by Reid Wilson
In Atlanta, Tom Frieden watched with growing irritation as petty squabbles overseas delayed his own teams. Several teams were delayed by bureaucratic hurdles, seemingly erected by local WHO officials who wanted to prove they could handle the outbreak themselves. When Pierre Rollin, the CDC’s preeminent Ebola expert, arrived in Guinea on April 1, he and four colleagues were delayed in deploying to the field. They spent several days cooped up in their hotel rooms, debugging software that would eventually help responders track the virus to trace those who might have been exposed. Fending off cabin fever, they worked virtually around the clock, toting their computers to dinner in the hotel restaurant, typing as they ate.3 Rollin busied himself briefing staff at the American, British, and French embassies on the basics of Ebola; a native French speaker, he held a special French language briefing for Guinean drivers and staff, who were most likely to come into contact with the virus when they went home at night.4
The delays, the infighting, were a feature, not a bug, in the global health response system—more specifically, in WHO itself.
The World Health Organization was established in 1946 under the auspices of the United Nations to control the spread of deadly diseases like tuberculosis and malaria and to improve health conditions, especially for women and children. The organization was meant to standardize procedures for disease reporting, a crucial factor in finding and eradicating outbreaks. Its main tool was shame: only the WHO could publicize outbreaks of some diseases, under the theory that any country with an outbreak would be forced to respond aggressively or risk lost tourism dollars and economic activity. In many cases, shame worked: the WHO helped eliminate smallpox, and over its seventy years of existence, it has saved countless lives by fighting the spread of measles, HIV/AIDS, and polio, among other deadly scourges.
But WHO is, at its heart, a patron of its client states. While it is headquartered in Geneva, WHO has divided the world into six regions, one on each populated continent. Directors of those regions are appointed by consensus among health ministers on each continent, and the director then appoints a senior WHO official in each of the countries under his or her jurisdiction. That means regional directors are answerable to health ministers, and governments, in their own region—not to the populations served by those governments.
In West Africa, that meant tiptoeing around health and information ministers, the former struggling to deal with a mounting medical crisis, the latter determined to avoid the negative publicity that could drive away millions of dollars in desperately needed economic development and tourism.
“WHO didn’t sound the global alarm early or effectively, long after there was plenty of data to demonstrate that [Ebola] was a problem,” said Rajiv Shah, then the head of the United States Agency for International Development (USAID). “They were enmeshed in the politics of not wanting to upset a country or a region.”
The African region of WHO is headquartered in Brazzaville, in the Republic of the Congo, close enough to the historic range of previous Ebola outbreaks but thousands of miles from West Africa. And the agency, which depends on private donations for about three-quarters of its annual budget, faced the pressures of the global recession just like any other charity: donations dried up, demanding painful budget cuts. In Africa, those budget cuts hit preparedness efforts. Between fiscal year 2010 and fiscal year 2014, the WHO’s epidemic preparedness and response budget plunged, from $26 million annually to just $11 million. Nine of the twelve emergency response specialists the WHO employed in Brazzaville were laid off.5
Though some government ministers in Guinea and Liberia downplayed the seriousness of the outbreak, its severity soon required robust responses. The woefully inadequate health care systems left over in West Africa after generations of war just were not capable of delivering those responses. WHO’s usual tactic, shame, wouldn’t work: Alpha Conde, Guinea’s president, and Ellen Johnson Sirleaf, president of Liberia, did the opposite of obscuring the presence of Ebola in their region—they publicly begged for help. Conde traveled to Geneva in late April for consultations with WHO. Johnson Sirleaf was in constant contact with American officials, asking for more aid.
WHO, however, was in no position to provide anything resembling an overwhelming response. Not only had their budget been hammered by the recession, but WHO proved early on it had done little to lay the groundwork necessary to send help when it was needed. There was no list of thousands of volunteer doctors who could help, no list of drugs in early stages of development that could be rushed through the testing and trial process, and no ready supply of materials necessary for building hospitals or mobile labs.
The world had assumed its chief global health watchdog had the capacity to respond to a deadly outbreak. The world had assumed wrong.
No organization worked more aggressively to pick up WHO’s slack than MSF.
Where WHO is an internationally sanctioned body, MSF is fiercely independent. It was founded in 1971, after French doctors volunteering with the Red Cross accused the agency of turning a blind eye to the Nigerian army’s murder of civilians. Today, MSF is funded almost entirely by private donors; the group will not accept grants from governments like the United States, for fear that taking the money would give the impression that MSF endorsed or condoned a donor government’s actions. It operates in the worst conflict zones around the world, from Bosnia and Rwanda in the 1990s to Iraq and Afghanistan today, where its doctors and nurses treat combatants from all sides; in Afghanistan, its hospitals cared for Taliban fighters and government troops, sometimes side by side (MSF had a history in West Africa, too, having responded to the Liberian civil war in 1990).
For a private nonprofit with a limited budget and penny-pinching ways, MSF’s actions in West Africa were nothing short of herculean. In the course of a year that the group spent responding to the Ebola outbreak in West Africa, it raised and spent $100 million, dispatched a total of 5,000 staffers, and built and maintained 15 Ebola treatment centers. All told, MSF cared for one in every three people infected with the virus.
