by Reid Wilson
In a way, the international community’s response to an Ebola outbreak was so well-practiced that it caused problems. The men and women in space suits showed up before news of the outbreak reached local communities. The fraught relationship between the government in Monrovia and the rural communities run by tribal elders made some question whether this wasn’t an elaborate plot—or worse. Was this disease real, some villagers wondered, or had these Westerners in space suits brought it with them? Virus-hunting teams sent to some small settlements were chased away by angry crowds.
In Liberia, the historical disconnect between the tribesmen who inhabited remote rural counties and the descendants of former slaves who ran the government in Monrovia picked apart a scab that never fully healed after the deadly civil war a decade earlier. But that distrust between governments and tribes was not unique to Liberia. Guinea’s president, Alpha Conde, was a member of the Malinke ethnic group, which made up about 15 percent of the nation’s 10 million residents. The majority Fula ethnic group were suspicious that Conde was using the virus as cover to delay an upcoming election (indeed, the election was delayed). Some in the Kissi tribe, an impoverished and persecuted minority who inhabited the Forest Region that straddled all three countries, believed the virus had been introduced to exterminate them.3
Some villages would not admit Ebola was in their midst at all. The poor health systems in Guinea and Liberia had weak, or nonexistent, diagnostic capabilities, so who could say what had killed someone? “In Liberia,” deVries explained, “there’s a lot of unknown death.”
Government officials in all three countries were terrified, too, that the presence of the disease could deliver another devastating blow to their economies. International corporations had only recently begun investing in Guinea, Liberia, and Sierra Leone; the last thing any of those countries and their beleaguered economies needed was evidence of new unrest.
That threat inspired denial at the highest levels of government. Four days after the first confirmed case in Guinea, and the day Liberia’s second Ebola case, Tewa Joseph, was being refused entry to the hospital in Foya-Borma, the Liberian Information, Culture and Tourism minister Lewis Brown told a local newspaper that his country was virus-free.4 The next day, WHO reported eight cases in Liberia, six of whom had died.
The Liberian Ministry of Health, which had held a press conference on March 24 to report on suspected cases, suddenly stopped referring to Ebola at all. The Forest Region, ministry officials said, only showed signs of a “suspected viral hemorrhagic fever.”5 Dr. Aboubacar Sidiki Diakite, the Guinean health official in charge of beating back the outbreak, insisted on counting only those who had tested positive for Ebola among the country’s roster of total cases, rather than including all suspected cases, even though testing facilities were working painfully slowly and some patients were obviously infected.
The WHO itself received strong pressure from West African governments. In one early conference call with global health responders, including several top American medical officials, a senior WHO official downplayed the threat. “We don’t want to make this out to be a real big problem,” the official said. “It’ll be a terrible problem for tourism and stigma.”
Anthony Fauci, participating in the call from his office at the National Institute of Allergy and Infectious Diseases at the National Institutes of Health outside Washington, almost fell off his chair, so shocked that tourism was a concern in the face of one of the world’s most deadly diseases.
“There was a certain amount of reluctance to accept the severity of the problem,” WHO’s Chris Dye recalled later, employing British understatement to the fullest degree. Margaret Chan, WHO’s director general, was on the phone with all three heads of state on a weekly basis, urging aggressive action. Her calls with Fauci, CDC director Tom Frieden, and others in the United States were becoming more frequent, too.
