70–30
AFTER A MONTH OF increasingly alarming reports, Jeremy Konyndyk decided he needed to get a firsthand sense of the scale of the outbreak, and Tom Frieden decided it was time to create a more formal structure to respond to the outbreaks. International panic was growing; between the time Konyndyk and Frieden booked their tickets on a British Airways flight through London’s Heathrow Airport, and the day the flight left, the airline had canceled its routes to the three West African nations. Konyndyk and Frieden had to scramble to rebook a Delta flight to Ghana, and to connect from there to Monrovia (British Airways was not alone; of 590 monthly flights to Guinea, Liberia, and Sierra Leone, 216 had been canceled by mid-August, an airline data provider reported).1
When they finally landed, the two Americans were immediately struck by the deeply worried mood they encountered. At one of their first meetings, with Ellen Johnson Sirleaf and her advisers, Konyndyk was struck by how grim the room seemed. Everyone was scared, and everyone was exhausted. They showed him a chart illustrating the virus’s explosive growth in recent weeks, a line that grew exponentially into a mountain of disease and death. There had been more cases reported in a single day earlier that month than during the totality of most previous outbreaks.
Frieden had arrived with the goal of organizing the chaotic response. None of the three West African countries had tapped a single person to oversee the governments and nongovernmental organizations (NGOs) now rushing in to help, and no one seemed to be taking the basic steps necessary to provide the number of beds necessary to quarantine patients, provide them with care, and stop the virus.
“You hit the tipping point when the Ebola treatment units [ETUs] got full. And that was for a few reasons,” Frieden said later. “One, they got unsafe, and health care workers got infected. Two, people couldn’t come there, so they went back to the communities and spread [Ebola] widely. Three, the care in the ETUs was so poor at that point that people said, Why go there? It’s just a place to die.”
In July, Frieden had thought they would need to build facilities capable of housing three hundred patients—one hundred in each country—to stop the virus. But that meant building other infrastructure as well. They would have to organize staff to care for the patients, transportation for those who might be sick, and laboratories to sample blood. It was an enormous logistical undertaking, unlike any even the Centers for Disease Control and Prevention (CDC) had attempted in years past. And as each day passed, the number of beds they would need to control the spread of the virus increased.
“The painful fact was, we knew in July if we could get 300 beds, we could end it. By November, we needed 3,000 beds,” he recalled later.
Frieden delivered a blunt message to Sirleaf: The world will not come to your aid fast enough. It was not possible for the world to marshal assistance fast enough. You have to mobilize your own communities, spread as much information as possible, while the disjointed international response got its act together.
The first task was to organize a single point person to run the entire response. In Liberia, that person was Tolbert Nyenswah, head of the Incident Management System. The IMS had become the common means by which the CDC handled outbreak responses, and increasingly the way other humanitarian groups organized responses, in the wake of the September 11 terror attacks in the United States. The goal, Frieden explained, was to take what seemed like a dauntingly massive problem—an international outbreak of a deadly virus—and break it down into solvable problems. “Instead of having a fog of war experience with just chaos going on, it’s a way of structuring your emergency response,” he said. “If you have a big problem, break it down to less big problems, and then solve each of those less big problems individually.”
Nyenswah chaired the daily meetings, which took place in a huge conference room in central Monrovia. Government agencies, foreign governments, nongovernmental organizations were all present, and teams tasked with tackling every aspect of the response would deliver daily status updates. Every meeting was heavily structured, to waste as little time as possible. Precision and timeliness were critical: briefing memos laying out decisions ahead had to be delivered on time, and once a decision was made, tasks needed to be tracked. Final decisions rested with Nyenswah, the unflappable deputy minister of health with an education from Johns Hopkins in Baltimore. Everyone else scaffolded, in Frieden’s words, around him. Ordinarily, someone who will run an IMS undergoes months of training. Nyenswah dove in with little more than a briefing from Frieden and his team.
While in Monrovia, Frieden and Konyndyk visited the huge ELWA 3 facility, run by Médecins Sans Frontières (MSF). Konyndyk was horrified to see patients being turned away. Just weeks after opening, the Ebola treatment unit was already full. Frieden was equally horrified to see the conditions inside the treatment center, where 125 patients were being overseen by a single doctor, Armand Sprecher. Sixty corpses lay scattered about the makeshift hospital, some lying dead right next to patients still struggling for their lives. Diarrhea, blood, excrement were everywhere. The nurses and technicians left alive to tend to the hot zone could not clean up fast enough. It was, Frieden recalled, like something out of Dante’s Inferno.
