by Reid Wilson
But while Nigeria could have provided Ebola’s vault to the global stage, officials at all levels had done something those in Sierra Leone, Guinea, and Liberia had not: they had prepared. If Africa’s most impoverished countries were an illustration of what happened when the global health system stumbled, Africa’s most populous nation, perhaps the most potent powder keg on the continent, would become an example of what happens when the health system works as it is supposed to.
With the outbreak raging out of control a thousand miles to the west of Nigeria, the major regional hub, Nigerian health officials were keenly aware of two very strong likelihoods: first, there were enough commercial and cultural connections between Nigeria and the three West African nations that it was almost impossible to screen every traveler coming by plane, boat, or bus across their borders. Second, they knew if the Ebola virus was going to spread globally, it would likely spread by way of Lagos.
Onyebuchi Chukwu, Nigeria’s minister of health, demanded his staff be ready in the event of an ill patient. Health-care workers across the country, and especially in the poorer neighborhoods of Lagos and the capital Abuja, were given crash courses in detecting a possible Ebola patient and in protecting themselves if and when that patient walked through their doors. The training was by no means comprehensive, but it was far more than health-care workers in West Africa had received.
The nation had other advantages, too: Nigeria, unlike the three West African countries that had suffered the brunt of the Ebola outbreak, has something approximating a modern health-care system. Nigeria’s oil wealth makes it the richest country in Africa, and some of that wealth had gone toward building medical capacity that would now become crucial to stopping the virus before it got out of hand. The country’s leading health experts also knew how to respond to outbreaks on grand scales. Though they had no experience with Ebola, Lassa was endemic to the region; that virus got its name from a small town in northeastern Nigeria, near the border with Cameroon. International organizations like the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) had spent decades fighting disease around Nigeria, making the Westerners in space suits known quantities both to federal and state governments and to the people they would be working to protect. Managed properly, the skepticism that international aid organizations faced in Liberia, Sierra Leone, and Guinea would not be a problem in Nigeria.
In those first hours after Sawyer landed, before most Nigerian officials realized they had their first Ebola case on their hands, they caught two crucial breaks. When Sawyer arrived on July 20, he had quickly been identified by immigration officials as a potential risk. Those officials had diverted him to a medical facility. The first break was that he had been allowed to fly at all. Had Sawyer arrived by bus, a more common mode of transportation through countries in West Africa, had he breezed by immigration agents, or had he been diverted to a public hospital, the index patient might have sparked a global catastrophe.
The second twist of good fortune appeared, on its face, as a stroke of incredibly bad luck. The day Sawyer landed, medical staffs at public hospitals were on strike. But that turned out to be a cloud with a bright silver lining: instead of being taken to one of Lagos’s major medical facilities, where thousands of patients and poorly trained health workers could have been at risk, he was transported to First Consultant Hospital, a small, privately run facility led by Dr. Adadeyoh.
Three days after arriving at the private hospital, Sawyer’s blood tests came back. Adadeyoh was startled, but not entirely surprised, to find that her suspicions had been correct all along: Sawyer had Ebola. The patient was less accepting of the diagnosis. Sawyer was irate. The doctors had gotten it wrong, he screamed. He insisted that he be allowed to leave. He pulled an IV line out of his own arm, spraying blood tainted with billions of Ebola virions around the room.6
Adadeyoh was pressured to free her patient from two other altogether more surprising sources: the Liberian Ministry of Finance and the Liberian ambassador. They both demanded that Sawyer be freed, first to continue on to the conference in Calabar, then finally, just to return home. Sawyer wanted to travel much farther than Liberia. His wife and children were waiting for him in Minnesota. Adadeyoh continued to refuse.7
In Abuja, news that Sawyer’s blood work had come back positive set off a mad, but orderly, scramble. Chukwu’s Federal Ministry of Health, CDC’s Nigeria office, and the national WHO outpost, led by Dr. Rui Vaz, declared an Ebola emergency that same day the results came in. CDC director Tom Frieden, traveling in rural Kentucky and struggling to maintain a cell phone signal, tracked down Babatunde Fashola, the governor of Lagos state. “Governor, if you don’t control Ebola, it’s the only thing you will ever be remembered for,” he warned.
Within hours, an Incident Management Center opened its doors to oversee the response. The center operated like a war room, dispatching dozens of teams to track down everyone who had come into contact with Sawyer, keeping tabs on those contacts, and mounting an aggressive public relations campaign to let Nigerians know: Ebola is here, but we are on it.
The contrast with the outbreak that began in Guinea could not have been more stark. Medical officials near Meliandou had not even suspected an outbreak had begun until two months after the toddler Emile had fallen ill. By that time, dozens had died and dozens more were infected. In Nigeria, officials knew they had their first Ebola case within seventy-two hours of his arrival.
The contrast was stark, but it wasn’t entirely an even match. Nigerians had decades of experience tracking down disease—which meant the populace had years of experience with the medical system that was now mobilizing to save them. Just two years before Ebola arrived, Nigeria had stepped up its efforts to eradicate polio, which was still endemic to the region. The government had been aggressive and innovative: The program used satellite-based global positioning systems (GPS) to ensure that children living in remote villages were vaccinated.
