Epidemic

by Reid Wilson

  “Just because something is a new risk,” Fauci explained later, “doesn’t mean it’s a greater risk than everything else in your life.”

  Obama understood the point: the op-ed would sell newspapers, and it would give Americans something new to fear, but it did not represent the realistic thinking of the scientists he was relying on to reverse the outbreak.

  The second news-making moment that sent Ebola responders reeling came not from an outside source, but from within the government itself. On September 23, data analysts at the Centers for Disease Control and Prevention released a new modeling tool to project just how bad the Ebola outbreak could become. The analysis, led by noted modeler Martin Meltzer, combined every factor it could, assuming—reasonably, to most of those responding to the crisis—that reports from the World Health Organization had significantly understated the number of Ebola cases in the three West African nations, by a factor of two and a half. They offered a careful assessment of the situation on the ground, the need to isolate as many patients as possible, and efforts already being made by USAID, the Departments of Defense and Health and Human Services, and global partners to ramp up the number of available treatment beds.

  But reporters covering the story, and the editors who needed a strong headline to drive reader interest, skipped over much of that to focus on a single, shocking number—the CDC’s model suggested that if nothing was done to control its spread, as many as 1.4 million people could be infected by the Ebola virus by January 20, just four months down the road. That top line number was shocking: it meant the population equivalent to San Antonio, Texas, America’s seventh-largest city, could be infected with one of the most deadly and horrifying diseases ever encountered by man.

  In the days leading up to the CDC’s stunning projections, the harmonious working relationships among the country’s top health officials started to fray. The CDC had included as many caveats as it could. The projections assumed a high number of unreported cases that had yet to be discovered. The 1.4 million number was an absolute worst-case scenario that no one expected to reach, a figure that represented the natural spread of the virus if no one bothered to do anything to fight it.

  But Fauci knew that reporters would only focus on that worst-case scenario. He called Frieden, the CDC director, to complain. So did USAID’s Rajiv Shah and Health and Human Services secretary Sylvia Matthews Burwell. Together with the White House, they begged Frieden to present a more measured assessment that factored in all the work that had already been done to stem the virus. The numbers were flawed, they all argued, because the outbreak didn’t exist in a vacuum. The ambitious response already begun by the United States, its international partners, and the three infected countries themselves were the opposite of a vacuum.

  The outraged calls were not only coming from Washington. Margaret Chan, director-general of WHO, called, followed by the presidents of Liberia, Guinea, and Sierra Leone. At a time when the few global responders who were on the ground in West Africa were desperately trying to attract new help, both from other governments and from NGOs that had stayed on the sidelines out of fear, such an extreme projection would only hurt their ability to attract new aid and investment.

  “That number was complete horseshit, and everybody knew it from the beginning,” one senior public health official who called Frieden to complain said later. “It was nuts. It was absolutely inaccurate the minute it came out.”

  Frieden, unbowed, stood by his analyst Meltzer. The two men had stayed up late into the night for several days before the model was released, reviewing again and again the factors that went into the assessment, and the number that came out. The CDC has always been independent of Washington politics—part of the reason it is headquartered hundreds of miles away, in Atlanta—and Frieden was determined to protect his analysts from what might be viewed as interference. Privately, Frieden was “pissed,” he later said, at the pressure he was receiving.

  “We’ve got to tell it like it is,” he said. “We have to mobilize a response and we have to be very specific about what’s needed. That model was very specific: Fix the burial teams first, and second, get safe care.”

  Frieden took no small amount of satisfaction when, months later, the CDC’s projection of what would happen if the response were ramped up mirrored almost exactly the actual number of cases and deaths on the ground. Forget the media’s hyperventilating about the top line number; the analysis had been correct.

  Even before the CDC’s terrifying new numbers came out, the most ambitious assault on Ebola had begun to take shape. The assault had its roots in the conversations Konyndyk and Frieden had begun even before their journey through Liberia, where an idea had been born that percolated to the highest levels of the National Security Agency. It would come to a head on September 11, 2014—three days after the WHO reported that 4,269 West Africans had become infected. Of those, 2,288 were dead.

  Centers for Disease Control and Prevention microbiologist Barry Fields stands outside the ELWA 3 hospital in Monrovia, Liberia. In the background, the trees under which patients waited to be admitted.

  A large tree on the edge of Meliandou, Guinea, where scientists believe two-year-old Emile contracted the Ebola virus. Villagers burned the tree after the government warned against eating bush meat.

  A rickety bridge stands at the entrance to Meliandou, Guinea. Neighboring villages shunned Meliandou’s residents after the Ebola outbreak began.

  In the streets of Meliandou, villagers hung laundry between their homes.

  In the Oval Office, President Obama hugs Nina Pham, the 26-year-old nurse from Texas Health Presbyterian Hospital, just fifteen days after she had been diagnosed with the Ebola virus.

  Obama received constant updates on the fight against Ebola. From left, Ron Klain, Ebola response coordinator, Obama, Lisa Monaco, homeland security adviser, and Denis McDonough, White House chief of staff.

