Epidemic
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Arriving back home at John F. Kennedy International Airport, the delegation went through the same security screening that every other traveler from West Africa endured. Their temperatures were taken, they told interviewers who they had met and where they had gone, and they wrote down their contact information and that of their personal doctors. Michelle Nichols, the Reuters bureau chief, snapped a photo of Ambassador Power having her temperature checked in the security line. For the next twenty-one days, Power—or, on occasion, her assistant—called the New York Public Health Department to report her temperature.
The fear spreading across the United States was born in part from a gross miscalculation of the actual threat that everyday Americans faced. But even those who were cognizant of the threat, the volunteers and scientists who lived day to day in the hot zone, felt the stress of the risk they were taking.
Their environment, where every surface could be crawling with the world’s deadliest virus, where skin-to-skin contact was prohibited, infused every waking moment and made peaceful sleep difficult to come by. The more intimately familiar they were with the virus, the more it could embed itself deep in their imaginations. Some feared touching armrests on the airplanes that ferried them home; for others, it took weeks to be able to shake a friend’s hand, or even to hug a loved one, without an instinctual fear. The virus’s incubation period meant twice-daily appointments with a thermometer for three weeks after returning home, another reminder of the danger they faced, even an ocean away from the hot zone.
Joe Woodring, the CDC investigator who deployed to Liberia’s northern Nimba County in October, hoped his mind wouldn’t play tricks on him as he returned to his Washington-area home. He landed on a Monday, and while he appeared perfectly healthy, his young daughter did not—she had a head cold. Just minutes after he hugged his family, Woodring’s daughter let out an explosive sneeze, all over her dad. Woodring’s eyes went wide as he looked at his wife—this is not good timing, he thought.
Three days later, on his second day back at his office at the National Center for Health Statistics, Woodring felt the uncomfortable beginnings of a fever. He had been the first scientist from his office to travel to West Africa, which made him something of a guinea pig for colleagues who might follow in his footsteps. And he felt it: Though he wasn’t showing any symptoms, and he had had no contact with anyone who might have been symptomatic in recent days, some of those colleagues, even those with medical degrees, were avoiding him. They made clear, subtly and overtly, that they were thrilled to welcome him back—after his three weeks of self-monitoring were over.
Now, Woodring started to worry. He was almost certain his temperature was rising thanks to whatever harmless bug his daughter had passed on. But now he felt a headache, too. It could be nothing, he thought. Or it could be the first sign of an infection. Woodring couldn’t find his boss around the office, so he sent a quick e-mail detailing his symptoms. I think I should go home, Woodring wrote. Seconds later, a response from his boss: Please go.
On the way home, Woodring called his wife. In a tone as cool and measured as he could muster, and one that certainly didn’t match the worst-case scenario playing out in his head, Woodring explained what was going on. It’s nothing, he assured her. It’s just that head cold. But just to be safe, they agreed his wife would take their children to her mother’s house nearby, just for the night.
Woodring took his temperature once again that night. It had edged slightly higher, north of 99 degrees, but it hadn’t spiked dramatically. He called the Maryland Department of Health’s special line, set aside for those who had reason to worry; once again, he explained his situation, and his symptoms, and asked their advice—at what point should he start to assume the worst? After a few minutes of consultations, they agreed that if his temperature hit 101.5 degrees, and if he developed any other symptoms—another headache, severe joint pain, diarrhea—he would need to go to a treatment facility capable of handling an Ebola patient, in his case nearby Walter Reed Medical Center. As the late afternoon turned to evening, Woodring worried, less about himself and more about what his case could mean for others.
“Oh my god, this is going to look so bad on CDC,” he said to himself.
But as the sun rose the next morning, Woodring’s temperature had subsided, down to a normal 98 degrees. He had not taken any Tylenol, which can mask a fever; this gave him more confidence that the readings his thermometer displayed were real. He was in the clear; his relieved wife and daughters came home that night.
He had learned a valuable lesson. When he came back from his second deployment, a month later, Woodring warned his family beforehand. If anyone is sick, even with a tiny head cold, dad was going to stay somewhere else for a while.
SIXTEEN
The Obama Phones
KEEPING TRACK OF HEALTH-CARE workers returning from West Africa, and deciding how to deal with any who showed symptoms, continued to vex the Obama administration, and the local governments in states and cities where those health-care workers lived. But Ron Klain knew that the greater threat of a potential outbreak spreading from West Africa to the United States would come not from the few dozen health-care workers, but from the hundreds of ordinary Guineans, Sierra Leoneans, and Liberians who made their way to the United States on a daily and weekly basis.
The paranoia being spread by some politicians, leading to calls for an end to flights from West Africa to the United States, was overblown, intentionally in many cases. They fed an angry and anxious public, serving the political interests of candidates running in November’s elections. But the crassness of the politics did not alter the fact that there were between 1,500 and 2,000 people from the three countries in the United States at any given time. That presented policymakers with a real dilemma—how does a government track so many needles in a massive, nationwide haystack?