Even the most determined efforts to deny the virus’s presence fell short, and the world took note. On April 1, Saudi Arabia announced it would stop issuing visas for Guinean and Liberian Muslims who wanted to participate in an umrah or a hajj, the traditional pilgrimages to Mecca, Islam’s holiest city. Three days later, an Air France flight from Conakry was quarantined on the runway at Charles de Gaulle Airport in Paris after a passenger threw up in an onboard lavatory. Every passenger was checked for fever as they disembarked.6
Not everyone worried about the financial bottom line. On March 27, five days after the virus was formally identified, Peter Sonpon Coleman, chairman of the Liberian Senate’s committee responsible for health, made the first request for money to fight an outbreak that was almost certain to cross into his country. He asked for $1.2 million.7
Outside of government structures, the virus was spreading. The trader who had arrived in Conakry with a fever had infected others, including some of the precious few health-care workers trying desperately to prop up Guinea’s terribly poor health system. When Rob Fowler, the Canadian physician dispatched by the WHO, arrived at Kipe Hospital in Conakry, he found that most of the likely Ebola patients were health-care workers. Just one nurse and a handful of doctors had managed to escape infection. None had been trained to take the precautions necessary when treating a suspected or confirmed Ebola patient. His reaction, he wrote later, was “no small amount of fear.”8 Across the entire city, a metropolis of 1.6 million, just four doctors and four nurses were treating Ebola patients.
By the beginning of April, MSF had established themselves as the NGO with the greatest capacity to mount the initial medical response. The group opened new Ebola isolation wards in Macenta and Conakry; sixty workers were dispatched, along with forty tons of equipment.9 But even those doctors, well-known in Guinea, were subject to local skeptics, some of whom turned violent. An Ebola surveillance team was chased out of one neighborhood in Macenta by an angry crowd; the crowd then smashed in the brand-new treatment center, too.
Hugonnet, the WHO official, was among the first to realize the extent of the public relations campaign the international organizations needed to mount. Ebola, after all, was unknown in West Africa, so much so that even the medical experts who had visited Meliandou several months earlier had not recognized what they were looking at. Now, as the disease spread, international organizations were going to have to find a way to communicate a few specific themes: The disease was real. It was deadly. But it was treatable.
It fell to Cristiana Salvi, a WHO communications specialist, to begin crafting that message in hard-hit Gueckedou. Salvi’s arrival in the city, population about 79,000, in late April, underscored its remoteness. Her tiny plane bounced along a rutted runway, seemingly in the middle of nowhere, that served as the regional airport. From there, a car lurched over even worse roads for two hours before Gueckedou emerged from the forest.10
Salvi was concerned that the messages Guinean authorities were spreading were not sufficiently tailored to those most likely to come into contact with Ebola. Those messages were largely the same as the ones spread in the Democratic Republic of the Congo and other countries that had been hit by the disease before. Residents in hot zones were told to give up some common practices that brought them into close contact with the disease, like washing bodies before burial. That worked in the Congo, where Ebola was known. In Guinea, no one knew what it was that killed their relatives. To distrusting villagers, the initial message sounded like Westerners interfering with centuries of cultural tradition.
The lack of knowledge about and experience with Ebola meant a basic education campaign was crucial. Women were especially at risk because cultural expectations in Guinea and Liberia held that women care for the sick, and then prepare the dead for burial. That meant women were coming into direct contact with Ebola victims at their most contagious stage.
Salvi and her colleagues began crafting a message, informed by focus groups, that would introduce Ebola as a danger, one with a massively high fatality rate. Radio advertising and billboards were soon ubiquitous around Gueckedou and other
parts of Guinea.
Some of the new procedures and protocols took hold. When Piet deVries met with a county health official in Lofa County, just across the border from Guinea, in late March, he put out his hand, ready for the customary Liberian handshake, half high-five, with a snap at the end. The health official just looked at him: handshaking was already forbidden.
But the initial message, Salvi later wrote, worked at counter purposes to the WHO’s goals. Warning of Ebola’s extreme danger gave Guineans the impression they would not survive if they were infected—and dying at home surrounded by family would be infinitely better than dying in a hot, fetid, putrid hospital surrounded by Westerners in moon suits. “Most of the people who catch [Ebola] will die,” read one poster. Other messages missed the point completely: Liberian and Guinean health ministry advertising urged villagers to avoid eating bush meat, or plums that had been nibbled by bats; epidemiologically, villagers did not have to worry about catching Ebola from the wild, they had to worry about catching it from their friends and relatives. Once again, patients began disappearing before they could be taken to an Ebola treatment center. Groups like Samaritan’s Purse, one of the first outside NGOs to arrive in the hot zone, pleaded with health ministries to change their messages.
