by Reid Wilson
The initial plans had called for as many as 30 new American-built Ebola treatment units across Liberia, expanding treatment capacity by 3,000 beds. Even knowing many of those beds would never be occupied by an Ebola patient, the Pentagon, in consultation with the White House, decided to finish the units already under construction. At the very least, they would serve as new medical facilities Liberia could use to begin rebuilding a health-care system already decimated by the virus. In the worst-case scenario, if Ebola had staged yet another comeback, the facilities would be ready to receive a new wave of patients.
“We couldn’t really be confident until December or January, when it was really clear that cases really were turning down and we had turned a corner in a pretty significant way in Liberia. We couldn’t be certain that we wouldn’t eventually need” all thirty planned facilities, Jeremy Konyndyk of the United States Agency for International Development (USAID) Office of Foreign Disaster Assistance said. “It’s much, much worse to get it wrong and try to catch up than to overdo it a little bit to be on the safe side.”
Still, even with the curve bending down, new facilities opened up at a breakneck pace. After months of inaction, and setbacks driven by fears surrounding the infections of Kent Brantly and Nancy Writebol, the global community was now more engaged than ever in the responses. Germany’s government funded new Ebola treatment units, even after there weren’t enough patients to fill beds. So did the Chinese government. Nongovernmental organizations that had stayed away in early months now built their own facilities.
Hans Rosling and Luke Bawo realized what had happened. Now that some NGOs had demonstrated their effectiveness, everyone else was rushing in to claim some kind of credit. Every NGO wanted to show its donors that they had helped, and to show news media broadcasting on channels watched by European and American donors that they were in the game. The Liberian Ministry of Health gamely let several NGOs hold elaborate opening ceremonies for the cameras, then quietly closed the facilities or reappropriated them for more pressing medical needs.
“The world was generous,” Rosling said. “To coordinate [all the new facilities], that was the difficulty.”
Back in Washington, the approaching holidays presented the White House’s Ebola response team with its most critical challenge. Ron Klain’s strategy, from the day he returned to the White House to oversee the fight against the virus, had been to keep careful tabs on visitors and citizens entering the country from Liberia, Sierra Leone, and Guinea. On a typical day, that meant monitoring between 1,300 and 1,400 people, a manageable task. But with Christmas just around the corner, that number ballooned to 2,700 people traveling from West Africa.
Public health departments were already stretched thin. Many staffers took vacation over the holidays, and the health departments wanted to know: Would travelers have to continue checking in to report their temperatures and any outward signs of illness on Christmas Day? Yes, Klain decided, they absolutely had to check in.
Klain had spent most of his weeks as Ebola czar cocooned inside the White House, or shuttling between USAID and Secretary Sylvia Burwell’s office at the Department of Health and Human Services. But a week before Christmas, he got his first chance to come face to face with a group of Americans who had gone overseas to fight the outbreak. The Americans who returned were young volunteers from the U.S. Public Health Service (PHS), doctors and nurses who traded their service for help in paying their student bills. Under ordinary circumstances, the Public Health Service members were deployed to Native American reservations and other communities that struggled to maintain adequate modern health services. These volunteers had been dispatched to care for Ebola patients at the Monrovia Medical Unit where Kugelman had been based.
After these volunteers arrived back in the United States, some of the communities the Public Health Service served were wary about their returning before the twenty-one-day quarantine period ended. The Public Health Service did not require its employees to quarantine themselves, but those who wanted or needed to stay away were put up in a Holiday Inn in Gaithersburg, up the road from Washington along Interstate 270.
The idea of a bunch of public servants spending the holidays alone and far from home did not sit well with Klain. “They had gone to West Africa, they had fought this disease. They weren’t allowed to go home,” he remembered later.
So the White House invited them for a visit, the day after Christmas, while Obama was in Hawaii on his annual winter vacation. Klain’s team showed the young doctors the West Wing, led them on a tour of the rest of the White House, and let them bowl in the president’s bowling alley. Klain brought his family, too. None of the PHS workers ever came down with the virus.
As the new year began, the slowing rate of Ebola cases illustrated the number of communities that had gotten the epidemic under control. On January 27, Médecins Sans Frontières closed its Ebola management center (EMC) in Kailahun, Sierra Leone, after forty-two days—two incubation periods—without a new case. Around the same time, the EMC in Bo discharged its last confirmed patients. MSF staff redeployed to Freetown, where they opened a new treatment center to help the capital end its outbreak. The last Army-built Ebola treatment centers opened in Liberia on January 28; of the eleven treatment units that the Army built, nine never treated a single patient.
The Army was stricter with returning service members than the PHS had been. When Tony Costello arrived home in Texas, he was quarantined at an old National Guard training center at North Fort Hood for twenty-one days, even though he had never even seen a patient afflicted with the Ebola virus. He thought the quarantine was overkill, but he spent his time honing his video game skills with fellow officers.
