by Reid Wilson
The light cycler Schoepp and his team relied on for diagnostics, the one that resembles a large coffeemaker, would test thirty-two samples at a time, contained in glass tubes. As the number of samples increased, Schoepp began asking, with greater and greater urgency, for upgraded equipment. The light cycler used technology that was more than a decade old. He wanted an AB 7500, a much more advanced machine that looks like a large, high-speed business printer (it is, in fact, quite a bit more expensive than a high-speed business printer). That machine could test ninety-six samples at a time, using a plastic tray about the size of an index card rather than glass tubes. Schoepp joked later, ruefully, almost relieved, that the presence of glass in a highly secure containment laboratory is not exactly ideal. It took weeks for the notoriously slow Pentagon procurement process to work, but when the new machine arrived, the diagnostic lab’s capacity for testing samples skyrocketed.
The tests on both machines would take hours to complete. In the light cycler, the tubes spun at high velocity, separating RNA from the blood sample and combining it with the assay. The AB 7500 dripped the assay into each space on its tray of ninety-six divots. As each machine recorded flashes of fluorescence, the indication that the assay had found its target and that a sample had Ebola, it would spit out its results in the form of a line graph on a laptop sitting nearby. The brighter the flash, the more certain Schoepp could be that Ebola was present; if a sample produced a line on the graph that peaked over a certain threshold, the patient had the virus.
In the movies, the testing process is clear and straightforward: sample goes in, computer spits out a clear result, and someone is either sick or well. In the sweltering heat of the Liberian rainy season, an ocean away from the carefully controlled laboratories of the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID), the testing process is far more fraught, and far less conclusive. The lines on the graph that were supposed to be so neatly logarithmic were instead choppy, and sometimes inconclusive. Schoepp feared the prospect of making a mistake and misdiagnosing a patient: tell an infected person they do not have the disease, and they will return home to infect their family and friends. Tell someone without the disease that they are infected, and they will enter an Ebola ward, where they are almost certain to catch Ebola, and then overwhelmingly likely to die.
Some samples were indeterminate. Others showed the presence of Ebola, but in patients who appeared to be getting better. Doctors in overcrowded Ebola treatment centers needed those beds for new patients who were suffering more, but Schoepp could not guarantee those patients were virus-free.
Each night, exhausted after hours and hours in oppressively humid personal protection equipment, the USAMRIID team would leave the converted HIV clinic to return to their rooms in an upscale corporate resort where the choicest rooms faced the beach and the Atlantic Ocean. By day, Schoepp worried that one of his technicians might become ill. By night, he worried that they might not make it back to the resort alive because the roads were so treacherous. There were no streetlights, and people and animals crossing the road were a constant danger. Every minor rise could be hiding a stalled truck, which barely bothered to pull off to the side as drivers worked without hazard lights to make their repairs. Even during daylight hours, driving in Liberia is different, and turn signals routinely go unemployed. The Liberians driving the team back and forth, trained in evasive driving techniques by American diplomatic security personnel based at the U.S. embassy, narrowly avoided countless accidents.
Back at the resort, the mental strain weighed on the diagnosticians. After spending their first deployment in fancy rooms overlooking the beach, slowly, one by one, they moved to rooms closer to the lobby; the sound of the ocean contrasted with their inability to unwind became maddening. In three long deployments, Schoepp found time to take a brief walk on the beach just twice.
At the same time, technicians and health workers in other parts of the HIV clinic were falling ill, and those who did not were still touched by the disease: they would return home at night to communities and neighborhoods ravaged by Ebola. None of Schoepp’s Liberian technicians ever fell ill, but several had family members who got sick. The technicians would bring in their own samples to be tested. Schoepp, alarmed, had to tell them to stop: He couldn’t stand to see his colleagues risk their own lives by drawing blood from someone who could be ill.
