Epidemic

by Reid Wilson

  Hundreds of experts like Woodring were there to convey guidance from national health officials to the local level. The physicians on the ground in the rural north still needed basic training in practical skills, such as how to properly mix chlorine solution to wash their hands and how to don and doff the protective gear that would keep them safe. Nimba County alone had about sixty-five outpatient facilities, where an Ebola sufferer might first encounter the health infrastructure. Each one, dotted along bumpy, rutted dirt roads with mud pits half the height of a vehicle, had physicians, nurses, even receptionists who needed training.

  In Nimba, Woodring awoke every morning in a virtually empty hotel once occupied by migrant workers plying the nearby mines. When the outbreak hit, the migrant workers had vanished. But the hotel’s owner, a relatively wealthy man in an impoverished region, had stayed open. Woodring asked him why. Every one of his employees, the man said, was supporting seven to ten relatives. Without the wages he paid them, those dependents would starve. He stayed open to give his employees a chance to feed their families.

  Fear was palpable in the northern counties. Residents were so afraid of Ebola that many were genuinely relieved to discover they were infected with malaria—a disease that kills half a million people a year. Woodring spent his Saturdays in a small town called Saclepea, where a college student, now without classes to attend, had started a new radio show to spread information about Ebola. Woodring and other CDC doctors spent hours taking calls from local villages, giving advice on how to prevent the disease from infecting new people.

  On the weekdays, Woodring bounced along tracks that could barely be called roads, traveling from village to village in a special Ebola response ambulance, a modified Toyota Land Cruiser. Along one road, the vehicle became stuck in a mud pit so deep they couldn’t even open the car doors. Amara, their driver, climbed out the window, hooked the Land Cruiser up to a bulldozer and pulled them free.

  Along the way, as he delivered CDC flyers showing how Ebola was transmitted and how to prevent its spread, Woodring was stunned by the heroics he saw among the facilities he visited. In one village, four physicians and fifteen nurses at an outpatient eye clinic had transformed their single building into an Ebola treatment unit, without being asked, without being paid.

  At another training session, at a small but surprisingly advanced facility deep in the bush, Woodring briefed the handful of health-care workers who would come into contact with any Ebola patients. The facility was one of the better medical outposts in Nimba County, about the length of a tractor trailer, painted light blue. There was no brick, but wooden walls separated different rooms, one of which served as a birthing suite. Construction of a new wing was under way, though the outbreak had halted work. Still, the local doctors had the drugs necessary to treat malaria or cholera, both of which frequently haunted their little village. The building even had a small lecture hall, where Woodring set up his presentation.

  He had come armed with a mishmash of slides from the international organizations fighting Ebola. Some carried the CDC logo. Others were donated by Médecins Sans Frontières (MSF) or WHO. One slide, from the Liberian Ministry of Health, showed precautionary steps that health-care workers had to take, in excruciating—and, to Woodring, painfully obvious—detail. One step that seemed laughably clear: Change gloves between each patient.

  “It’s really important that you switch up the gloves,” Woodring told the group as he clicked through the slides. One physician, sitting in the back, broke out into a broad smile, a grin that unnerved the American. “I’m curious to know what’s funny about what I just said,” Woodring told the man.

  “You talk about changing gloves between patients,” the physician answered. “We have no gloves to wear.”

  Two weeks before his arrival, the tiny Ebola treatment unit had taken in three confirmed Ebola patients. Without gloves to treat them safely, the doctors had used the only thing within reach to shield their hands: plastic bread bags. The taxi driver who had brought one of the patients protected himself by turning his jacket inside out. A shiver went up Woodring’s spine.

  The lack of basic medical supplies had plagued the rural regions of all three countries for months. The supply, in fact, did exist: nongovernmental organizations had shipped gloves and aprons and body bags and spacesuits into Monrovia and Freetown and Conakry by the planeload, and warehouses in all three capitals groaned under the weight of lifesaving materials. But those supplies were not being distributed to the field, where they were most desperately needed.

  In some more remote areas, Ebola victims had trouble even getting to a treatment facility. David Blackley, another Epidemic Intelligence Service officer, was dispatched to Bong Town, a settlement that began in the 1950s as a home for miners who excavated iron ore at the nearby mine. There, local health officials were using an old soccer stadium as a quarantine site for those who might have come into contact with Ebola. The United Nations Children’s Fund had donated four large tents, which gave health officials a rudimentary way to segregate the sick from those who did not show symptoms. Still, the families who arrived had to sweat out the equatorial heat with little hope of finding shade. Similar stadiums in small towns across the rural north served similar purposes, and local officials and their international partners cycled through a series of names for these facilities—Ebola care centers, community care centers, holding centers. Their very existence highlighted the fact that there weren’t enough beds to treat Ebola patients.

  The situation in Bong County also illustrated the difficulties of logistics in a third world country. When Kim Lindblade arrived from the CDC in October, she found that the official in charge of disease surveillance did not even have his own vehicle. When he could borrow one, the man didn’t always have the petrol necessary to get it moving.