Konyndyk himself had seen the aftereffects of Liberia’s civil war, and the long road to recovery the nation had walked; this was worse. “They’re a very resilient country. They’re no strangers to tragedy and crisis,” he recalled later. “But this was just totally unfamiliar.”
It became clear that the situation was unfamiliar to the NGOs on the ground, too. Konyndyk and Frieden came away from a meeting with World Health Organization (WHO) officials deeply unimpressed by what they heard. Konyndyk and Frieden were “absolutely on fire,” Konyndyk said later. “We were being outpaced by the disease. We were losing.”
After Konyndyk returned to Washington, Frieden continued traveling through Guinea and Sierra Leone, where he told their presidents what he had told Sirleaf. He was struck by the differences in each country’s approach: Sierra Leone was employing its military far more than the other two nations, and imposing curfews on villages and communities where the virus was present, sowing even more distrust between traditional villages and the central government.
In Guinea, President Alpha Conde had implemented a practice his government called micro-cerclage: The military and police would arrive in an infected village and surround it, though residents were still free to come and go. Anyone leaving simply had to leave their cell phone number with guards, so they could be tracked. The government shipped in food and medical supplies, so that a village did not get the sense that it was being shut off from the outside world and left to die.
“We have an expression in the U.S.: You catch more flies with honey than with vinegar,” Frieden told Conte.
“Yes,” Conte replied. “But the honey has to get there before the flies leave.” Frieden was struck by Conte’s underlying point: his government was building trust. Breaking the vicious cycle of mistrust between government and community, Conde believed, would break the virus’s back.
Konyndyk was still contemplating how his office, the Office of Foreign Disaster Assistance (OFDA), could best contribute to the effort. He and Frieden both concluded America needed to ratchet up its response, and quickly, by building new Ebola treatment facilities and sending hundreds, maybe thousands, of medical personnel. But OFDA was not equipped to handle a response of the magnitude necessary. Even the CDC wasn’t technically in the disaster response business. Konyndyk and Frieden started to throw around ideas of just who could handle such a mammoth response. They settled on one outside-the-box possibility, the only agency that could marshal thousands of people with cutthroat efficiency: the United States military.
Back home, the American response was taking shape: the United States Agency for International Development (USAID), through OFDA, led the effort, coordinating and managing logistics and procurement. The CDC was the deputy lead, with primary responsibility for the science and epidemiological elements.
The Americans had a model, one that suggested how to bend the curve downward. Based on previous outbreaks, the virus would eventually be contained if they could isolate 70 percent of those infected—completely isolate 30 percent of all infected patients in Ebola treatment units, and partially isolate another 40 percent, at home and away from family. Even if the remaining 30 percent were not isolated, statistical analysis suggested that they would not be able to infect enough friends, family, and neighbors to keep the disease spreading. Trying to isolate everyone, given the scary growth curve and the number of contacts each of those patients would have had, was not practical. “Once you had a massive urban outbreak, at this scale and pace, you’re not going to isolate all those people,” said Raj Shah, Konyndyk’s boss at USAID.
Under this strategy, eventually, the virus would run out of fuel. Inside the CDC, and eventually at the White House, the strategy became known as 70–30, for the percentage of patients partially or totally isolated and the percentage responders could afford to miss. But even reaching 30 percent completely contained was a threshold of staggering proportions: by August, just 18 percent of patients with Ebola were being cared for in hospitals.2
In the White House, President Obama was keeping close tabs on the virus’s spread, a topic now being covered daily in his early morning security briefings. Several times, he made calls to members of USAID’s Disaster Assistance Response Team (DART), calls that boosted morale in Monrovia.
Obama also made calls to foreign heads of state, working around the United Nations and the WHO to solicit commitments of support. He asked for health-care workers, construction material, and manpower to build new Ebola treatment units and, critically, logistical help in ensuring that the international community had the ability to evacuate any aid worker who might get sick in the course of treating patients. Many nongovernmental organizations had communicated to Shah, Konyndyk, and others that the prime concern keeping them out of the fight was the worry that they wouldn’t be able to get one of their own out of the country if the worst happened.
For weeks, Gayle Smith would make the walk across the small driveway separating the White House from her office in the Old Executive Office Building. She sat in the Oval Office as Obama contacted presidents and prime ministers from across the globe. Canada, historically reluctant to get involved in foreign engagements, especially outside its sphere of influence, declined to make serious commitments beyond its public health service. Governments in South Korea, Japan, and Germany gave freely of their money and manpower. In early October, Obama called Stefan Lofven, who had been installed as Sweden’s new prime minister just days earlier. Congratulations on winning election, Obama told him. Now send money to West Africa.