Back at the hospital in Kenema, where Khan and his team were so experienced in diagnosing and treating Lassa, the Sierra Leonean doctors and nurses set the stage for a new attack on Ebola, one that would require genetically sequencing the disease to discover its secrets—and, potentially, its vulnerabilities. Khan and Pardis Sabeti, a biology professor at Harvard, collected samples of Ebola-infected blood left over after other samples were sent to the diagnostics labs. They ended up with samples from forty-nine individuals who were either infected or suspected to be infected; those samples, after being sterilized with chemicals to ensure the virus was dead, traveled by DHL Express to Sabeti’s lab at Harvard. The package arrived on June 4; Stephen Gire, one of Sabeti’s fellow researchers, had to open the box with his car keys because he had forgotten to bring a knife.3
The alarming death rates among West African health-care workers spooked those Westerners who had arrived to help. By the time Joe Woodring arrived in Liberia for his first deployment, it was clear the efforts to diminish the presence of Ebola were long gone—no one entered or left any building of significance without washing their hands in chlorine solution. Men armed with handheld devices to measure body temperature were positioned everywhere, checking for fever. No one shook hands; some greeted each other by touching elbows, but even that sterile contact made others nervous.
Woodring, a native of the Philadelphia area, was deployed as a senior medical specialist by the Centers for Disease Control and Prevention (CDC). He stepped into an atmosphere of strict rules designed to keep health-care workers safe, and he soon found himself developing what was effectively a four-foot bubble, staying far enough away from anyone who might possibly be infected, and even those who had contact with the potentially infected. Soon, subtly, without noticing it himself, Woodring began positioning himself upwind of anyone who had even the slightest cough.
When, on occasion, Woodring had to break the bubble, a shiver of terror ran up his spine. Once in a while, when paying for lunch, he might make inadvertent contact with a waiter or cashier. They would freeze, meet each other’s eyes in a moment of panic, and think to themselves: “Oh, shit.”
The safety precautions extended to those he worked with most closely. After leaving Liberia at the end of his first deployment, Woodring said goodbye to his colleague, a partner with whom he had spent a month in the hot zone. The two men realized that, for the entire month, they had never made physical contact—no handshake, no pat on the back, no grab of the arm. Standing in the bustling terminal of the Brussels airport, minutes before catching connecting flights home, the two men embraced.
In those early weeks of June, many of the scientists who had breathed sighs of relief just a month earlier were returning in force. New Ebola treatment centers opened around all three countries: MSF’s facility opened in Foya in early June; another MSF facility would open in Kailahun, in Sierra Leone, three weeks later. A nongovernmental organization called Eternal Love Winning Africa—ELWA for short—opened its first facility in Monrovia, sandwiched between a major highway and the Atlantic Ocean, a few blocks from the Sugarcane Beach Lounge. There, a Samaritan’s Purse doctor named Kent Brantley, who had served as a missionary physician in Liberia since the previous October, welcomed the first patient on June 11.
The mystery over the sudden influx of new cases demonstrated the underlying problem that world health officials had from the beginning. Though they believed they had accurately tracked the number of people who were sick and dying, it became clear that the estimates had entirely missed new outbreaks in places like the Forest Region and in rural counties where international borde
rs meant nothing, where tribal connections ran deep, and where suspicion of national governments was pervasive. The number of cases had never gone down; the infected patients had so distrusted the men in moon suits that they simply hid, preferring traditional treatments from shamans and snakes to a seemingly guaranteed death in a harsh and desolate treatment center.
The need to accurately track and positively identify those who have been in contact with someone who is sick is as critical a tool in outbreak response as actually treating a patient. That practice, known as contact tracing, is relatively easy when an outbreak takes place in the remote forests of the Congo, where an entire village and its contacts may number no more than a few hundred. But in Conakry, Freetown, and Monrovia, cities of hundreds of thousands of people, and in highly mobile rural areas, tracking down complex social webs is frighteningly challenging, whether in slums or far-flung villages. Making matters more complicated were tribal suspicions and customs, which created a tough-to-navigate social network worthy of volumes of anthropological and cultural research.
The best contact tracers in this world of uncertainty were those who already knew the contours of the deeply woven relationships. The best contact tracers were people like Mosoka Fallah.