At times, however, MSF’s altruism grated on the nerves of other responders. When American agencies began introducing some of the drugs it was testing, both possible treatments for those infected with the virus and vaccines designed to protect health care workers from getting infected, MSF officials bristled at the caution with which drug testing took place. If one patient was going to get an experimental drug, MSF believed, all patients should get that drug.
That startled the American agencies that already thought they were moving as fast as was medically responsible in testing potential cures and diagnostic assays.
Those American agencies had been quietly at work on Ebola for more than a decade, since the attacks of September 11, 2001, and subsequent anthrax attacks raised the prospects of a terrorist attack using biological weapons long before the virus arrived in Guinea, Sierra Leone, and Liberia. Both the National Institutes of Health (NIH) and the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) had spent more than a decade preparing to respond to an epidemic, whether naturally spread or spread by terrorists.
In 2009, David Norwood, chief of USAMRIID’s diagnostics systems division, sat down with top officials at the Food and Drug Administration (FDA), the agency that must approve both drugs and the chemical compounds that would demonstrate proof of a virus’s presence.
Those chemical compounds, called assays, work by bonding with a virus’s RNA strand, which produces a burst of fluorescent light. The delicate and expensive computers analyzing a sample of blood detect those emissions, which show that the virus is present. Winning approval for a specific assay was easier than getting a new drug approved, but it still required lab results that showed it would work. The problem was that the companies creating the assays could not always show that their compounds worked with diseases like Ebola, because they didn’t have any Ebola to test. Only government agencies like the CDC or USAMRIID had samples of the virus, locked away in highly secure bio
containment suites. They were not in the habit of handing out samples of something as deadly as Ebola.
Still, in the event of an outbreak, Norwood told FDA regulators, they would need to move fast. To prepare for whatever came next, Army doctors sent more than seventy assays to the FDA, testing for everything from Ebola and Marburg to anthrax and botulism. The moment a new outbreak cropped up, the appropriate assays would be given immediate priority. Together, the two agencies prepared for an Emergency Use Authorization, a declaration by the secretary of Health and Human Services that would allow them to speed the approval process by skipping a few more rigorous steps, all in hopes of getting the diagnostics to the front lines as fast as possible.
The NIH and CDC had been busy with their own preparations. They had a promising drug to treat Ebola patients, known as Favipiravir, that had already undergone early testing regimens on volunteers in the United States and some African countries, and a few possible vaccines that might prove effective after more testing.
But like USAMRIID, the NIH and CDC faced a lack of test subjects. Medical drugs are routinely tested in monkeys and chimpanzees, but nothing can be approved for widespread use in humans before a rigorous set of tests on subjects. And there weren’t a lot of humans with Ebola walking around the suburbs of Washington, D.C., where the NIH is based, or Atlanta, the CDC’s home turf.
That meant Favipiravir and other potential solutions could go through what is known as phase-one testing, designed to show whether a drug was actually safe for human consumption, but not later-stage tests aimed at deciding whether a drug is actually effective against a specific disease.
So when Favipiravir arrived in West Africa, NIH officials thought they could race through the testing process in a few months, something approaching record speed in the staid, glacial field of medical testing. But they still had to follow the same broad testing regimen any new drug undergoes: some patients would get the drug, a control group would not, and the mortality rates would be compared.
MSF officials were incensed. If a potential drug was available, they argued, every patient should get it, as soon as humanly possible. To withhold a potentially life-saving treatment, they believed, was a moral outrage.
“They interpreted research as not caring about the individual patient,” said Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases (NIAID) at the NIH. “They had no interest in answering in a definitive way the question of what [drugs] you would need for the next time” an outbreak swept through a community.
To Fauci, a wiry and compact epidemiologist with a thick New York accent and decades of experience with infectious disease, the impulse was understandable. Of course a treatment should be made available to anyone who might need it. But his experience gave him pause; over his career, he had seen even the most promising drugs harm patients.
Fauci has lasted longer in his post than most government officials. Appointed to head the NIAID in 1984, he arrived in the director’s office just as the AIDS epidemic reached the height of the public imagination. During his three decades leading his institute, housed in a 1950s-era office building in desperate need of an upgrade on the NIH campuses just outside of Washington, Fauci’s moments in the limelight have come during epidemics and outbreaks across the world, though much of his work has focused over the years on finding treatments for HIV and AIDS. So many of the drugs that made it to stage-two or stage-three testing, he said in an interview, were just as likely to harm a patient as to help.
Early tests of Favipiravir appeared to show promising results. The data showed that in Liberian villages where the drug was used, mortality rates were dramatically lower than in villages where the drug had not been distributed. According to MSF, that showed the drug was working and that it should be mass-produced and disseminated to all three countries. Fauci and his American colleagues looked beneath the toplines to draw a starkly different conclusion: The patients being treated with Favipiravir were surviving because the drug wasn’t the only treatment they were receiving. Across the board, Favipiravir was administered in places where patients received much higher-quality medical treatment than in villages where the drug was not part of the treatment plan. Fauci and others concluded that the drug wasn’t working at all; the mortality rates were coming down because Liberians and their nongovernmental organization partners were getting better at treating patients.