As the military began rotating troops home, and once the federal government had helped local hospitals develop their own domestic Ebola treatment capabilities, Klain began to feel that his work was done. He had been called in to create a wholly new capability to treat a deadly disease, and now it was time to fold that capability back into the normal structure of government. When Klain arrived at the White House, laboratory facilities in just thirteen states had the technical ability to test for the Ebola virus, and only three hospitals were capable of treating an Ebola patient. By the time he left, fifty-four labs in forty-four states could run those tests, and fifty-one medical facilities were capable of treating an Ebola patient.
“We could tell the epidemic was nearing an end in West Africa, the U.S. response was up and working well, and it seemed like it was time to turn off an extraordinary response and put it back into the system,” Klain said. By early February, he was packing up, preparing to return to his day job working for Steve Case.
But before Klain left, he helped to stage-manage some public recognition for the work that Americans from a dizzying array of backgrounds had done to stem the outbreak. On February 11, four days before Klain’s last day on the job, President Obama stood before dozens of employees and volunteers from the CDC, USAMRIID, USAID, and the National Institutes of Health, along with a handful of NGOs, to thank them, and to highlight just what they had done. In remarks carried live by several cable news networks Obama said:
Last summer, as Ebola spread in West Africa, overwhelming public health systems and threatening to cross more borders, I said that fighting this disease had to be more than a national security priority, but an example of American leadership. After all, whenever and wherever a disaster or a disease strikes, the world looks to us to lead. And because of extraordinary people like the ones standing behind me, and many who are in the audience, we have risen to the challenge.… People were understandably afraid, and, if we’re honest, some stoked those fears. But we believed that if we made policy based not on fear, but on sound science and good judgment, America could lead an effective global response while keeping the American people safe, and we could turn the tide of the epidemic.
By the end of April, Obama said, all but one hundred of the thousands of Americans dispatched to West Africa would be home. But the jo
b, Obama stressed, was not over.
“Our focus now is getting to zero [cases]. Because as long as there is even one case of Ebola that’s active out there, risks still exist. Every case is an ember that, if not contained, can light a new fire. So we’re shifting our focus from fighting the epidemic to now extinguishing it.”4
Before he entered the South Court Auditorium to thank the responders, Obama had met some of the survivors of the disease. Brantly, Craig Spencer, Amber Vinson, Nina Pham, and a few others were there, along with their families. White House photographer Pete Souza snapped dozens of photos of the survivors hugging the president of the United States, a preplanned effort to remove the stigma of having served in West Africa.
After the event, Klain’s team took the survivors back to a conference room at the Old Executive Office Building, the room where he had spent so many hours building foreign and domestic threat matrixes to get a handle on the growing outbreak. For what seemed like hours, they just sat and talked, sharing stories of the highest highs and the lowest lows they had experienced. Amber Vinson’s mother said her family had to move; even months later, the local pizza shop would not deliver to her house. Someone kept leaving nasty messages on her doorstep.
Klain and Gayle Smith were struck by the extraordinary diversity in the room. Brantly, the deeply religious, deeply conservative doctor who worked for Franklin Graham, had shared an experience with Spencer, the liberal New York do-gooder bent on saving the world. Vinson is African American. Pham is Asian American. Writebol and her husband were much older than most of the others. Together, they represented a cross-section of what could be a divided country, brought together by their determination to help others and to do what was right.
If that sentiment was not enough to choke up even the most hardened political operative like Klain, Brantly pushed him over the edge.
“I went to Liberia because I was called by God,” Brantly told the hushed room. “I became deathly ill. I was alone, I couldn’t touch my children or my wife. I was going to die. And my government came to get me and saved my life.”
One by one, tears began streaming down faces around the room.
NINETEEN
Medicine without Borders
AS THE CALENDAR CHANGED from 2014 to 2015, the World Health Organization’s (WHO) weekly case count report showed the number of new Ebola cases in Guinea, Sierra Leone, and Liberia plunging, almost as quickly as the curve had risen in August, September and October.
In December, the three nations reported 3,272 new cases. In January, 1,886 people were infected; in February, 1,637 new cases; in March, 1,484; and just 1,120 in April. After months at the brink of a global catastrophe, the Ebola outbreak was coming under control.
As the number of new infections fell, scientists and public health officials faced new questions about those who had survived the disease, and new opportunities to unlock the secrets of the virus to prevent the next big outbreak.
Never before had so many people survived the Ebola virus. By official counts, more than 17,000 people had recovered from the disease. Thousands more survivors who never reported their symptoms probably meant that number was far higher. Ebola is unlike most other viruses, both in its contagiousness and its lethality. But it also leaves behind scars, mental and psychological, that few had anticipated.
Once someone recovers from Ebola, they cannot contract the virus again—which makes the antibodies in their blood so useful for transfusions. But those survivors reported horrible nightmares and memory loss. More than half had serious muscle and joint problems. Three in five suffered eye problems, even blindness, according to a report compiled by Liberian epidemiologist Mosoka Fallah.1 A team of WHO researchers who interacted with Ebola survivors beginning in the fall of 2014 began referring to what they called post-Ebola syndrome. It gave a name to the vacant stare in the eyes of the woman who had lost her husband who Tom Frieden had seen at the ELWA hospital in August 2014. Now thousands more people experienced those same symptoms.