So Salvi crafted a new message, one that highlighted survivors. Though they were few, at the outbreak’s initial phase, there were some. They proved Ebola was not necessarily a death sentence if a victim sought treatment early enough. In advertisements and in newspaper stories, survivors shared their experiences—how they were infected, how they were treated, and, just as important, how they were fed as they recovered. Communicators on WHO’s staff had to convince the communities they were trying to reach the basic fact that they were there to help, not to spread the mysterious disease within the community.
The groups fighting Ebola on the ground in Gueckedou, and increasingly in Conakry, needed to communicate beyond those who were infected. They needed to reach those patients’ families, who had to deliver them to hospitals. Early on, families were given disposable cell phones so they could contact their loved ones inside an isolation unit. Families were also given money for taxis to visit their relatives in person, even if they were separated by the plastic walls of a treatment center.
The race to set up clinics was a logistical nightmare. The few medical professionals who lived and worked in the rural settings where Ebola now raged knew nothing of diseases that could be so easily transmitted between humans. They were accustomed to other deadly pathogens—cholera, malaria—that were ubiquitous, but not contagious.
That meant the frontline clinics, where Ebola patients would first encounter the medical system, needed upgrades, and fast. The supplies Piet deVries and his team at Global Communities raced north included only the most basic personal protection equipment—PPEs, in epidemiological shorthand. They brought thousands of body bags, gallons of chlorine to disinfect any surface on which Ebola might survive, and crates filled with gloves and masks.
The need for even basic supplies was acute. In some more remote areas, gloves, life-saving essentials for any medical professional, began selling for the equivalent of fifty cents a pair, in an area where most residents lived on less than a dollar a day.
Nongovernmental organizations worked hard, too, to convince villagers that Ebola was real, not some curse cast by rivals, not some trick of a sinister government. Global Communities was the only NGO to have operated for such a long period of time in rural counties, meaning that their employees had credibility with villagers and, more important, with tribal leaders. Their decade-long campaign to change sanitation behavior by demonstrating a link between open defecation near water sources and cholera—a program called Community-Led Total Sanitation, or CLTS—had been implemented by hundreds of environmental health technicians.
Now, those technicians, so used to demonstrating how to dig a safe latrine, were pressed into far more dangerous circumstances. Through April, May, and June, the technicians held dozens of meetings at clinics around Lofa, Bong, and Nimba Counties, where they helped village leaders develop action plans and response activities.
At the same time, the United States Agency for International Development (USAID) and its partners at UNICEF began their own massive education campaign, and their own networks of tribal leaders. USAID and UNICEF helped tribal chiefs, women’s groups, and others spread the word about Ebola in their own villages.
However late it was, the international response, five months after Emile came down with a terrible fever, had finally come to the rescue. By mid-May, the familiar pattern of an Ebola outbreak appeared to show itself: daily case counts began to slow, and some previously suspected cases turned out to be something else. The total number of cases in Guinea continued to grow, but at a slower pace. Over the last week of April and the first week of May, just ten new cases were reported. By April 9 Liberia isolated the last of the dozen cases that initially broke out on their side of the border. A few weeks later, the country went three weeks with only one new case. Sierra Leone, which experienced one scare in late March, had not reported a single new case.
Still, as the global health community descended on Guinea and Liberia, the power of a virus so small weighed on those first responders. By the end of April, a month after WHO confirmed that Ebola had begun to kill, 234 people had been infected. Of those, 157 had died.