“It was the better medical care” that was bringing down mortality rates, Fauci concluded. “It likely had little to do with the drug.”
But back in those early days, on the ground in Guinea and Liberia, the relief workers who had feuded so bitterly began to think the outbreak was following a similar pattern, running out of the fuel it needed to survive, and to thrive. WHO experts keeping tabs on the number of new cases saw those numbers tumble, from a dozen or more a day to a handful, then to zero. Between the end of April and the first week of May, just ten or so new cases were reported. A week went by with just two new cases in Guinea; that same week, doctors ruled out one possible case in Liberia, meaning the number of its infected actually fell, to twelve. For the rest of the month, Liberia would not record a single new case of Ebola.
The relief workers and virus hunters who had raced to the latest outbreak began to allow themselves the hope that maybe, just maybe, the outbreak would not be as disastrous as they feared. Arriving on May 5 in Lagos, Nigeria, for the World Economic Forum, USAID director Raj Shah detected a palpable sense of relief—the world might have just dodged a dangerous bullet.
“There was an early response that was geared to what people knew of an Ebola crisis in Africa,” Shah explained later, drawing the typical bell curve that had defined earlier outbreaks on a lined legal pad. “It had a pattern and a strategy and a distribution, and we felt it was dissipating based on the trend lines.”
Others saw the same hopeful trends. On May 6, 2014, Samaritan’s Purse, a nongovernmental organization run by the American evangelist Franklin Graham, wrapped up its disaster response in Liberia. They had created a six-bed treatment center at a hospital in Monrovia, none of which had ever been filled.6 The next day, Pierre Rollin, the CDC expert who had spent five and a half weeks in the hot zone, flew back to headquarters in Atlanta, ten days after his team had seen their last new case. MSF sent its staff in Liberia back to Guinea, where they could care for those still fighting the virus. Even the WHO began drawing down its operations.
In March, Piet deVries had begun holding initial meetings with friends at the Liberian Ministry of Health to plan a handover of Global Communities’ water hygiene project after a decade on the ground. The handover halted as Global Communities pivoted to fight Ebola. Now, after spending a month and a half shipping supplies and resources to Liberia’s northern rural counties, he too thought a corner had been turned. He headed back to Monrovia, to continue wrapping up his mission.
By May 22, Liberia had gone forty-two days without a new infection, a major milestone. Once infected with Ebola, the longest a patient can go without showing symptoms is twenty-one days. Once a country went the length of two consecutive incubation periods without a new infection, it would be deemed virus-free. In a news conference that day, Bernice Dahn, head of the Liberian Ministry of Health’s Ebola response team, celebrated, cautiously, her country’s accomplishment.7
“It looked like we had really beaten Ebola,” deVries recalled later. “A very optimistic view of [the] circumstances would be that the virus was self-limiting and the epidemic was going to disappear,” WHO’s Chris Dye said.
Around the same time, Fabian Leendertz and his team of seventeen virus hunters were crossing the rickety bridge that connected Meliandou to the outside world. Contact tracers, working diligently to chart the virus from Sierra Leone and Liberia back across the border to its roots near Gueckedou, had settled on the small town atop a hill as the virus’s likely source. Leendertz, an infectious diseases expert at the Robert Koch Institute in Berlin, hoped to solve the mystery of just where Eb
ola lives when it is not infecting humans. They knew whatever reservoir host passed the virus to little Emile had been in Meliandou, so they set off to search the village in hopes of identifying the culprit.
In the months since the outbreak began, Meliandou had undergone hard times. Neighboring villages had shunned its residents, and as many as a third of those who lived there had fled. Leendertz and his team, arriving in jeeps bumping along the single red dirt path, had to work overtime to win the villagers’ trust.
“When those cars are coming with white people inside, they are normally to extract someone who has Ebola. But that was not our mission,” Leendertz said. “They were really stigmatized from the other villages around. The good taxis would not go there anymore, and they were really isolated from the outside world.”
Leendertz and his team visited Meliandou twice a day for ten days to win villagers’ trust. Each time they left and returned, they had to brave the bridge, which outsiders had burned in hopes of isolating the village. It had been rebuilt, haphazardly, so Leendertz’s team tested the untrustworthy logs positioned over the small river before each crossing. “For four times a day, we had to cross that stupid bridge,” he recalled later.
Once the villagers trusted Leendertz and his team, the Europeans began asking questions: What kind of wildlife is around? There were no primates on which to feast, one manner of zoonotic transmission that had caused earlier outbreaks in Central Africa; the nearest rainforest, where monkeys and apes might live, was about three hours away. But there were bats, rodents, and a few other smaller species, all of which they set out to catch. One young man from the village helped the team cut branches into sticks they used to hold up bat-catching nets. It was important to Leendertz, and the anthropologist he had brought with him, to make Meliandou’s remaining inhabitants aware that the Europeans valued their input, their advice, and their theories.
