remote tribes living at the intersection of all three countries ignore border lines on irrelevant maps, crossing freely to do business and see family in neighboring towns.
After centuries of colonization and decades of war, Liberia, Sierra Leone, and Guinea were left destitute. Few nongovernmental organizations were present. American aid continued to flow to Liberia, in particular, through the United States Agency for International Development, but extreme poverty had decimated the national health-care systems in all three countries. Those health systems were so underfunded and ill-prepared that even basic medical care was impossible: Public health experts estimate a nation needs to have 22.8 medical professionals—doctors, nurses, midwives, and others—for every 10,000 residents, just to provide basic levels of care. Before the outbreak, Sierra Leone had just five professionals for every 10,000 residents.
It was into this atmosphere, this tinderbox, that the spark of Ebola landed. Suddenly, the nations that the international community had ignored for so long demanded immediate attention.
THREE
Into the Fight
FOR DAYS IN THE middle of March 2014, the global health community held its breath, waiting for confirmation from the French laboratories that the fire raging through the Forest Region was Ebola. The virus didn’t bother to wait; it spread, first across the border to Liberia, then closer and closer to the largest cities in West Africa.
Tewa Joseph, who had carried her sister Tamba to the hospital in Foya-Borma, fell ill the same day Tamba died. By the time she arrived at the same hospital, doctors and nurses knew a killer disease was in their midst—and they had no protection from its spread. They refused the young woman admission. New cases began appearing faster than Guinea’s already-insufficient health system could cope: by March 27, 103 cases had been reported. By the thirty-first, 9 new cases were confirmed. On April 1, 10 more patients were identified, the next day, 5 more, and 25 more in the following 5 days, in Guinea alone.
The mortality rate shocked local officials. By April 7, of the 151 cases reported in Guinea, 95 people had died.
But while an Ebola outbreak was unprecedented in West Africa, the global community’s response was well-practiced. And once the World Health Organization (WHO) announced the presence of Ebola in Guinea, virus hunters reprised their familiar roles. After two dozen or so outbreaks across central Africa, the early moves were so familiar they happened as muscle memory. Epidemiologists and virologists from Africa, Europe, and the United States rounded up their equipment, jumped on planes, and descended on the hot zone. Those with years of practice quarantining and treating patients and hunting for the Ebola virus in nearby forests began arriving in Conakry, Guinea’s capital. Many, seeing old friends and occasional rivals at the relatively posh Palm Camayenne Hotel, exchanged hugs.1
In the United States, the Centers for Disease Control and Prevention (CDC) dispatched its first team, including some of the most experienced Ebola responders in the world. President Obama heard about the outbreak for the first time on March 24, when officials from the Central Intelligence Agency included a mention of the WHO’s declaration in his morning security briefing. The first American tasked with marshaling a response to the epidemic would be Michael Schmoyer, director of the Office of Security and Strategic Information, a division of the Department of Health and Human Services.
Médecins Sans Frontières, or MSF, already had a presence in Guinea, where they had been vaccinating residents against cholera and malaria. Just a day after WHO declared Ebola present, an MSF team opened its first Ebola treatment facility in Gueckedou, near the virus’s epicenter. Two days later, MSF opened its first Ebola Management Center, a higher-tech facility, at Donka Hospital in Conakry; over the next year, that facility would admit and treat more than 1,800 patients.
The same day, Dr. Stephane Hugonnet, a senior WHO official in charge of global capacit
ies, alert and responses, landed in Guinea to oversee the response. WHO brought a mobile lab to Gueckedou, capable of testing up to fifty blood samples a day.2
In neighboring Liberia, another nongovernmental organization (NGO), Global Communities, worried about the possible spread across an international border. Piet deVries and Brett Sedgewick, two veterans of decades of disaster relief operations in some of Africa’s most war-torn environments, led the group’s operations in Liberia, where it ran a water sanitation program in remote rural counties hours by car from Monrovia. DeVries called his counterparts at WHO to offer help, and within days, Global Communities trucks were racing supplies north to Lofa County, just across from the affected region.
In a culture where the very concept of viral disease is virtually unknown, many of those rural residents believed Ebola was little more than a ruse. Rumors in Gueckedou and the surrounding communities mounted almost the moment the first Ebola treatment facilities were opened. Some watched their relatives enter the mysterious white tents, manned by foreigners in what looked like space suits. Those relatives never came out. When those who nursed their loved ones fell ill themselves, some refused to go to a treatment center. Others tried to escape from medical facilities, carrying the disease with them.