FOUR
A Turning Point
EVERY VIRUS, LIKE A fire, can only survive as long as it has a fuel source. The speed with which a virus consumes its fuel source determines just how long the outbreak’s lifespan extends. What scared epidemiologists during that chaotic first month, when the Ebola outbreak migrated from Meliandou to Gueckedou and then toward more densely populated urban areas in both Guinea and Liberia, was that the virus had apparently found a fuel source far greater than ever before. Conakry and Monrovia are large, terribly impoverished cities, where hundreds of thousands of residents live in densely packed slums. These were not the remote jungles of the Congo, where previous outbreaks had erupted and then calmed for lack of anyone else to infect; they were perfect fuel sources for a voracious virus in search of new human hosts.
But in the chaos of those early days, the global health community’s initial response to the Ebola outbreak was muted and confused, even as the virus worked toward urban centers.
On the surface, the race to contain one of the world’s deadliest diseases appeared robust: World Health Organization (WHO) foot soldiers from Geneva and around the globe arrived within days. Médecins Sans Frontières (MSF), or Doctors Without Borders, shipped tons of supplies and hundreds of their own volunteers. The first Americans, including some of the world’s most qualified Ebola responders dispatched by the Centers for Disease Control and Prevention (CDC) in Atlanta, parachuted in just days later.
But the rapid activity masked a deep, disturbing reality: The global health network was completely unprepared to respond to an outbreak of the magnitude now spreading from rural villages toward West Africa’s largest cities. And even though the outbreak threatened to become the largest, most widespread emergence of Ebola in world history, its seriousness did nothing to stop the squabbling—some of it alarmingly sophomoric—among the response groups that arrived in late March and early April of 2014.
The internal fights began almost the moment scientists confirmed Ebola’s presence. On March 31, just a week after confirmation, senior MSF officials realized what they faced. Already, the international organization had sixty staffers on the ground, including doctors, nurses, epidemiologists, and sanitation experts, and the data they were collecting was terrifying. New cases had sprouted up all over, from remote Gueckedou to urban Conakry.
“We are facing an epidemic of a magnitude never before seen in terms of the distribution of cases in the country,” warned Mariano Lugli, MSF’s coordinator in Conakry. The group’s headquarters staff, in a press release, called the outbreak “unprecedented.” A Twitter message warned that the
strain of Ebola detected in Guinea, EBOV, had a mortality rate of up to 90 percent.
In Geneva, WHO officials bristled at what they saw as MSF’s alarmism. “Don’t exaggerate,” WHO spokesman Gregory Hartl tweeted in response to MSF’s warning of the extremely high mortality rate.1 In another Twitter message, Hartl downplayed the seriousness of the early spread: “You want to disrupt the economic life of a country, a region [because] of 130 suspect and confirmed cases?” he sneered.
MSF officials were aghast. Here was the top spokesman for the World Health Organization, the international body ostensibly in charge of fighting back against these outbreaks, seemingly playing games with one of the most deadly viruses on the planet.
Those who counted on WHO to organize a robust response quickly became disillusioned. The organization, based in Geneva, is not built to orchestrate a global response to a massive crisis—or even a small crisis—and it has neither the authority nor the funding to do so. For years, Margaret Chan and others had been begging donor countries to fully fund WHO’s budget for just such an occasion as a massive outbreak of a deadly virus. For years, donor countries, including the United States, had cut their commitments instead. What’s more, WHO simply isn’t built as a worldwide response operation.
“We’re a really normative agency. We gather scientific evidence and provide advice on the nature of ill health,” Chris Dye, WHO’s director for Strategy, Policy and Information, said later. “We’re not typically an operational agency. In other words, we don’t do what the World Food Programme does. We don’t do what UNICEF does. We’re not in the trenches.”
Pierre Formenty, one of the world’s top Ebola experts, experienced WHO’s lack of standing and authority firsthand. He was part of WHO’s initial team of thirty-eight dispatched to fight the outbreak in Guinea. When he landed in Conakry, he was passed over for a role as a team coordinator.2 The job went, instead, to someone who had never been involved in an Ebola outbreak.
