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. Mark 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 few 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.
Frieden’s first request of Stokes was to find donors to build new emergency operations centers in each of the three affected countries. The structures would represent a massive and lasting contribution: they would act as data centers, hubs for multidisciplinary teams that could direct resources on the ground to their most efficient targets while analyzing both local and national-level data. Nothing similar existed in Sierra Leone, Guinea, or Liberia; putting everyone under one roof, the thinking went, would dramatically improve the efficiency of operations.
But they were not cheap. Each center would cost an estimated $3 million, so Stokes needed to find $9 million. He spent an early fall weekend calling potential donors, coming up mostly empty—until he reached Paul Allen.
Allen, one of the original founders of Microsoft, has spent hundreds of millions of dollars over the years on philanthropic causes. He told Stokes he was interested in funding the emergency operations centers. Stokes initially misunderstood—he thought Allen wanted to fund one complete center. No, Allen told him, he would write a check to build all three. When costs spiraled, raising the total price by about $3.9 million, Stokes called back to apologize; would Allen like to cover the cost of just two of the emergency centers? Again, Allen told Stokes, he would write a check to cover the higher, total cost.
The finished products were massive, like huge gymnasiums, built by the same prefab contractor the foundation had used in Haiti. When Stokes visited the emergency operations center in Freetown, Sierra Leone, he found more than a hundred people hard at work, divided between critical teams. Some were British military, others CDC staffers or World Health Organization (WHO) officials. Ministry of Health staffers worked side by side with their international partners. British officers and members of Sierra Leone’s army stood shoulder to shoulder in front of maps, flat-screen televisions, and tablet computers. Outside, backup generators hummed. In a nation where just 1 percent of the population has access to the Internet, the emergency operations center, built with a tech billionaire’s money, buzzed with connectivity.
In one corner, a team of operators manned a series of phones. Surveillance teams, armed with some of the cell phones Stokes had purchased from Walmart, would call in to report suspected cases of Ebola or dead bodies that needed to be carefully contained. The operators tapped information into a specially created computer program that prompted all the right questions: Who was the victim? Where, exactly, was the body? Who lives nearby who we can call to learn about the family or the neighborhood? Once answered, the operators would call an ambulance or a hearse to pick up the victim.
Nearby, another team mapped the cases the operators charted. Walls covered in white boards and local maps showed the locations of any suspected or confirmed cases, an effort to plot the spread of the disease and, hopefully, get ahead of it. Every night at 9:00 p.m., the heads of each team met to report on their daily progress.
In Guinea, Stokes visited an emergency operations center in the basement of the only significant Western-style hotel in Conakry that offered reliable Internet access. It seemed like a nice facility. But the power cut out three times; at 11:00 p.m. on the night of his visit, Stokes found himself stuck in an elevator between the first floor and the basement. He was worried he would have to spend the night cooped up between floors.
It was clear that the officials Stokes was helping to pay for had spent many nights in the hotel basement. When he visited in January, a dismal Christmas tree sat neglected in a corner, weeks after the holiday had come and gone. Family photos adorned the walls.
In the field, the foundation funded smaller satellite centers. Stokes visited Bo, a regional capital about three and a half hours east of Freetown, where the CDC had built a lab center in a ramshackle government building. Even here, far from the country’s largest city, the Internet worked, and backup generators thrummed as centrifuges spun. The once run-down building now hosted a high-containment laboratory, where blood samples were processed in metal shipping containers. Stokes was baking in the heat; he could not imagine what the lab technicians, decked in head-to-toe personal protective equipment, must be feeling.
Samples arrived seemingly all the time, flown in by United Nations helicopter and carted in on the backs of motorcycles. Once in the hands of lab technicians, the samples would be sprayed with chlorine, then opened. The paperwork associated with the blood samples would be laid out on the sidewalk, and sprayed with chlorine. Finally, the sample itself would be rushed into one of the containers for processing.
The connection between far-flung villages and the laboratory in Bo, and similar lab outposts across all three countries, largely relied on men on motorcycles. Ranging across three nations with dismally poor road systems, the motorcycles could reach even the most remote and isolated villages, dodging mud pits that would have consumed a car, zipping down forest tracks too narrow even for a small vehicle to navigate. If a sample that reached the lab tested positive—and by the fall of 2014, it seemed there were few samples that were not testing positive—the operations center could dispatch an ambulance to transport the patient, or the body, to an Ebola treatment unit or a morgue.
But Sierra Leone, Guinea, and Liberia are desperately poor countries, with desperately little infrastructure—and desperately few vehicles, motorcycles or not. Frieden told Stokes they needed to shorten the time between a blood sample being taken and a blood sample reaching the lab. That meant more motorcycles, and that meant reaching out to more donors.
Stokes found another set of donors who had made their money in the burgeoning technology industry, and who were now looking to give much of that money away. This time, it was Mark Zuckerberg and Priscilla Chan, the founder of Facebook and his physician wife. The couple wrote a $25 million check—one of the largest individual contributions the foundation had ever received—with shockingly few strings attached. Do what you want with the money, Zuckerberg and Chan told Stokes. Just tell us how you spent it afterward.
