Epidemic

by Reid Wilson

  The data Rosling found were a mess. Parents might give conflicting information about their children’s ages to contact tracers. Complicated Liberian names might be transposed, making it more difficult to trace those who were infected, or double-counting cases that actually existed. When investigators in rural northern counties didn’t find an Ebola case in a given village, they would enter a “0” on their spreadsheet. That zero suggested there were no cases in that village. Rosling preferred to leave those spaces blank: It was more accurate to say investigators had not found an Ebola case, he said, than to say there were no cases to be found.

  Rosling overhauled the Liberian database and asked Ministry of Health officials to scrub the lists they did have of duplicate names. That allowed precious resources to be conserved for actual cases, rather than forcing investigators to chase after cases that did not exist. The Ministry of Health began tracking multiple sets of numbers: the number of reported cases, to be certain, but also the number of funerals being held in rural counties, and the number of calls made to emergency medical lines.

  He also used his celebrity to request a grant from a major Swedish foundation, established by a family that had made its money in part from mining the very West African countries that now suffered. Funding for the grant came through within forty-eight hours. He and Bawo became fast friends, keeping tabs on each other over the next several months. At meetings with international NGOs, the Swedish epidemiologist sat on the Liberian side of the table. Every other week, Bawo would take Rosling with him to report to President Sirleaf and her cabinet on the state of the outbreak. Bawo had to force Rosling to take Sundays off. Rosling, unwilling to leave his work even for the holidays, spent Christmas with Bawo’s family.

  Even with years of experience, the climate in Liberia was the scariest Rosling had ever encountered. Alone in his hotel room every night, he took to listening to the speeches of Winston Churchill for inspiration.

  Rosling had his own moment of panic one night, when he came down with a case of diarrhea. He skipped dinner and took his temperature every two hours as he wondered whether he, too, had come down with the virus. Still, he finished a nightly report he was working on. When he woke up the next morning, he felt fine.2

  In the meantime, they worked feverishly to compile the new data. Embedded with the Liberian government, Rosling became deeply cynical about the international response, which he found weak and enfeebled. He reserved his harshest criticism for the World Health Organization, which he came to view as worthless at best, actively unhelpful at worst. He favored two American Army lieutenants who had been sent to help crunch numbers in Microsoft Excel; the Americans, Rosling thought, were much more reliable than the WHO. Rosling was also resentful of international media reports that portrayed Westerners coming to the rescue of helpless Liberians; in Bawo and others, Rosling had found a set of deeply competent, deeply committed Liberians who were saving their own country.

  The results of spreadsheets over which Bawo, Rosling, and their team labored were eye-opening. The number of Ebola cases in Liberia was not increasing as dramatically as CDC projections suggested they could have, but the situation was worse than the government itself portrayed. More important, the data showed them where to look for the next front in the war against Ebola.

  But even with the CDC’s increased efforts and Rosling’s best data science, the case curve continued bending north. By the beginning of October, more than 7,150 West Africans were infected with Ebola, and more than half of those cases had occurred in Liberia. The dead already totaled 3,330 people. By the end of the month, more than 13,500 people would be infected, and 4,900 had died. The world needed a more robust response.

  TWELVE

  Deployment

  AFTER AN EYE-OPENING VISIT to Liberia, Jeremy Konyndyk and Tom Frieden took stock of what they had seen. The three West African countries were trying, and failing, to come to terms with a disease that had infiltrated both hard-to-reach rural areas and crowded slums in major cities. The health care systems in Liberia, Sierra Leone, and Guinea were so overwhelmed that other diseases were going untreated. Pillars of civil society in all three countries were breaking down; markets were shut, schools were closed. The World Health Organization (WHO) was plumbing new depths of ineptness on a near daily basis, while the vast majority of nongovernmental organizations (NGOs)—with the exceptions of Médecins Sans Frontières (MSF), Global Communities, and a few others—had pulled up stakes. On returning to Atlanta, Frieden had called President Obama to describe his experiences, and how the United States should respond. He was, by his own admission, worked up by what he had seen.