  Blackley and Scott Laney, another CDC epidemiologist, began traveling through northern Liberia, touching base with public health officials in other remote rural regions as part of a CDC plan known as the Rapid Isolation and Treatment of Ebola (RITE) strategy. They crashed in whatever local guesthouses and small hotels they could find as they dove ever deeper into the bush. But accommodations were at times scarce. After being dropped off by a U.S. military Black Hawk helicopter in a remote part of Gbarpolu County, the team slept on the floor of the local church, after they moved the pews out of the way.

  At every turn, they were attended by Isaac Kamboe, a young Liberian man of about thirty who told them about his small family. Kamboe began as the team’s driver, navigating the tricky and treacherous roads. Soon he became a much more integral player, translating the local Bassa dialect into English, making connections with local tribal leaders where the Americans could not, and helping track down potential victims who had fled into the bush in fear. Within a few weeks, Blackley and Laney were including Kamboe in their daily planning and strategy meetings. His opinions had become as valuable as those of other team members who had gone through years of formal training.

  Almost every team the CDC sent into Liberia had an Isaac Kamboe, a driver whose knowledge of local customs would be invaluable to outsiders. And many of the drivers had long histories of working with Americans. After the Peace Corps pulled out of Liberia, drivers who were once employed shuttling volunteers from place to place signed on with the CDC, swapping pay stubs from one American agency for another.

  At times, the West Africans working alongside CDC colleagues served as chilling and important reminders of what was at stake. On another deployment, Leisha Nolen watched as the young Sierra Leonean woman assigned to enter case data found her own aunt’s name in the roster of new patients. Over the next excruciating days, on the papers she handled the woman watched her aunt’s life come to a slow end. She updated the case file as the older woman was admitted to an Ebola treatment unit, as her condition deteriorated, and when she died.

  By the early fall, as case counts continued to rise, the early skepticism about Ebola had almost entirely vanished from rural, remo
te villages. Traditional leaders more openly engaged with outsiders, be they Americans or health officials from the central government, which they still distrusted. But enforcing quarantines for a family of an infected patient could, and did, lead to heated tempers and shouting matches. Few CDC officials felt as if they were in any real danger, though occasionally their local minders had to step between them and someone who might have had too much to drink.

  But those in the field knew danger was ever present, and that a single wrong move could put dozens of people at risk.

  Dan Martin saw the Ebola outbreak as a test of his own personal values. A pacifist, he felt called to serve something greater than himself, but he could not bring himself to sign up for the military. Instead, deploying to West Africa was his chance to make a big difference in the world. Soon after he landed in Freetown, he and John Redd drove north to Makeni, the fourth-largest city in Sierra Leone, which lies near the border between Bombali District and Tonkolili District. Martin would be in charge of the CDC response in Tonkolili—Tonk, in local shorthand—while Redd managed Bombali. They swapped notes every night by the pool at the Wusum Hotel, over dinner and a few local Star beers.

  Redd was struck by efforts the hotel’s proprietor made to maintain a sense of normalcy. One night, when he dropped his laundry off at the front desk, the host asked him if he would care for rush service—even though Redd, Martin, and their small teams were the only ones in the entire hotel. Redd saw it as the host’s effort to preserve a veneer of the mundane amid the chaos of an outbreak.

  In the field, the CDC’s role was to advise the District Health Management Teams, made up of Sierra Leoneans overseen by the Ministry of Health. Martin and Redd were clear that they were not in charge, but they were there to help.

  In Tonkolili, Martin found the barest beginnings of an outbreak response; they did not even have a computerized list of where cases had been popping up. So Martin and the district team leader hunched over a map, marking villages where Ebola was present with a felt pen. The patterns that emerged informed the district team, which would be dispatched to identify cases and quarantine homes. Sometimes in the face of local reluctance, the district teams acted as detectives: freshly dug graves, an abandoned house, nervous villagers—anything that could be a sign of an Ebola case would raise suspicions and warrant further investigation.

  Martin spent most of his days riding along with the district health team, sometimes two or three hours at a stretch to reach far-off villages. One day, they traveled to Masokori, a village north and east of Tonkolili’s capital, Magburaka, to investigate reports of a suspected case. When they arrived, Martin watched an ambulance pull up—not to pick up the ill, but to return five survivors who had weathered Ebola’s horrible storm at a treatment center in Kailahun. The survivors, all women, were met by joyful villagers who escorted them into town. Four returned, beaming, to their homes. But as if he needed a reminder of the terrible toll he was witnessing, Martin watched the fifth woman collapse, sobbing, on her doorstep. A member of the district health team told Martin that the woman had gone to the treatment center in Kailahun with her daughter. The mother returned. The daughter had not.

  In Bombali, Redd spent most days hurtling between one crisis and the next. On October 21, his morning was spent at the local hospital in Makeni, where an eighteen-month-old boy had exposed most of the nurses to Ebola. Redd scrambled to find new nurses as the others quarantined themselves—nurses to take care of the nurses. Redd realized they might have to close the pediatric ward, another blow to Sierra Leone’s already-weakened public health system.