  President Obama hosts West African leaders in the Cabinet Room. Alpha Conde, president of Guinea, sits on the far left listening to the translation; Ellen Johnson Sirleaf, president of Liberia, faces Obama; while Ernest Bai Koroma, president of Sierra Leone, sits on the far right.

  CDC director Tom Frieden undergoes decontamination after touring the Ebola ward at the ELWA 3 treatment unit in Monrovia.

  Crosses mark the graves of Ebola victims at Disco Hill Cemetery, which opened in December 2014. The Liberian government formally took over management and operations of the cemetery in January 2016.

  President Ellen Johnson Sirleaf tours the cemetery at Disco Hill.

  Major General Gary Volesky has his temperature taken by a Liberian Army soldier. Although they did not come into contact with Ebola victims, some U.S. Army officials had their temperatures taken as often as eight times a day.

  Piet de Vries, Global Communities’ lead official in Liberia, addresses a community meeting.

  An Ebola treatment unit built by the U.S. Army, as seen from above. Patients would be treated in the white tents in the foreground. Many ETUs were built in forested areas, meaning Army engineers had to clear trees and level the ground before construction could begin.

  All three West African governments mounted massive public relations campaigns to raise awareness about Ebola. Here, a billboard in Monrovia warns residents to be safe around those who might have the virus.

  ELEVEN

  Darkest Days

  THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) sit on a pristine campus in the Druid Hills neighborhood of Atlanta, on land donated by Emory University. Gleaming modern buildings have been erected in recent years to replace older facilities, and the perfectly landscaped grounds, populated by groups of serious-minded experts having lunch outdoors or strolling between offices can make the place feel like the headquarters of a Silicon Valley tech giant.

  On the third floor of the CDC’s main tower, however, the Emergency Operations Center (EOC) has a more urgent feeling. On a normal day, the several hundred computers, arranged in rows facing
large display monitors that show everything from CNN to computer-generated maps and graphics, the EOC monitors everything from outbreaks across the world to flare-ups of some disease as routine as the flu back in the United States. The people who occupy those desks represent different divisions within the CDC—logistics, personnel, transportation, epidemiology, and others. Other desks are reserved for liaisons from partner agencies, the military, or nongovernmental organizations (NGOs). Bordering the room on the right side is a row of emergency operators who oversee any ongoing or emerging disasters. In the back, senior officials can be briefed in a conference room that looks over the entire EOC.

  By the close of summer, virtually every desk in the EOC was dedicated to some aspect of the response to the Ebola virus. Communicating across divisions of an agency that can sometimes be too insular was critical: When Tom Frieden or the EOC manager on duty led briefings in the crowded conference room, every word spoken was broadcast into the EOC itself, and every slide the agency’s leaders saw was displayed on the monitors in the main room, so no one was kept out of the loop.

  The urgency that thrummed through the operations center reflected a larger state of change within the CDC. Since its founding in 1946, the CDC had routinely dispatched its experts to global disease hotspots, whether it was combating polio, malaria, Ebola, or any of a hundred other deadly bugs. But the scale of the teams that would fly out of Atlanta’s Hartsfield-Jackson International Airport was relatively small. The agency had a habit of patting itself on the back when they got fifteen epidemiologists out into the field. To respond to the Ebola outbreak, especially as the case curve grew at an alarming rate, the CDC would need to dispatch a hundred times that number.

  And the case curve was shooting skyward: in the first week of September, responders had identified almost 900 new Ebola victims, the number of cases had jumped from 3,052 on August 28 to 3,944 on September 6. Ten days later, another thousand people had been infected. A week after that, the case count was up to 5,843. As of September 22, 1,008 Guineans had contracted Ebola. Sierra Leone was dealing with 1,813 cases. And an incredible 3,022 Liberians were sick with the disease. The major outbreak in Lofa County had spread south and east to Bong and Nimba Counties, while another viral epicenter in Monrovia spread into Montserrado and Margibi Counties, along the coast.

  But as the situation grew more grim, the CDC began its remarkable evolution. Hundreds of epidemiologists, virologists, lab technicians, and rank-and-file doctors volunteered to deploy to West Africa to lend their assistance. Some would become contact tracers. Others would monitor ports and borders. Still others would trek through the dense forest and canoe up remote rivers to advise far-flung villages on quarantines and other preventative measures. French-speakers were the most valued. Anyone with even a rudimentary memory of their high school French classes would be sent to Guinea, where the outbreak was showing new life. In all, 1,897 CDC staffers would deploy to Liberia, Guinea, and Sierra Leone in the subsequent months.

  Those staffers felt a sense of duty, but also a sense of excitement. Here was their opportunity, they knew, to exercise their very specific skills to bring to heel the biggest public health crisis in a generation—maybe of their whole careers. For half a century, CDC legends had been sent to fight the most deadly outbreaks the world had ever known, and now a new generation would have the chance to add their names to the history books. They were not excited by the outbreak of a virus, they were excited about the chance to kill the virus.

  But when Leisha Nolen landed in Freetown in early August, the region she had visited only a few months earlier demonstrated just how much work she and her colleagues had ahead of them.