  The Centers for Disease Control and Prevention (CDC) had asked for volunteers to deploy to West Africa, and those volunteers were being trained as fast as possible. But even the rapidly expanding American response was becoming overwhelmed. Members of the United States Agency for International Development Disaster Assistance Response Team (USAID DART), supplemented by doctors arriving on an almost daily basis, were no match for a disease that was infecting hundreds of new people every week.

  Back in Washington, Konyndyk and Frieden shared the recognition that they needed more—more people, more resources, more expertise. Their agencies had never dealt with an emergency of this scope and complexity. In the following days, they briefed Anthony Fauci, of the National Institute for Allergy and Infectious Disease, who had heard similar reports from his own staff who had been to Africa. Together, they realized that the full force and weight of the entire American public health care system might not be enough to contain the outbreak.

  Over the next two weeks, Konyndyk, Frieden, and Fauci dreamed up what they believed an effective response would look like. They needed thousands of responders to quickly—and safely—build the infrastructure necessary to care for so many more patients. They needed to project a sense of security, both for the West African people and for the foreign NGOs with the experience to fight an outbreak. They needed a regimented process to train the thousands of health-care workers who would be required to provide that medical response. They needed, in short, to create conditions on the ground that would be conducive to a long-term medical response.

  There was only one organization in the world that had the capacity to deliver the manpower, the training process, and the security necessary to create those conditions: America needed to send in the U.S. Army, the single greatest logistical force the world had ever known.

  “The decision to call in the military was a recognition that they can deliver speed and scale to a degree that no one else in the world can,” Konyndyk recalled later. “It signaled to the world that this is a big deal, at a time when, frankly, very few others recognized that.”

  Konyndyk, Frieden, and Fauci first raised the prospect of sending in the military to other senior officials at the National Security Council (NSC), and with the Defense Department. Almost immediately, the NSC began gaming out the enormously complex questions a deployment to West Africa raised: How would they define the Army’s mission? What, exactly, would they be doing? If one of the troops got sick, how would he or she be evacuated? How and where, in the case that an American soldier actually died of Ebola, would the Armed Forces medical examiner conduct an autopsy on the body?

  The Defense Department and Army general Martin Dempsey, chairman of the Joint Chiefs of Staff, was largely cooperative, the NSC and public health officials recalled. But Dempsey insisted that soldiers would focus on a narrow mission, to build treatment facilities, not to treat patients. Health-care agencies, he made clear, had their mission; the military would have its own. There would be no crossover between the two. Some at the National Security Council found that position needlessly inflexible. Others understood exactly why Dempsey wanted to draw such a bright line.

  “The military was there to support the humanitarian effort, and they were constantly of the mindset of, ‘Who are we working with, and how do we build their capabilities so this is a short-term military engagement,’ ” Shah s
aid. Amy Pope recalled Dempsey’s clear guidelines: “Our role needs to be well-defined, and our role needs to come with clear objectives and timelines.”

  Frieden thought otherwise. He had been led to believe by Department of Defense officials that the Army would be able to set up and operate field hospitals within thirty days of deployment, and then staff those hospitals to serve patients. But Dempsey made clear to Frieden and others that the Army would not be staffing hospitals with sick patients.

  To Dempsey, just a year away from retirement, the rules of engagement would dramatically reduce the risk any soldier faced. The military was already stretched thin after more than a decade at war in Iraq and Afghanistan, and Dempsey had neither the interest in nor the desire to get bogged down in another deployment with no clear exit strategy. Before a single Army soldier touched down in Liberia, Dempsey wanted to know who or what organization would be rotating in to replace them after their short deployment. Before the first tree was felled or the first cinderblock set, the Army had a plan to hand off each of the facilities it would build to a specific NGO.

  The NSC worried, too, about the possibility that an American might get sick. The positive message such a show of force would convey, both to Liberians and to the world, could be completely undermined if the outbreak reached the Army. Even a single soldier falling ill would be a massive public relations disaster.