Then, the Ministry of Health had opened an Incident Management Center to track the fight against polio. Now, many of the same people who worked in the center reprised their roles as virus hunters; the deputy manager of the center during the polio campaign was promoted to manager. The same GPS that had been used to track villages where children were vaccinated against polio were now used to keep tabs on the growing list of those who had contact with an Ebola patient, who would need to be monitored for three weeks. Nigerian health officials opened a makeshift Ebola treatment unit in just fourteen days, twice as fast as anyone else had been able to open a new facility.
The center operated as the hub from which separate spokes branched out, all working together to stamp out any chance the virus might have of escaping their ever-contracting web. Separate units oversaw the response’s strategy and coordination campaigns; one was dedicated to case management, another to infection control. A media and public affairs team handled social mobilization, alerting community leaders of the virus in their midst and helping those communities build response strategies. A team of scientists oversaw any necessary laboratory services. Another team managed every point of entry into the country.
Each played a well-practiced role. The social mobilization team worked to spread as much information about Ebola as it could and to reduce the stigma of contracting the disease. (Ending the stigma, as West African officials came to learn, was critical to identifying the extent of any outbreak: if people are scared of being ostracized by their communities, they won’t come forward to be treated.) They personally contacted residents in about 26,000 homes.8 The team charged with watching ports of entry kept a vigilant eye out for anyone else who might carry the disease with them, checking temperatures of everyone who crossed into Nigeria, by plane or bus or boat. The strategy team organized shipments of protective equipment to health care centers around Lagos, then organized trainings for medical personnel.
Others worked with the media, traditional and religious leaders to teach them about the science of Ebola—the
ease of transmission, the importance of getting early treatment, the danger in caring for a sick family member or preparing a body for burial following traditional guidelines. Traditional and religious leaders had worked with government officials on the polio vaccination program two years earlier. A parallel public relations campaign, broadcast over radio and television airwaves, featured prominent actors from Nollywood, Nigeria’s growing and hugely popular film scene.
Most crucial were the tracers, those dispatched to find anyone who might have been infected by Sawyer. Forty epidemiologists and 150 staffers trained in the art of contact tracing fanned out across Lagos. They hunted down passengers from Sawyer’s flight, the immigration officials who had stopped him, airport personnel, the driver who brought him to the hospital, any nurses or technicians or doctors who might have come into contact with him at the hospital. They searched through slums, where many of the houses had no street numbers. Any home or vehicle or public space that might have been contaminated got a thorough hosing with virus-killing chemicals.
Tracing Sawyer’s contacts and the contacts of others who came down with Ebola made a massive difference. In West Africa, Ebola had spread undetected through several successive generations of victims before contact tracers arrived to identify those at risk. The aggressive contact tracing in Nigeria meant that anyone who was infected would be identified, isolated, and treated as quickly as possible, severely curtailing the number of others they might infect in turn. Second-generation spread, a key metric epidemiologists track in any outbreak, was far lower in Nigeria than it was in Sierra Leone, Guinea, or Liberia.
Even under the high-quality care of a private hospital, it was too late for Sawyer. He succumbed on July 25, just two days after his blood work came back positive. But the contact tracers were still hard at work, identifying seventy-two people with whom Sawyer had had contact between the time his plane landed and his lab results came back positive. Anyone who showed symptoms was immediately moved to an isolation ward, their blood shipped across town to new high-tech facilities at the Lagos University Teaching Hospital for testing. If Ebola was in their blood, the patient would be transferred to an equally high-tech treatment center.
In spite of the Nigerian government’s quick action, Sawyer had managed to spread the disease. And as in West Africa, health-care workers once again bore the brunt of Ebola’s toll. Eleven of the twenty people who would eventually fall ill in Nigeria were health-care workers. Nine of those people had contracted the disease before Sawyer’s blood work came back.9 Many did not understand how they had gotten sick.
“I never contacted his fluids. I checked his vitals, helped him with his food,” nurse Obi Justina Ejelonu wrote in a post on Facebook. “I basically touched where his hands touched and that’s the only contact. Not directly with his fluids.” She was among the nine who got sick after treating Sawyer before his diagnosis came back.10 So was Dr. Adadevoh. The veteran physician, the anchor of the private hospital, died August 19.
The tracers found another 279 people who had contact with others who got sick in Lagos. Just one victim managed to slip the net by flying west to Port Harcourt, Nigeria’s main oil port. That patient, who left to seek medical treatment from a private physician, infected three others, including the physician, who died after two agonizing weeks, on August 23.
Again, tracers dispatched by the Incident Management Center went to work canvassing Port Harcourt. They were startled to find that the doctor had come into contact with hundreds of people in the ten days between his initial contact with his patient and his development of symptoms. Eventually, the number of contacts in Port Harcourt rose to 526—more than enough to set off an explosive outbreak in another densely populated city. Tracers kept close track of all 526 people for the three-week incubation period. Incredibly, only two got sick.11
By September 5, little more than a month after Sawyer’s death, the last of the twenty cases of Ebola Nigeria would experience was diagnosed. Eight of the twenty patients had died, while the final patient walked out of Lagos’s Ebola treatment center nineteen days later, on September 24, with a clean bill of health. On October 20, forty-two days—or two incubation periods—after the final case was confirmed, WHO officially declared Nigeria to be Ebola-free.