  When he returned to his headquarters, Redd called Jonathan Towner, a CDC lab technician based in Bo. Every day, blood samples would be ferried from Makeni to Bo, where Towner’s lab would look for the telltale signs of Ebola’s presence. Every day, Towner and Redd spoke by phone, ticking off the list of people who needed to be transported to a treatment unit, or quarantined at home.

  On this day, however, something was odd: one of the tests had come back inconclusive. One of the indicators of the virus’s presence had been triggered, but the other had not. That meant they had to test the patient again. Redd asked who the sample belonged to. When Towner read the man’s name, Redd felt his stomach drop—the sample had come from a member of the district health team.

  Redd found the team outside, gathered around their colleague who might have just received a death sentence. He had to get to the holding center at Makeni’s hospital, where he could be quarantined while his blood was tested again. When they finally found an ambulance to take him, the rest of the team felt a sense of complete deflation. Many wept openly.

  But slowly, another, more frightening realization set in: The man was their colleague. They had worked together, in close proximity, for days. If he had Ebola, the district health team, the CDC team, and the WHO officials in Makeni had all been exposed. Redd returned to the Wusum, his head spinning, worried about the effects of a close call on the district team—or even worse, an exposure.

  That night, meeting with his fellow virus hunters at the hotel, Redd explained what had happened, from a safe physical remove. The night was sticky with tropical heat; the air conditioner had picked that day to shut down, and the atmosphere in the upstairs lounge where they gathered felt repressive and confining. They had to get the young man’s blood retested, and fast. But in a cruel twist of fate, the person who usually transported blood from Makeni to Bo had been in a car accident and was now confined at the local police station.

  Martin volunteered to make the drive the next morning. Until then, Redd and Tiffany Walker, an epidemiological investigator who had also had contact with the young man, would quarantine themselves in their rooms to wait.

  The next morning, Martin and Redd showed up at the holding center at Makeni’s hospital, where the young man had sweated through a sleepless night. The phlebotomist who was supposed to draw the man’s blood was late, so late that Martin himself began preparing to insert the needle. Once the phlebotomist arrived, he followed the careful procedures for transporting potentially contaminated blood—the blood flowed into a glass tube, which was placed inside a screw-top specimen container. That container was in turn placed inside a plastic box, lined with double polyethylene liners. The box went into another, larger box, to add yet another layer of protection. They checked and rechecked everything they had done—and they realized they had put the blood inside the wrong kind of glass tube. A test from that kind of tube, one with a yellow stopper instead of one with a purple stopper, indicating a different kind of chemical regimen, might be inconclusive yet again. They told the phlebotomist to draw blood yet again. The technician let his irritation show.

  Once they knew they had gotten the process right, Martin jumped into a car for the four-hour trip to Bo. Floor it, he told the driver. They made it in three. When they arrived, Towner and one of his colleagues met them at the door to begin the testing process.

  By the evening, Martin arrived back at the Wusum, spent and mentally exhausted from worry. He stopped by Redd’s room, just in time for the phone to ring. It was Towner: The tests had come back negative, the young district health team worker did not have Ebola. Redd and Martin didn’t even bother to try to suppress the relieved flood of tears. They raced to the holding center to get the young man out.

  “We were often short on good news in those days,” Redd said later. It was a small victory, but one they cherished—not least because they were the ones involved. “You had to have faith that the interventions we were doing were going to work. Because it sure wasn’t obvious right off the bat.”

  The village-by-village surveillance collected by teams in Foya and Bong and Bombali and Tonkolili yielded data that filtered up the chain, from regional capitals to Monrovia, Conakry, Freetown, Geneva, and Atlanta. The data illustrated where the virus was spreading and where it might spread next. That sort of meta data collection was relatively new to ministries of health in all three countries, though it was critic
al to stopping Ebola’s spread. Without that data, contacts could melt away into the interior’s dense jungle, lost until they started a new hot zone of their own.

  Collecting and analyzing data became a critical tool in fighting the Ebola virus. Just as retail businesses, tech companies, and even political campaigns were coming to rely on Big Data to better understand their customers and constituents, so too were humanitarians starting to use data science to understand what was happening around them. But even by September and October, the man tasked with collecting these data—Luke Bawo, the Liberian Ministry of Health’s head of Ebola surveillance—struggled through charts and sheets submitted from around the country, many of which were riddled with inconsistent and misleading information.

  One day in October, a tall Swedish man walked into Bawo’s office, in room 319 of the Ministry of Health’s expansive building. Hans Rosling was something of a celebrity in the global health community, a no-nonsense believer in the power of numbers, built after decades of experience responding to some of the worst tragedies in Africa. Rosling, the former head of the Karolinska Institute in Stockholm, is mobbed by fans when he attends prestigious gatherings like the World Economic Forum in Davos, and his TED Talks sell out in an instant.

  But Bawo did not know who Rosling was until the Swedish professor introduced himself. He had canceled his lectures and his classes, Rosling said, to volunteer. Within twenty minutes, Bawo had given Rosling a desk.