A Waning Tide
WHEN LEISHA NOLEN RETURNED to Sierra Leone in November, she felt as if she were visiting a different country from the one she left in August. After her last deployment, the normally active Centers for Disease Control and Prevention (CDC) Epidemic Intelligence Service officer had been so depressed about the spiraling virus that she sat, moribund, on her couch for weeks on end. During that deployment, the daily case counts were growing by the dozens—on some days, by the hundreds. Nolen and some of her colleagues spent their time in Sierra Leone and Liberia wondering whether they, or anyone, could actually get a handle on the growing crisis. The looks on the faces of the Sierra Leoneans she worked with were grim; unlike Nolen, they were not going to rotate home for a break. Their home was the one on fire.
But a few months later, Nolen found a different situation entirely. Her third deployment took her to Kambia, in northern Sierra Leone, a town of about 40,000 inhabitants about halfway between Freetown and Conakry. The number of reported, suspected, and probable cases of Ebola in West Africa continued to rise, from about 4,800 at the beginning of November to 7,100 by the beginning of December, but Nolen detected a notable change in the country’s mood.
Employees working for the CDC, Médecins Sans Frontières (MSF), Global Communities, and others detected the same change in the last few months of the year. The case curve, which just a few months before had been growing exponentially, was starting to level off. Elders in villages facing the virus for the first time were no longer skeptical that Ebola existed; instead, they started asking questions about how to stop the spread of the danger in their midst, a credit to the national education programs airing on radio stations around all three countries. The international response had finally caught up with the severity of the outbreak, to the extent that even smaller countries were contributing what they could. The Dutch government spent more than €18,000 for a Stop Ebola card game, modeled on the game Memory.1
In his morning meetings, Major General Gary Volesky began to see a downward trend in new case counts. Every day, Volesky would review the “heartbeat chart,” a graph that showed weeklong averages of new cases and projections of cases in the future, which gave responders a sense of which regions needed urgent attention. The upward curve that resembled a hockey stick when he arrived had begun to bend slowly downward through November.
“By December, you’re saying, wow, there’s less than 30 cases reported total a day,” Volesky said. But he remained leery: A single person had started the initial outbreak in Guinea. A single person had spread the virus over the border into Liberia. A single person had brought Ebola to the heart of Monrovia, sparking an outbreak in densely packed urban slums. “It only took one person to start this before,” he said later.
A new cluster of Ebola cases in Cape Mount County, on Liberia’s northern border with Sierra Leone, showed just how much progress the nation had made. Even before the first cases popped up, burial teams trained by Global Communities were patrolling villages in Cape Mount. The first bodies those teams were called to pick up showed that the villagers still did not fully buy into the virus’s lethality—the bodies had been washed and dressed for the afterlife.
But where education efforts directed by Monrovia’s government had not worked, the nongovernmental organizations (NGOs) working in Cape Mount turned to their second line of attack: traditional leaders.
Cape Mount is a predominantly Muslim county, one of the few in Liberia. So Global Communities found the highest-ranking Muslim traditional leader they could: Musa Kamara, who headed the Paramount Chiefs Council, a group of traditional elders, in neighboring Lofa County. Chief Kamara had seen the toll Ebola took on villages in his Quardu Gboni District, and he knew how urgent it was for Cape Mount to take action quickly. A day after receiving a call asking him to visit, he was in the car.
Once he arrived, Chief Kamara and a local grand mufti organized a meeting with traditional leaders in Cape Mount, especially those who were skeptical about the virus. The disease is real, they told their counterparts. After the meeting broke up, the chief visited nearby villages to spread his message beyond the traditional leadership. Ebola, Kamara said, was survivable, but only if those who were ill sought treatment in time. Save Cape Mount, he urged villagers, from the horror Lofa went through.
Within days, those who had fallen ill started showing up at newly built Ebola treatment units. Where the government in Monrovia had little credibility, Kamara had served as an important validator of the point they were trying to get across. The mistrust between traditional leaders and the central government might still exist, but the two sides knew when they needed to work together.
As the infection curve bent downward and as virus hunters started believing they could strangle the disease, a new batch of scientists began arriving, a group more accustomed to dealing with the microscopic, rather than the human, element of an outbreak.
Just as virus hunters had arrived in West Africa sensing the opportunity of a lifetime, their best chance to practice their craft under the highest possible pressure, so too did microbiologists see an opportunity in the Ebola outbreak.