A series of joint studies conducted by the National Institutes of Health, the Liberian Ministry of Health, and a handful of other medical institutes, based in Fallah’s offices at John F. Kennedy Medical Center in Monrovia, revealed many of the most persistent symptoms. The Partnership for Research on Ebola Vaccines in Liberia, or PREVAIL, hoped to enroll 1,500 survivors of the viruses, and 6,000 of their closest contacts, for five years of studies.
The pervasive eye problems proved especially disturbing. Ian Crozier, an American physician who had come down with the virus in Sierra Leone in October, went back to his doctors after just two months, when his eye changed color. Those doctors drew samples through a needle from his eye, where they found a heavier viral load than had been in his blood weeks before.
The virus lived on, too, in semen. WHO had warned survivors to practice safe sex for ninety days after recovering, a period defined by a 1995 outbreak in Zaire when the virus was still evident nearly three months after recovery.
But in West Africa, some former patients still had Ebola present in their semen six, nine, and twelve months after they had been given a supposedly clean bill of health. A handful of flare-ups of the Ebola disease, from March to November 2015, started after survivors returned home and had intercourse with their spouses or partners. The PREVAIL studies found that more than a third of male survivors had the disease present in their semen at least once.2 One survivor still had Ebola present eighteen months after he first showed symptoms.
Other studies showed just how deeply damaging the Ebola outbreak had been in all three countries, and how long the damage would linger. So many health-care workers had fallen ill, and so many had died, that even standard health-care practices had all but stopped. At the height of the outbreak, few hospitals conducted Caesarian sections on pregnant women. Malaria vaccinations ceased. Tuberculosis patients went untreated.
In all three nations, the toll was immense. Ebola had been disproportionately likely to hit those between the ages of fifteen and forty-four. Women were more likely than men to contract the disease, largely because of the cultural roles women played in caring for family members and funerary traditions. That meant those who were most likely to have been struck down by Ebola were the most able-bodied workers in society, and women in their prime childbearing years. Their losses were tragic not only for their families but for their nations. All three countries were left with a missing generation, one that cannot reach its full economic potential or raise the next generation of West African children.
Even before the virus broke out, health systems in West Africa had been among the poorest in the world. With the threat of Ebola lurking, those systems virtually shut down and patients stayed away from medical facilities, causing a cascade of otherwise preventable deaths from other, usually more manageable maladies. In Liberia, outpatient doctor visits had declined 61 percent. Vaccinations dropped by half, and measles broke out in Liberia and Guinea during the early months of 2015. HIV patients, tuberculosis patients, and malaria victims went without medicine.
“More people died because of Ebola than from Ebola,” Tom Frieden said later. “It collapsed the health care systems.”
Efforts to halt the spread of the virus by limiting public interactions came with their own negative downsides. After schools were closed in July 2014, the number of adolescent pregnancies skyrocketed. So did infant mortality rates. Violence against women and girls jumped dramatically.3 The schools did not begin opening again until February and March of 2015. As many as 23,000 children lost one of their parents, or both.
As the crisis waned, the response effort mounted by Liberians, Sierra Leoneans, Guineans, and their international partners turned from containment to recovery. But the road to recovery would be—and still is—long. The global donor community had generously pledged more than $5 billion to help all three nations recover. But as is so often the case in humanitarian crises, those pledges did not always come through. By early 2016, more than a third of the money pledged by int
ernational donor nations, $1.9 billion, had not arrived to help, according to an Oxfam report. Oxfam said it couldn’t even be certain that the remaining $3.9 billion pledged had arrived because donor nations do not always disclose what they give, and how.4
To help repair the damage done, unusual agencies began lending assistance. The World Bank mobilized $1.6 billion to finance the response and recovery, sending money directly to the governments of Liberia, Sierra Leone, and Guinea to plug budget gaps and pay for key supplies. The International Finance Corporation (IFC) made available $450 million in commercial financing to small and medium-size businesses; the IFC’s business consultants gave advice to more than 800 businesses on health, security, and environmental efforts to help them recover.5
The United States Agency for International Development (USAID), which had received most of the money set aside by Congress to fight the outbreak, transitioned American dollars to rebuilding more fundamental elements of the economy. At the height of the crisis, as some countries banned flights and trade, food had become scarce. Markets closed, store shelves went bare. To prevent mass starvation, USAID’s Food for Peace program delivered three hundred metric tons of rice to Liberia alone. Between the three West African nations, more than 1.5 million people received support from U.S. food programs. USAID also funded antidiscrimination campaigns aimed at eliminating any fears among the community about the thousands of survivors who had fought off the virus. Far from being a threat to their communities, their immune systems now swarmed with Ebola antibodies, which could help others who might contract the disease.
American governmental organizations like USAID and the Centers for Disease Control and Prevention (CDC) also went to work rebuilding the broken health-care system, including new immunization campaigns, maternal care, and, most basically, the rebuilding of trust between communities and health-care providers. The new message they aimed to spread: Ebola was no longer killing people, but avoiding health care for fear of catching Ebola would lead to other causes of death.