Fallah is a big man in his mid-forties. His friends describe him as a man with a loud laugh and a kind face. He is a study in perhaps the starkest socioeconomic contrast that could possibly exist. Raised in Monrovia slums with names like West Point and Chicken Soup Factory, he won a scholarship to study at Harvard, where he became an epidemiologist and immunologist. His international connections allowed him to speak comfortably before donors and officials at the world’s most important nongovernmental organizations, to his own government ministers, and to well-placed officials in the United States and Europe. He was equally comfortable in Monrovia, speaking to a mother living in a ramshackle hodgepodge of corrugated iron and wood, whose son might have Ebola.
As Ebola raged around him, Fallah led contact tracing teams into the neighborhoods where he had grown up. His teams found countless Ebola victims, and countless more potential cases. But sometimes, as in the case with the young mother, Fallah had to employ a special touch.
The mother lived in West Point, one of Liberia’s impoverished slums. She had refused to tell any of Fallah’s investigators, who arrived in their frightening space suits, where her eight-year-old child had gone. The boy had come into contact with a neighbor who had Ebola, putting him at high risk for catching the disease. But as curious neighbors gathered around the men in space suits, the mother’s anxiety rose: if her child had Ebola, the family would be shunned, the stigma of the virus forcing them out of their homes.
The next day, Fallah arrived in the slums, alone. He parked his car far away from the mother’s home, so the neighbors would not see; all he brought with him was lunch. While they ate, they talked. The mother said her son’s father was abusive, and rarely present. When he did appear, he would take his son out. If his mother objected, she was beaten.
She had already taken the risk of reporting her son’s contact with an Ebola patient, the same report she denied making the next day. The boy’s father had come for one of his occasional visits; if he knew the boy’s mother had included their son on the Ebola contact list, the beating would be especially severe. The only way she could find her son, the mother told Fallah, was to hire a motorbike taxi. But she had no money.
Fallah dug into his pocket and produced a crisp bill. The woman recoiled—no one in the slums had a crisp bill. If the money in her pocket weren’t dirty and soiled, her neighbors would know something was amiss. Fallah crinkled the bill, rubbed it on his clothes, anything to give it a well-worn look. Still, the mother rejected his gift. Finally, Fallah walked to a nearby market, where he bought something small, exchanging his newer bill for the old, ratty currency that circulated in the slums. The mother sped off on the back of a taxi. The next day, Fallah’s team found her son back in his mother’s home.
“This is not data. This is rapport. This is the ability to speak to a vulnerable woman,” said Hans Rosling, an internationally recognized Swedish epidemiologist who knew Fallah well and who related the story. “Anthropology is as important as statistics. Understanding the individual is as important as counting them.”
“Let them see you as part of them,” Fallah told an alumni magazine at his alma mater, Harvard’s T. H. Chan School of Public Health. “When I entered West Point, I never stayed in my car. I got out and I walked and I met the leaders. I walked with them in the houses and in between the houses. I never touched them—it was an epidemic, and I kept my distance. But I wasn’t bringing this big Harvard degree to them. I wasn’t telling them that I knew it all. I let the leaders make decisions and I guided them and followed them.”4
More Fallahs were racing back from their homes overseas. On June 21, MSF tried to grab the world’s attention: The epidemic, they said, had spiraled “out of control.” By the time MSF opened their thirty-two-bed facility in Kailahun five days later, they were immediately overwhelmed. The facility eventually grew to sixty-five beds to accommodate as many of the sick as they could.
Back in the United States, senior health officials were beginning to hear alarming reports from their own people. Cliff Lane, a researcher at the U.S. Institute of Allergy and Infectious Diseases, returned from a visit to Liberia, where he had been setting up a trial of a new vaccine. Briefing his boss, Anthony Fauci, Lane called the outbreak a “catastrophe.” Tom Frieden, the director of the CDC, told Fauci much the same thing. But even the CDC acknowledged later it had not taken proper heed of MSF’s warning, and of the increasingly troubling reports from the field.