Transportation Security Administration officials, those who would greet West Africans as they arrived at the five hub airports across the country, represented the front line. Reports that landed on Klain’s desk and on Centers for Disease Control and Prevention (CDC) director Tom Frieden’s desk showed that customs officials were taking temperatures of about 75 percent of travelers from West Africa who arrived in the country. That 75 percent would then be tracked over the twenty-one-day incubation period, to ensure that they did not develop symptoms later, once they had arrived at their destinations.
From a statistical point of view, screening three-quarters of the most at-risk population was enough to make the odds of an outbreak erupting on American soil very small. From a public confidence perspective, however, it was not good enough. Klain lived in fear that one of the 25 percent who went unscreened would show up at a hospital with Ebola, which would reignite public angst and calls for restrictive policies like travel bans, which would ultimately impede the response and cost lives. Statistical anomalies, after all, are not easily explainable to the public in the age of Twitter and cable news.
“I understood, and this is where I will not apologize for a certain amount of politics coming into the process—politics not in terms of partisan politics, but politics in terms of understanding how public perception was going to react to this—that having 25 percent of the people unfindable was unacceptable,” Klain later recalled. Better record-keeping raised the number of those they could track to 80 or 85 percent, but still the margin for error was too high. “We couldn’t lose people,” he said.
The increasing prevalence of cell phones and smartphones made the administration’s job marginally easier. Many travelers could simply give their phone numbers to government officials, who would then call to check in for the next three weeks. But a growing number of West Africans were arriving with cell phones that did not have the right SIM cards, which meant the phones would not work outside of their home countries. Klain and others racked their brains, trying to figure out how to track those without working phones.
Outside the White House, some businesses raced to fill the void. M
ark Penn, the longtime political strategist who had guided then-Senator Hillary Clinton’s presidential campaign against President Obama in 2008 and who had moved to Microsoft, called Klain one day to pitch his own solution: the Fitness Tracker, a wearable device similar to a FitBit. Penn said Microsoft would donate the Fitness Trackers, free of charge, to take temperatures of those coming in from West Africa. The data would be relayed back to public health officials, who could use the information to spot a potential Ebola case early in the process.
Microsoft sent the devices to CDC headquarters for testing, but two problems nagged at Klain and Frieden: first, the device took temperatures well enough for general health assessments, but not precisely enough for medical purposes; that imprecision could lead to false positives—or, worse, false negatives.
Second, Klain was not thrilled with the idea of the U.S. government slapping a wristband on people who arrived from specific countries, especially at a moment when a growing number of fringe groups were warning about the federal government overstepping its bounds. “It felt a bit like, do we want the government putting bracelets on everybody?” he said. It wasn’t even clear that wristband technology would be effective. Ultimately, the administration passed on Microsoft’s offer to help.
At the beginning of November, Frieden had another idea, one that would toe the critical line between perceived government inaction and overreaction—why not give travelers entering the country from West Africa a temporary cell phone? That would allow health officials to keep track of travelers entering the country, while at the same time representing a relatively minor expense; there were only about seventy or so travelers from affected countries arriving in the United States every day, and cheap cell phones—burner phones, in popular parlance—would not cost that much.
More important, it worked: The CDC started a pilot project using the phones at one of the five airports just days later, demonstrating that handing out phones to West African travelers, recording the numbers, and then calling those travelers a few times a day could increase response and coverage rates to 98 or 99 percent. The phones virtually eliminated the margin for error that kept Klain worried.
But Klain had survived the first several years of the Obama administration, when conservative critics lobbed all kinds of loony theories at the White House to paint them as big-government socialists determined to redistribute wealth. One of those rumors early in the administration had centered on “Obama phones,” a program that allegedly handed out free cell phones to low-income minorities and welfare recipients. Conservative websites like the Drudge Report highlighted those free phones as more evidence that the administration was favoring the poor, and predominantly minorities, over whites and those who paid their own way.
In truth, there was a new program that helped low-income Americans get cell phones, though the administration had little to do with it. A decades-old program known as SafeLink helped subsidize phone services for those with low incomes, in order to expand access to 911 emergency lines. The program is funded by telecom companies, rather than tax dollars; in 2008, during George W. Bush’s presidency, those telecom companies expanded the program to cover cell phones and about an hour of airtime per month for Americans lowest on the economic spectrum.
But explaining decades of telecom history to conspiracy theorists—especially those who already believed Obama was born outside the United States, among other more far-flung tall tales—was futile. Klain could foresee the headlines that a new program to hand out phones to travelers would generate. “Great,” he thought ruefully, “Obama’s giving free phones to everyone from West Africa.”