Obama also spoke with China’s president, Xi Jinping, about sending help. The administration had spent years carefully courting Xi and his predecessor, coaxing China onto the world stage. China’s growing influence and its desire to become a world superpower were leading to investments in foreign nations, including in Africa, where it could mine precious resources for its booming manufacturing industry. Foreign policy experts in the United States, conscious that they could not contain China but eager to manage its emergence on the world stage, tried to convey to China’s leaders there was more to being a superpower than just extending tentacles to other corners of the world for industrial purposes; with power comes responsibility, including the responsibility to respond in humanitarian crises.
Smith repeatedly cornered the Chinese ambassador to Washington, hammering a single message: the United States and China, she told him, were the only two countries big enough to sit on the infection curve and bend it downward. The ambassador took note; he later told a State Department official, weighing his words carefully, that Smith “is very passionate.”
The Chinese were intrigued. The CDC had worked in conjunction with its Chinese equivalent, the Chinese Center for Disease Control and Prevention, since the 1980s on health crises that would occasionally pop up in Asia. Now, the Chinese agency agreed to send doctors and technicians to West Africa to help respond. They peppered the CDC in Atlanta with technical questions about how to build an Ebola treatment unit, and how to protect its citizens in the hot zone.
The African Union, eager to show its own ability to contribute to a crisis in its own backyard, sent hundreds of doctors to the scene, seeded by money from the United States, the European Union, and China.
At the same time, the coordination between the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) and the Food and Drug Administration (FDA) were paying off. The chemical compounds Army scientists had sent to the FDA for pretesting, a deal negotiated by David Norwood, began deploying to West Africa, to speed up the diagnosis process and reduce the time between a patient’s first contact with medical professionals and confirmation that Ebola was or was not present.
Norwood began shipping new assays, the chemicals that would create a visible reaction if Ebola virions were present, both to Liberia and to public health department labs in all fifty states, in the event that Ebola ever reached American shores. It was the first significant step a federal government agency had taken to reassure American governors—many of whom were getting nervous about the prospects of an Ebola outbreak in their backyards—and the public. But Norwood’s decision also sent an important message to the Liberian government, where some were skeptical that their populace would be used as test cases for unproven vaccines and medicines: The very same assays that would test American blood, Norwood made clear, would test Liberian blood. There would be no double standard.
Along with the new diagnostics tests, USAMRIID deployed teams of physicians and technicians to every American hospital where Ebola might show up, to evaluate plans for isolation wards and safety precautions. Eventually, about fifty hospitals were certified to handle patients with viral hemorrhagic fever.
USAMRIID was also starting to hear from pharmaceutical companies, both big and small, that had experimental compounds that might aid in the fight against Ebola. The economic calculations necessary to invest in a treatment for Ebola were complicated. It costs millions of dollars to develop a new drug. And while a treatment for something common like high cholesterol would allow a company to recoup those research and development costs many times over, a treatment for something as rare as Ebola would not pay similar dividends. Even if a company charged hundreds of dollars for a course of treatment, earlier outbreaks had been so small that the company would only be able to sell a few hundred doses a year, at most.
Testing any potential drugs was made almost impossible, too, because none of the pharmaceutical companies experimenting with new compounds had access to a disease like Ebola. It is easy to find a laboratory rat with high cholesterol, but the government isn’t about to allow a private company, no matter how trustworthy, to possess viral hemorrhagic fevers outside of the tightly controlled, highly secure labs at Fort Detrick or in Atlanta.
But other factors led pharmaceutical companies to send compounds to be tested. For a small firm, developing a landmark treatment for something like Ebola would lend a level of prestige that no amount of money could buy. For larger firms, which were slower to send their own prototype drugs, providing an answer to Ebola was less about breakout prestige or financial gain and more about demonstrating their philanthropic work.
All told, some sixty-two compounds—some potential vaccines, others potential cures—made their way to USAMRIID laboratories, where Army scientists led by Dr. Travis Warren ran exhaustive batteries of tests. Each compound was tested for toxicity, to make sure a drug would not kill a patient before it killed the virus. Then they were tested in vitro on human cell lines infected with Ebola. If those tests went well, rodents and primates were next. At each stage, scientists would measure the antiviral activity of a compound against the Ebola virions.
Even if results looked promising, there could be hurdles in production and manufacturing. One reason so few doses of ZMapp were available was that the companies that developed the drug had only limited abilities to produce the compounds from which it was made. While testing took place, the USAMRIID scientists would try to learn from the companies that created each compound whether they had the ability to produce it in mass quantities. The best drug in the world, after all, isn’t any good if it can’t be manufactured with sufficient speed.