So Stokes dramatically increased the number of vehicles tooling around the rural communities of West Africa. The Facebook money bought 206 Toyota pickup trucks, so many that Toyota had to make a special shipment. Before the ship arrived, the foundation arranged to deliver many of the new pickups by airlift. The four-wheel-drive vehicles would allow ambulance teams to get in and out of remote villages, even during the rainy season, when torrential downpours could turn rural roads into frothing mud baths.
Stokes used more of the money to buy four hundred new motorcycles to spread between the affected counties in all three countries. Those motorcycles cut the time between when a patient showed symptoms and when his or her diagnosis came back from a few days to a few hours. “These guys were amazing how quickly they could cover these distances,” Stokes said.
They saved lives, too. Early treatment dramatically improved the survival rate of Ebola patients and, just as important, isolating a patient before they spent several days showing symptoms could save their family members, too, and stop the spread of the disease.
Stokes also visited a small community centered around a palm oil farm, where a once-vibrant market now sat dormant. The CDC Foundation had supplied tents used to quarantine those with Ebola before they could be transported to a proper treatment unit. The market had once been the lifeblood of the community; now, food and water were being trucked in whenever the roads were passable. A CDC staffer manning the quarantine tents pointed to one of the motorcycle riders who helped bring samples in from far-out villages. The motorcyclist had not been paid in two months, the CDC staffer told Stokes; the CDC was giving him as much food as it could, so he could feed his own family.
Zuckerberg and Chan publicized their gift, and therefore the CDC Foundation itself, in a post on Facebook. Allen, the owner of the Seattle Seahawks, flashed advertisements to donate on the Jumbotron during home games. For a foundation used to handling a small number of seven-figure checks from corporate partners and major philanthropies, the huge number of small-dollar gifts that started to roll in almost overwhelmed their system. Ten dollars here, a hundred dollars there—they had never handled contributions on such a scale. Many of the most prominent charities in the country began sending larger contributions. The Robert Wood Johnson Foundation wrote the first million-dollar check of the campaign. The Bill and Melinda Gates Foundation contributed, then the Silicon Valley Community Foundation, an important gateway to big tech money. Henry Schein, the company that makes personal protective equipment, donated money and gear; the hospital firm HCA wanted to donate beds, so Stokes directed them to the U.S. military. Johnson & Johnson wrote a seven-figure check, too.
Stokes thought that building the foundation’s credibility was key to keeping the money spigot on. In normal circumstances, the CDC Foundation would take a percentage of each contribution to cover its own internal operations, like paying the rent on its Atlanta headquarters or paying the salaries of its employees. With the Ebola outbreak raging, Stokes suspended that overhead charge. Instead, he took $1 million out of the foundation’s reserve fund to handle overhead.
In Africa, the speed with which the foundation could move impressed both government ministers and other nongovernmental organizations alike. The CDC’s central emergency operations center in Atlanta could request money for some specific project. So could leading CDC officials in each of the three West African countries.
When a team of health ministry workers in Sierra Leone planned to mount a massive campaign to conduct door-to-door surveillance in a particularly hard-hit neighborhood, they asked the CDC Foundation for a grant of $160,000 to hire and train 400 staffers. The request hit the foundation’s inbox on a Thursday; within two hours, the money was wired to the appropriate accounts. By Sunday, the 400 newly trained staffers were canvassing the neighborhood.
“A need could arise one day and be approved that day, and we would move funding that week, sometimes that day,” Stokes said. During his January visit, a top CDC aide based in Sierra Leone stopped Stokes to tell him about the door-to-door canvassing effort, and the money that made it possible. “It literally blew our minds,” the official told him.
As a side effect of the foundation’s spending spree, the group was able to funnel some money to residents whose businesses had effectively been shut down by the spread of the disease. Accountants, lawyers, merchants, university instructors, and students, all of whom had seen their livelihoods vanish as society pulled inward on itself, were suddenly put to work driving vehicles or manning phone lines. To speed the purchasing process, the foundation partnered with eHealth Africa, a nongovernmental organization that had built an emergency center to track polio in Nigeria with CDC Foundation money. On the ground, eHealth had the foundation’s permission to buy what it needed to run the operations and lab centers, including everything from generators and fuel to water and toilet paper.
The flexibility in spending brought a measure of order to what had been a chaotic response. Officials with different organizations, whether the CDC or WHO or local health ministries, would wake up each day with a new idea about how and where to spend money. Priorities changed on a daily, sometimes hourly, basis. No government purchasing process would have been able to keep pace. But the foundation, not beholden to any particular set of rules, could dash off a check when a need arose, without marching through a procurement process.
“There are some emergencies for which even a nonprofit with flexibility like us still needs that extra step of unrestricted money. I don’t think there will ever be a way for government to fill that gap,” Stokes said later. “The typical grant-making process would not have worked here. There was no time for that.”
In just a few months, as the U.S. Congress dithered over whether and how to fund the fight against the deadliest disease known to man, the CDC Foundation raised and spent $55 million—eleven times what they had raised to help Haiti recover from its earthquake.
Today, the emergency operations centers in Conakry, Freetown, and Monrovia are still in operation. The once-temporary facility in Freetown is now permanent, and bulked up with a new second story that houses permanent offices for CDC officials, who help train disease detectives to look out for other viruses that plague the populace.
But the emergency operations centers represented just one front in the war on Ebola. In the rural counties well inland from the crowded capitals, another front was opening up, one that would ultimately bend the deadly curve of an out-of-control virus down, for good.