In the Oval Office, Klain and Frieden told Obama about the phones. They could drastically improve response rates, and quickly, but it would open them to a political attack. “Our opponents can say Obama’s giving free phones to people from West Africa,” Klain told the president. Obama laughed; he was not immune to the criticisms leveled by the conspiracy theorists. He promised to take the political heat if the phones became an issue, and told Klain and Frieden to get the phones to airports.
But even by November, nearly a year after the outbreak began in Meliandou and three months after the American government began to engage in a serious way, money was an issue. Obama had asked Congress to appropriate several billion dollars to the fight, money that would cover everything from the military’s deployment to Liberia to provisions for hospitals back at home. Yet Congress had spent most of October campaigning ahead of the midterm elections. A formal proposal was slow to form; some Republicans did not want to spend more money without cutting other programs out of the budget. (The bill that eventually emerged was a bipartisan affair, albeit one that appropriated less than Obama wanted. Some Republicans, including South Carolina Senator Lindsey Graham and Georgia Representative Jack Kingston, worked closely with the White House to pass a funding measure.)
The government procurement process added another layer of red tape. Contracts of any substantial size had to be opened to public bidding and internal review, a process that could take weeks or months. Frieden, especially, warned of the consequences of getting bogged down in layers of bureaucracy that came along with operating the largest government in the world. “Every day that we spend planning,” Frieden told associates, “is a week we lose in the battle. There is no time to plan.”
This was not a new problem for Frieden. Often, the CDC had faced tight timelines that were not conducive to the standard open procurement process. To get around those pesky rules, the CDC always turned to a long-trusted partner, the private CDC Foundation and its president, Charlie Stokes.
The CDC Foundation had been created by Congress specifically for the purpose of moving things along. Since its inception in 1995, the foundation had served as a repository for donors who wanted to assist the CDC itself, in support of the various crises around the world. Over the previous twenty years, the foundation had spent some $620 million backing up CDC operations in places like Haiti, devastated by an earthquake, and Indonesia, smashed by a massive tsunami. They even helped in New York City; the day after the September 11, 2001, terrorist attacks, CDC planes stocked with needed supplies purchased by the foundation were the only nonmilitary planes in the skies over the Northeastern United States. CDC rescuers working the Twin Towers told the foundation they needed computer batteries and satellite phones, so that’s what the foundation bought.
Stokes, the only chief executive officer the foundation had ever had until his retirement in January 2016, had been in regular contact with Frieden. When the CDC director returned from West Africa in August 2014, Frieden had called to warn Stokes that the CDC would probably need the foundation’s help again. The situation on the ground was bad, Frieden warned Stokes. “I think he had a sense early on that he would need the flexible funding,” Stokes recalled of those early conversations.
Now, Frieden called Stokes again, with a specific request: We need you to buy thousands of disposable cell phones to keep track of the travelers coming back from West Africa. Stokes, on vacation in Missouri, stepped out into a driveway to take the call on his own cell phone. He apologized to his hosts, then spent the rest of the weekend researching where to buy so many phones. Stokes settled on Walmart. Within days, 4,654 phones were on their way to Africa, thousands more to the five U.S. airports where travelers from West Africa would arrive. The giant and oppressive rules governing procurement for federal agencies did not apply to Stokes’s foundation; he just wrote the check.
Once the phones arrived at airports in New York, New Jersey, Chicago, Atlanta, and Washington, every traveler entering the country from West Africa went through the same process: CDC employees would take down a traveler’s phone number and e-mail address; if they didn’t have a phone that worked inside the United States, they would get one of Stokes’s disposables. They also got a thermometer. Twice a day for the next three weeks, the travelers would call their local health departments to report their temperatures. Stokes, who traveled to all three countries a fe
w months later himself, got a firsthand look at how the procedure worked as a backstop: When he came home, he forgot to check in for a few days. The CDC sent him an e-mail, reminding him to contact his local health department.
Stokes and Frieden had been thinking through ways to use the foundation’s independence for months. While they could realistically rely on a handful of corporate partners to write big checks, Stokes knew from years of experience that most philanthropists like to hear how their money is spent, and that the bigger and sexier a project was, the more likely a donor was to give again—even if what a disaster relief effort really needed was some decidedly unsexy set of supplies, like body bags or paper towels. In Liberia, the Swedish data wizard Hans Rosling was experiencing the same thing. There were plenty of donors to go around, but those donors wanted to make sure their money was being spent prominently.
“All of the international organizations wanted their piece of the cake, and they wanted their piece of the cake to look beautiful,” Rosling said. “Being on the Liberian side, this was our main headache. No one was bad, no one was evil, it was just that urge to show what my organization had done.”
Stokes worried that the need for mundane equipment and supplies might scare away or bore some donors. But he began seeing signs that a new type of philanthropist was gaining prominence, a generation born of the tech industry, one that cared more about data and effectiveness than prominence and stature.