The spread of Ebola to one of the world’s largest cities represented the worst nightmare of epidemiologists and public health officials around the globe. But while other cities might not have been ready, in Nigeria the officials had been unusually prepared to defend Lagos. The preplanning—made possible by smart investments in a solid foundation of public health and prior efforts to stamp out disease through an organized campaign—left Nigeria with a blueprint for beating back an epidemic. Every player, from the minister of health Onyebuchi Chukwu to the contact tracers walking Lagos’s slums, knew exactly what they were supposed to do, and none tried to delay or deny the virus’s presence. Incredibly, the contact tracers from the Ministry of Health, and another team from MSF, tracked down all but one of the 894 people who had primary contact with an Ebola victim in Nigeria.12
“That was the moment of maximum terror,” the CDC’s Frieden recalled later. “It was literally days from being out of control. [Ebola] would have been all over Lagos, all over Nigeria, all over Africa for months and years to come. This was the moment at which the world was on the brink of a catastrophe.”
The city, the world, caught its share of breaks: that public hospitals were on strike limited the contacts Sawyer could have; that a sharp-eyed immigration officer spotted the ailing man. But without the years of preparation and groundwork Nigeria had laid, those bits of luck would have been but drops in the bucket. The fast action from Abuja to Lagos and Port Harcourt demonstrated how to handle an outbreak effectively enough to minimize danger, both to a crowded country and the world. They were lessons that those in Liberia, Guinea, and Sierra Leone—not to mention the World Health Organization itself—would learn from in the coming months.
EIGHT
The Samaritans
IN LATE JULY, RANDY SCHOEPP of the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) took a rare few hours away from the diagnostics clinic he ran outside Monrovia to visit a new facility on the other side of town. It was a new Ebola treatment center, built at an existing hospital in Paynesville City, a major suburb along a bustling highway. The hospital itself had been maintained by Eternal Love Winning Africa (ELWA), a Christian missionary organization, since 1965. Now, another missionary group, Samaritan’s Purse, had become the first nongovernmental organization (NGO) outside of Médecins Sans Frontières (MSF) to open an Ebola treatment center. The facility would be called ELWA 2.
Schoepp was impressed with the new treatment center. For Liberia, still struggling to build its medical capabilities, it looked relatively modern, with as many protections for doctors and nurses as one could reasonably expect in a field hospital. The unit had forty beds, making it one of the larger facilities in Liberia at the time; half were reserved for confirmed Ebola cases, the other half for suspected cases.
A bright-eyed young Samaritan’s Purse doctor with closely cropped red hair named Kent Brantly guided Schoepp and a few other Army doctors around the building, showing them the new shower facilities that would decontaminate anyone walking from an isolation ward back into a clean zone. Brantly asked one of his colleagues, a Liberian nurse, to demonstrate the process of donning and doffing a protective suit; he was clearly proud, eager to show off the skill of both the American missionaries and the Liberian nurses and technicians who would staff the ward. Brantly asked what Schoepp thought, a sign of respect from one young doctor to an older, more experienced expert. Schoepp could not help being struck by his enthusiasm.
But something else struck Schoepp at the same time: Brantly didn’t look terribly well. Brantly had apologized when he refused to shake Schoepp’s hand when they first met, explaining he was a little under the weather. Neither the refusal nor Brantly feeling a little ill was odd. Almost no one
was making physical contact amid the heightened tensions of the outbreak, and almost every Westerner making a first visit to West Africa would experience some kind of symptoms, whether a headache or an upset stomach. Schoepp thought nothing of it as he stood shoulder to shoulder with Brantly, watching the donning and doffing demonstration.
Back at the HIV diagnostics clinic a few days later, though, a new blood sample crossed Schoepp’s desk. It was labeled Tamba Snell, a name he recognized, one he had seen before, and one that was obviously fake. That meant the sample probably came from an employee of a nongovernmental organization; NGOs had a habit of labeling their employees’ blood samples with aliases, both to protect their privacy and to avoid the stigma of even being tested for Ebola in the first place. Schoepp thought back to the day before, when he had stood so close to Brantly, well inside the three-foot buffer zone recommended by health officials.
Then another sample crossed Schoepp’s desk, another alias, Nancy Johnson. Both came back positive. He asked his sources for the real identities of Tamba Snell and Nancy Johnson. The answers: two American missionaries working at the ELWA 2 hospital. One was named Kent Brantly.
A chill went up Schoepp’s spine. The fact that they stood so close together now meant that the Army doctor and the rest of his team were possible contacts, too. They spent the next three weeks testing their own temperatures at least twice a day, monitoring themselves for signs of the virus. Many times, one member of the diagnostics team would catch another with a thermometer. They exchanged knowing, fearful looks: You okay? Should I be worried? Every slight twinge or minor headache sent paranoid thoughts of Ebola racing through their heads.