  The prospect of a Western responder falling ill had already scared away many nongovernmental organizations. To prepare for the worst case scenario, and to alleviate fears that were keeping both the Army and foreign NGOs out of West Africa, the Pentagon decided to open a new Ebola treatment unit, one that would be reserved for Westerners alone, near the airport in Monrovia. It would be run by the U.S. government—more specifically, by the U.S. Public Health Service, a team of medical professionals more likely to be deployed to poor rural regions and Native American reservations with limited access to health care than to a hot zone like Liberia.

  Rear Admiral Scott Giberson, who headed the Public Health Service, and Michael Schmoyer, who had coordinated the response to the Ebola crisis until members of DART deployed in August, traveled to West Africa to oversee construction of the facility, formally named the Monrovia Medical Unit. The bland and beige half-dome oval tent where patients were to be treated would be surrounded by supporting tents full of laboratory equipment and beds for the Public Health Service personnel.

  On their way to Liberia, Giberson and Schmoyer missed their connection in Brussels. After three days cooling their heels in a hotel near the airport, they arrived in West Africa to find a metropolis on edge. Few cars were on the road, even in the middle of what should have been a busy workday. Even simple human courtesies went overlooked: when they came across a woman who had been hit by a car, screaming for help in the road, a group of Liberians would not come within ten feet of her, for fear she might be sick.

  But the Monrovia Medical Unit itself was a wonder in the middle of a country in desperate need of help. By the time Rajiv Shah, Konyndyk’s boss at USAID, toured the new unit, it was the most advanced medical facility in Africa, capable of delivering nearly the same level of care that an infected patient would have received at Emory or the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID).

  At a meeting of NSC principals held Thursday, September 11, top officials agreed to formally ask the Pentagon for a plan. Department of Defense officials had been working on that plan for a few weeks; they delivered it to the NSC the following day, a Friday.

  At the same time, the phone on Brian Gentile’s desk rang. Gentile, a stoic-looking colonel, served as deputy commander of USAMRIID, the Army’s medical research laboratory at Fort Detrick. He is steeped in Army culture, more comfortable reading through a PowerPoint presentation than speaking extemporaneously. Now, a top-ranking general needed quick action. He needed Gentile and his team to train the units that would deploy to Africa on the president’s order. And that training had to happen fast.

  Two days later, Gentile’s first teams of trainers arrived at Fort Campbell, Kentucky, home of the famed 101st Airborne Division. They deployed another team to a military base in Germany, where troops were already preparing to deploy. Others went to Fort Bragg, in North Carolina, Fort Leavenworth, Kansas, and Fort Bliss, on the border between New Mexico and Texas. Within just a matter of weeks, USAMRIID deployed on 38 training missions, teaching more than 4,800 military and civilian personnel how to protect themselves from one of the most deadly viruses known to man. Some trainers returned home to Fort Detrick, in Maryland, only to be sent off to another base to train even more soldiers and civilians mere hours later.

  Training is an important part of USAMRIID’s mission. Initially created to explore possible biological warfare agents, the institute now considers itself the U.S. government’s 911 emergency operator. They are the first call when another government agency—the military, humanitarian workers, or any other outfit—discovers a biological agent with which they are not familiar. A hotline, staffed twenty-four hours a day by medical experts, exists to help those other agencies identify what they are looking at in the field. USAMRIID even trained the Armed Forces medical examiner on how to conduct an autopsy of an Ebola victim, under biosecurity level-4 conditions—moon suits and all—in case Dempsey’s worst fears of an infected service member came true. With a plan in place and training already begun, the NSC presented President Obama with Operation United Assistance, the mission that would ultimately deploy 2,692 U.S. troops to Liberia and Senegal,1 where a few hundred support staff were based. The first commanding officer on the ground would be Major General Darryl Williams, the head of U.S. Army Africa Command, based in Vicenza, Italy. The Pentagon would then deploy thousands more troops from a division stationed back home.