By the first week of September, as the Disaster Assistance Response Teams found their footing on the ground in Liberia and Sierra Leone, as Konyndyk and Frieden contemplated how to ratchet up the American response, as President Obama worked the phones, and Army scientists ran every test they could think of, USAID’s DART members in Monrovia got their first major infusion of new help. On September 9, about 100 medical professionals, including 25 doctors and 45 nurses, arrived. That moment offered a window into the speed at which the United States had ramped up its response: By then, just a month after DART had landed, USAID money was already funding 1,000 Ebola treatment unit beds.
At the same time, the WHO was starting to explore new ways to engage critical communities, to inspire some badly needed trust. Beginning in September, WHO technicians began traveling from village to village in hard-hit Lofa County, in northern Liberia, just across the border from the outbreak’s epicenter. They began challenging chiefs and religious leaders to take more of their own responsibility for fighting a disease that was killing their people. The communities created their own task forces to spread word that the disease was real. To dispel ugly rumors about what happened inside an Ebola treatment unit, newer facilities would include see-through windows in the plastic walls, so that families would be able to lay eyes on a loved one.
Across the border in Sierra Leone, the country’s president decided to impose a mandatory three-day lockdown, beginning September 19. Some health officials were worried that such a harsh government action would undermine the already-tenuous trust they needed to build with the community to find new cases. Others said it would allow health workers to find patients more effectively, by going house to house.
Yet while the American public was only now waking up to the tragic crisis unfolding in West Africa, two news-making moments were about to catapult the outbreak above the fold in every major newspaper in the country.
The first came on September 11, in the pages of the New York Times. In an op-ed piece, Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota suggested there was something scientists had been afraid to say: that Ebola could mutate and become airborne.
“You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next,” Osterholm wrote. “If certain mutations occurred, it would mean that just breathing would put one at risk of contracting Ebola. Infections could spread quickly to every part of the globe, as the H1N1 influenza virus did in 2009, after its birth in Mexico.”3
The op-ed caused a minor panic at the White House, and at the National Institutes of Health (NIH). On Pennsylvania Avenue, President Obama’s top advisers were cognizant of the politics—especially with an election just around the corner in November. They had worked hard to portray an administration capable of handling an outbreak, a government competent enough to protect its citizens. Hinting at the notion that Ebola could become airborne, which is exactly what happened in the 1995 movie Outbreak, loosely based on Richard Preston’s book, also suggested that Ebola was destined to spiral out of control.
At the NIH, the panic bordered on apoplectic rage at Osterholm. He had given voice to a doomsday scenario, one seemingly so unlikely from a scientific perspective that even talking about it as a possibility could do more harm than good.
Obama summoned Tony Fauci to the White House for an explanation. Ushered into the Oval Office, Fauci saw that Obama was not amused.
“Tony, explain to me what that’s all about,” the president said. “Could it go airborne?”
In his dealings with President Obama, from the H1N1 outbreak to the H5N1 virus and other moments of public health crisis, Fauci had come to appreciate Obama’s interest in and understanding of scientific rationality. Other Obama aides describe the president as a geek, someone fascinated by the intricacies of the latest research. Fauci appealed to Obama’s inner scientist, though his own training demanded he hedge at least a little bit.
“In biology, you never say never, and you never say always,” Fauci began. “It isn’t impossible. But the chances of that happening are so vanishingly small that it’s beyond a distraction. We have more important things to worry about.”
“Why are you so reasonably sure about that?” Obama wanted to know.
Fauci explained the structure of the Ebola virion, what science knows about its ability to survive and thrive when exposed to various conditions. Ebola cannot survive in the air; it needs a liquid substance in which to live, like blood or other bodily fluids. The notion that a virus that has existed in that form, presumably for thousands or millions of years, would suddenly become airborne, Fauci explained, was almost inconceivable. The difference between what Ebola was today and what it would take to become airborne was an evolutionary chasm that was just too wide to fathom.
“If you look at the history of virology, viruses have mutated, a lot, always. Sometimes they become a little bit more virulent, sometimes they become a little less virulent, sometimes they get a little bit more efficient,” Fauci told the president. “But there are no instances that we know of, in the history of virology, where a virus has completely changed the modality of how it is transmitted.”
But Fauci recognized that a pivotal line had been crossed in the American consciousness. While scientists can be rational—and while even presidents in times of crisis are capable of logical thinking—the human brain is conditioned to react to new threats in far different ways than it reacts to old, more common threats. Humans fear being struck by lightning or being attacked by a great white shark far more than they fear being struck by a car. Statistically, that is a completely illogical construct: thousands of Americans are struck and killed by cars every year; a bad year for shark attacks might mean half a dozen victims. We fear any new terror, no matter how improbable the odds, much more than those we have been warned to avoid since we were children.
“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.