“We got it wrong, as did a lot of people, when we thought the outbreak was contained,” Frieden said later. “Within a couple of weeks, we realized, Woah, [the MSF warnings] were completely right. This is different. We’ve never seen anything like this before. This is urban Ebola.”
Still, the World Health Organization hesitated. On June 15, WHO sent its first monitors into Sierra Leone, alarmed by a rapid spike in new cases. The next month, it established a regional coordinating center in Guinea. Fauci and Frieden in the United States, and virtually every other group on the ground in West Africa, watched with increasing alarm as WHO resisted making a formal declaration of an emergency. That declaration would get the world’s attention, allow more resources to flow into West Africa, and stanch the damage before hundreds, maybe thousands, more were infected.
“When the cases were on their way up, had not yet peaked, it was very, very clear to Tom and I … that the WHO was not recognizing the seriousness of this,” Fauci later recalled.
The WHO’s July 2 report showed that 413 people had been infected in Guinea, 107 in Liberia, and 239 in Sierra Leone, almost certainly just a fraction of the real number that had come down with the disease. The mortality rate stood north of 60 percent; in Guinea, 75 percent of those who contracted Ebola had died.
“The world writ large missed the uptick in mid-June to late July,” said Rajiv Shah, head of USAID.
SIX
Death of a Hero
ALMOST EVERY TOP EPIDEMIOLOGIST and virologist streaming into West Africa already knew Sheik Umar Khan. For a decade, Khan had run the region’s only medical ward dedicated to treating and researching Lassa fever, at Sierra Leone’s Kenema Government Hospital about 190 miles from Freetown. His big, gregarious smile, teeth exposed, erupted at the sight of friends and colleagues; even in a community of energetic professionals known for pushing themselves to and beyond their physical limits, Khan developed a reputation for his enthusiasm. He would end many long days with colleagues—Randy Schoepp, the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) diagnostician who worked in the Lassa ward, and Robert Garry, the Tulane epidemiologist—over beers, excitedly discussing their progress and what they could investigate next. In early May, Garry and Khan had traveled to a conference in Nigeria; they spent eight hours at Freetown’s a
irport during a flight delay, talking.
Now, as May turned to June, Khan found himself on the front lines in the battle to contain another hemorrhagic fever, Ebola.
Friends say Khan was driven by a deep desire to improve himself—just weeks before the outbreak came to Sierra Leone, he had completed a training course to improve his knowledge of clinical medicine, and he was scheduled to take a sabbatical at Harvard, to help map the genomes of hemorrhagic fevers.
He was also driven by an urge to improve his country, scarred as it had been by civil wars. He had fled into exile in neighboring Guinea three times during the 1990s, when rebels rose up and captured Freetown. Several of his siblings moved to the United States and urged him to follow; he refused, and he was one of the first to return to the capital when British troops forced rebels out.
Khan had developed his fascination with medicine at an early age. One of ten children of a school headmaster in Lungi, just outside Freetown, he befriended the children of a nearby couple who ran a clinic for expectant mothers. Just a few years after earning his medical degree, at the age of twenty-nine, Khan leaped at the chance to take over Kenema’s Lassa ward, when his predecessor, Aniru Conteh, died after getting infected through an accidental needle prick.
Khan quickly became a staple in Kenema, where he maintained a private practice treating patients alongside his duties in the Lassa ward. He could be found at the Capitol, a hotel and restaurant near the hospital, watching his favorite team, AC Milan, play soccer on the satellite television. Some patrons might have been alarmed to see him celebrate goals by ripping off his shirt and waving it over his head.1 His dedication to the hospital cost him his marriage to a childhood sweetheart, who moved to London.
And when Ebola arrived, perhaps no medical professional in all of Sierra Leone was better prepared. Khan knew Ebola was lurking in the nearby jungles, and he took precautions to protect himself; he saw the first suspected patient, the young pregnant woman, while decked out in full personal protection equipment. Her blood test came back negative for Lassa, but it was clear the young woman was suffering from a hemorrhagic fever.