  The White House wanted to announce the mission as quickly as possible. The perfect opportunity was right around the corner, on Tuesday, September 16, when President Obama was scheduled to travel to CDC headquarters in Atlanta. That visit would provide a perfect backdrop to highlight the extent of the American response, to send a message to international partners and to an increasingly nervous American public that the situation would be brought under control.

  But the timing was tenuous. When Obama landed at Atlanta’s Hartsfield-Jackson International Airport that morning, Williams was in the air, headed to Liberia from his base in Italy. A line in Obama’s speech declared that Williams was already on the ground. But speechwriters made clear to Gayle Smith, riding a few cars behind the president as the motorcade zipped toward the CDC base, that they would cut it if it was not accurate. As Obama’s motorcade drew closer to Frieden’s office, Smith pressed a cell phone to her ear, connected with a Department of Defense attaché at Monrovia’s airport, monitoring Williams’s plane. Just as Obama pulled onto the CDC campus, Williams landed. The line stayed in Obama’s speech—Williams “just arrived today and is now on the ground in Liberia,” he said.

  “Our forces are going to bring their expertise in command and control, in logistics, in engineering,” Obama announced after touring the CDC with Frieden. “And our Department of Defense is better at that, our Armed Services are better at that than any organization on earth.”

  The speed with which the deployment came to fruition stunned even those who were pushing to make it happen. It had taken just weeks for a major military deployment to go from concept to execution. It was a testament, in the minds of senior NSC officials, to just how seriously the administration was taking the outbreak. On the day Obama announced the new deployment, the cost of the United States response crossed the $100 million threshold.

  “I don’t know that I’ve ever seen a high-level policy decision-making process that’s moved as quickly and decisively as that,” Smith said a year later.

  The military’s arrival hailed a new moment in the fight against Ebola. At the darkest hour, when the situation felt so desperately out of hand, the most powerful force in the world was descending on Liberia
to turn things around. Sending in the Army, American officials had hoped, would serve as a “hope multiplier.” Deborah Malac, the U.S. ambassador to Liberia, later recalled Williams’s arrival as a turning point. The next morning, she told Frieden, it felt as if hope was in the air once again.

  Williams’s first order of business was to open an “air bridge,” an intermediate staging base that could accommodate the thousands of troops and the tons of construction and medical supplies bound for the area. The base needed to be close by, but not in-theater; Liberia’s infrastructure could not handle so much American military traffic. They settled on building a temporary base in Senegal, about 1,000 miles away.

  As the first hints that the Army would be involved, Major General Gary Volesky did some quick calculus and concluded that he and the men he commanded in the 101st Airborne Division were likely to get the call. Of the Army’s ten active-duty divisions, several were deployed to Iraq and Afghanistan, several more had just rotated home, and some were training to return to combat zones. One more was on permanent guard on the Korean Peninsula. That meant, if the Army was looking for thousands of troops to send to West Africa, they would probably turn their attention to the 101st.

  “When the Ebola outbreak occurred and the president made that announcement, there were really three courses of action, and we were number three,” Volesky said later. “It became apparent that the other two courses of action were not going to work.”

  Volesky had taken command of the 101st just a few months earlier, after the division returned from Afghanistan. They were scheduled to deploy back to Afghanistan the following year, and rotating back into the field earlier than planned would present a logistical challenge—and a strain on the families who had just welcomed their soldiers home.

  In New York, Samantha Power was running her own set of traps. Power, a former journalist and human rights expert who served as one of President Obama’s earliest foreign policy advisers, had become the American ambassador to the United Nations a few months before the first Ebola cases began popping up in rural Guinea. She and other senior members of the Obama administration’s foreign policy cohort, including Secretary of State John Kerry and National Security Advisor Susan Rice, had watched with growing alarm as the international public health community had fumbled the initial response. Now, as the case count skyrocketed, Power set to work convincing her fellow delegates to the United Nations to take the strongest stand they possibly could. The Americans hoped to send a message to the rest of the world that Ebola was serious, and that if they did not stop the disease in West Africa, they would be fighting it at home.