  Nolen, a thirty-seven-year-old Harvard-trained pediatrician, was one of a few dozen members of the CDC’s Epidemic Intelligence Service,1 a postgraduate course that prepares the next generation of virus hunters. She had been among the first to travel to Liberia in mid-April, first to Foya in northern Lofa County, just across the border from the outbreak’s epicenter in Guinea. After three weeks, she drove south to Monrovia. At the time, no new cases popped up in Liberia, and Nolen flew home, hopeful that the disease had exhausted itself.

  But even without any new cases, Nolen spotted something that concerned her: funerary traditions required Liberians to wash their dead before burial. That would put the family of an Ebola victim in close proximity to the virus at a time when the body was most infectious. The international health community could warn Liberians all they wanted about the dangers of funerary traditions, but Nolen worried that the pleas would fall on deaf ears. Those traditions were deeply woven into Liberian society, she saw, and no one gives up their cultural traditions easily.

  In August when Nolen deployed for the second time, this time to Sierra Leone, she found a situation very different from the one she had left in April. In Freetown, the Ministry of Health was scrambling to respond. Few NGOs were operating at a high level. There were just two working ambulances in the entire country, and the beginning of the rainy season meant that many of the already-difficult roads became impassible. The system, Nolen recalled later, was “completely overwhelmed.”

  Nolen and her team of six other CDC workers soon grew to fifteen. They spent their days tracking down trucks that could be used as ambulances, dispatching body management teams and identifying new clusters of Ebola. Some of the decisions the team was asked to make were moral dilemmas with no clear answer: One day, a colleague called Nolen looking for an ambulance to take an infant showing symptoms to an Ebola treatment unit. They couldn’t find a car seat for the child, and putting the baby in someone’s arms for the six-hour drive to the hospital would mean putting that person at risk. Eventually, they decided to strap the baby into a basket and hope for the best. The infant made it to the hospital, but it did not survive the disease.

  Through August, September, and October, almost every story ended the same way: Liberians, Guineans, Sierra Leoneans, and their international partners went to extreme lengths to get their neighbors, friends, and families to treatment centers, and those people almost always died. The growing case counts wore on doctors and health-care workers who succumbed, in their darkest moments, to fears that they were hopelessly behind the curve.

  “Most of us who were there had a really hard time imagining how we were going to stop it,” Nolen said later. Nolen returned from her second deployment in a state of near depression. Normally physically active on a regular basis, for three weeks, she did nothing but sit on the couch.

  As the case counts mounted, the CDC dispatched more and more experts to West Africa. Peter Kilmarx arrived in Freetown, Sierra Leone, in mid-September, to lead the CDC’s response from there. His plane landed after midnight, and he did not make it to his hotel until 6:45 a.m., less than an hour before his first meeting of the day. Kilmarx’s team headquartered themselves at the Radisson Blu hotel, where the thirty-person team met in a boardroom with about a dozen chairs. As the team grew, Kilmarx moved the daily status meetings to the hotel restaurant, then to a three-hundred-seat ballroom they called the Cave.

  Day after day, the reports were the same: supplies were limited, infections were showing up in new villages, and the response was clearly falling short. If he was lucky, Kilmarx would manage four hours of fitful sleep a night.

  As CDC staffers poured in to West Africa, Kilmarx and his colleagues made sure they followed four strict rules meant to keep them safe. They were never to enter an Ebola treatment unit, a hot zone off limits to all but those directly responsible for patient care. They were never to provide direct patient care. They were not allowed to collect specimens, which needed to be handled by specially trained researchers following highest biosecurity protocols. And they were never to interview a possible Ebola contact from within three feet.

  The CDC grappled with the way it would treat returning Ebola workers. Ultimately, senior officials decided against a mandatory quarantine once a health-care worker returned to the United States—but doctors and investigators retu
rning from West Africa would have to call in to both a CDC operator and the health department in their home state twice a day for three weeks, to keep an eye on their temperature.

  The physical distance required to keep them safe, paradoxically, was another source of stress for many of the responders. Joe Woodring, the CDC doctor who deployed twice to Liberia and Sierra Leone, recalled the strain of staying away: “I am used to playing with kids on the street, holding the hand of a patient or giving big hugs to my CDC colleagues,” he told a conference in September 2015, nearly a year after his first deployment. “This disease was too virulent and transmissible” for any of that.

  Woodring reached Monrovia for the first time in mid-October. He spent his first several days squirming through seemingly interminable meetings at the embassy, antsy to get out the door and begin practicing the craft for which he had trained his entire professional life. Finally, he asked the deputy director to send him to the rural north, to the heart of the outbreak.

  The CDC sent him to Nimba County, where he found two standoffish World Health Organization (WHO) officials skeptical of his arrival. Why, they wanted to know, was the CDC showing up just now?

  The CDC’s mission spanned from the immediate needs of dead body management to the long-term goals of encouraging behavior change among at-risk communities. It had to help ferry supplies and samples over treacherous roads, too. Back in Monrovia, laboratories worked to link strains of the disease together, to paint an accurate picture of how Ebola had spread, and to extrapolate how it would spread in the future. In Atlanta, others studied what procedures had worked and, as importantly, what was not working, to alter their tactics and strategies accordingly.