Before 2014, only a relatively small number of people had ever come into contact with the Zaire strain of the virus, dubbed EBOV—and even fewer had caught any of the three relatives that have been shown to harm humans. Only 1,383 known cases of the EBOV, or Zaire, strain had been diagnosed before the outbreak in West Africa; just 778 cases of the Sudan strain (SUDV) had been diagnosed. Over the course of just two known outbreaks, 185 people had come down with the Bundibugyo (BDBV) strain. And the Tai Forest virus had been found only a single time in that one unfortunate Swiss graduate student, working in the nature preserve in Côte d’Ivoire in 1994.2 In almost every outbreak, the Ebola virus burned through a population so fast that the disease had disappeared before microbiologists arrived to study it.
Put another way, before the outbreak in West Africa, scientists knew little about one of the scariest viruses on the planet—which meant that their efforts to create new treatments and vaccines had not progressed as fast as with other, better understood diseases. Lab tests at places like the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) and the CDC could only go so far. Seeing the virus in the wild, understanding how it morphed and mutated between patients, would give scientists an invaluable leg up in the war against such a deadly pathogen.
Captain Jeff Kugelman was among the first genetics experts deployed to Liberia to slice open Ebola virions in hopes of finding new ways to prevent the next wave of infections. Trained as a viral geneticist at the University of Texas at El Paso, Kugelman, bespectacled and with the shaved head of a career Army man, is serious about his work at USAMRIID. He arrived in Monrovia on November 17, 2014, armed with an Illumina MiSeq, a high-tech gene sequencer about the size of an office printer.
The MiSeq is an extremely expensive, extremely delicate machine, designed to sequence the genetics of any given specimen. Sequencing any Ebola virion, isolating the base pairs of A, T, C, and G proteins that make up RNA, would take between three and seven days; Kugelman’s mission was to sequence as many samples as possible, to understand the various threads of infection that had radiated out from Meliandou nearly a year beforehand. Diagramming those infection chains would help virologists understand how Ebola spread, and how it had mutated along the way.
The company that produced the machine knew it would not be able to send engineers to the hot zone to conduct repairs in case something went wrong, so Kugelman took a two-week course to become a certified engineer qualified to fix the MiSeq. Illumina bent over backward to help, maintaining a twenty-four-hour rotation of technicians based in London and the United States to advise Kugelman if he needed help. The technicians and the course came in handy immediately. The day Kugelman arrived, the local contractor hauling the sequencer to his makeshift laboratory dropped the box. The machine broke, but Kugelman had the skills to repair it using only the tools at his disposal.
“It survived a pretty close to worst-case scenario,” Kugelman chuckled later, nervously eyeing his delicate machine as it sat on his desk at Fort Detrick.
Kugelman set up shop near Liberia’s airport, at the Monrovia Medical Unit, the Ebola treatment unit that had been reserved for any Westerners who might come down with the virus. The facility was designed as a crude horseshoe, built of cinderblocks, with nothing more than a covered breezeway connecting his lab to the treatment unit. It had been a forward staging base for the U.S. Navy during World War II, and so it had a few apartments, though Kugelman stayed closer to town at an Army hotel, an hour down the road.
From the start, Kugelman and his small team had to cart in virtually everything they needed to do their work. Their lab had no clean water, no fuel for generators that kept the machines whirring. They were working on a biosafety level-4 (BSL-4) pathogen in what amounted to BSL-2 conditions, with far fewer safety precautions than they might have liked. Kugelman kept three backup battery packs, each with about seven hours of life, on standby to make sure the MiSeq and their computers would not shut off in the middle of hours-long sequencing processes, so they wouldn’t lose their work. Power spikes kept blowing out converters as surges coursed through the system. The results they generated would lead to a better understanding of how Ebola worked—and later, the virus’s lasting effects on someone who had survived its initial, devastating onslaught.
As Kugelman worked, the first Army-built Ebola treatment units began opening in Liberia. But by then, the infection curve had begun to level off from its exponential growth in September, October, and the early part of November. That meant the demand for beds to treat Ebola patients dropped, and the Army had to decide whether to continue building the facilities already under construction. It was becoming clear that the military had planned to build more facilities than would actually be needed—a conundrum that led to some criticism back home, but Army officials thought it was a better problem than the one they would have faced had they built fewer than the number of facilities required.3
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 job, 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.