A Call for Help
IN EARLY AUGUST, Liberian president Ellen Johnson Sirleaf called her chief ally on Capitol Hill, Senator Chris Coons, the chairman of the U.S. Senate Foreign Relations Subcommittee on African Affairs. Coons admired Sirleaf, a bipartisan cause célèbre in Washington at a time when there had not been many success stories in Africa. When Sirleaf was elected president in 2005 as the unity candidate capable of healing the deep wounds left over from the country’s second civil war, First Lady Laura Bush and Secretary of State Condoleezza Rice had attended her inauguration. Sirleaf had given a joint address to Congress, a rare honor for a foreign leader; George W. Bush had awarded her the Presidential Medal of Freedom, the highest civilian award an American president can bestow; and Barack Obama welcomed her to the Oval Office in 2010, crediting her “heroism and courage” in helping Liberia heal. She shared the Nobel Peace Prize in 2010, an award she won for her work to promote women’s rights (though the timing of that award, coming just days before Sirleaf won a second term, was not without controversy).
Coons, a freshman Democrat from Delaware, knew more about the desperate poverty of Africa than most of his colleagues. He had served as a relief worker in Kenya and written a book on South Africa during apartheid. And he knew Sirleaf well. He had attended her second inauguration, after she won reelection with 90 percent of the vote (the opposition candidate had boycotted the election after the controversy over the Nobel Peace Prize). The two politicians, one a brightly dressed African woman in her seventies who had seen the worst of civil war, the other a low-key backbench senator with a graduate degree from Yale Divinity School, formed an unlikely bond; Coons thought Sirleaf was tough and resolute.
But now Coons heard a desperation in Sirleaf’s voice. Her country, she told him, was dissolving around her, laid prostrate by a virus the public health infrastructure had no ability to defeat. The World Health Organization (WHO) was so miserably behind the curve that the number of Ebola cases was beginning to skyrocket, both in the remote rural counties up north and in crowded and impoverished Monrovia itself. Help, she said, was nowhere on the horizon.
“Everything was shutting down. They were feeling a sense of abandonment by the world. Airlines were stopping [flights], cargo ships were no longer coming,” Coons recalled later. “They increasingly felt isolated.”
Coons promised help. He thought he had grasped the seriousness of the situation, but when Sirleaf made a specific request for funding, Coons realized the true magnitude of the burden Liberia faced: Sirleaf’s country needed help building a crematorium to dispose of dead bodies that would otherwise infect someone new. They simply did not have the space, or the time, to bury the dead.
Over the scratchy transatlantic connection, Sirleaf and Coons prayed together.
On the ground in Liberia, the situation looked even worse. In one twenty-four-hour period in the second week of August, 113 new cases were reported in Liberia alone, and the real number was probably far higher. On August 12, Mosoka Fallah, the Harvard-trained epidemiologist, found Ebola patients in West Point, the overcrowded Monrovia slum where safe sanitation was virtually nonexistent, creating an atmosphere ripe for infection. Community leaders admitted they had been burying their dead without reporting them to authorities.
“It became apparent that what we were seeing was the tip of the iceberg,” Fallah recalled later. “There had been secret burials. The people had been sworn to secrecy.”1 Within weeks, victims were dying so fast their bodies were being thrown into two nearby rivers.
Johnson Sirleaf’s government tried to clamp down on the outbreak in West Point, imposing a strict quarantine on the slum’s tens of thousands of residents on August 19, a week after the first cases there turned up.
Most international health experts advised against cordoning off an entire Monrovia neighborhood. Doing so, they warned, would leave the impression that West Point had been left to die on its own. But Johnson Sirleaf sided with her Army chiefs, who proposed the idea in the first place.
“We have been unable to control the spread [of Ebola] due to continued denials, cultural burying practices, disregard for the advice of health workers and disrespect for the warnings by the government,” Johnson Sirleaf said in a statement announcing the quarantine the night before it took effect, issued after most West Point residents had gone to bed for the evening. “It has thus become necessary to impose additional sanctions.”2
The riot police and Coast Guard units who showed up the next morning to enforce the quarantine met crowds of angry West Point residents. Groups of young men threw rocks and attacked riot police, who showed up one Wednesday morning to enforce the lines of demarcation. Thousands of residents worried they would not be able to get to their jobs in other parts of the city. A fifteen year-old boy, Shakie Kamara, died after being shot in the leg during the clashes. More people might have died had not a torrential rain storm sent people fleeing back to their homes.3
Many residents disregarded the quarantine on a regular basis. Some swam around the quarantine lines. Others slipped through loosely-guarded sections. There was no shortage of soldiers willing to accept a few dollars in bribes in exchange for turning a blind eye to the escapees.
Those who left were more worried about starving to death than about contracting Ebola. Thousands lined up every day, waiting in lines for government handouts of rice and water as a thriving black market for other goods flourished.
Johnson Sirleaf toured West Point a few days later, surrounded by heavily armed guards in protective gloves who kept the angry crowd away from Liberia’s president at what may have been her government’s lowest ebb during the outbreak. She apologized to Shakie Kamara’s family for his death. Though she did not make any public comments during her visit, a man in her entourage threw wads of bills at some of the loudest protesters—quieting their yelling, but sparking fist fights over the cash.4
Days after the president’s visit, her government lifted the quarantine. It had not done much good, even as a public education campaign.
“Most people here still don’t believe there is Ebola in West Point,” the manager of a drug dispensary told a reporter for the New York Times. “They’re saying that the government came and didn’t find Ebola, and so that’s why they’re leaving.”5
The disease was decimating more than the bodies of the victims themselves. Pillars of society—a very vulnerable society at that—began to shut down. Businesses closed. Food and fuel were in short supply. Regular health services, in a region where malaria was a constant danger and where the infant mortality rate was among the highest in the world, collapsed almost entirely. Because caring for a family member who is ill or the body of one who has died falls to women in West African society, a huge number of pregnant women were becoming infected. Rick Brennan, head of WHO’s emergency assessment team, called delivering a baby in Liberia “one of the most dangerous jobs in the world.”6
Nongovernmental organizations (NGOs), whose selfless labor was desperately needed to stem the spread of Ebola, were looking to the U.S. embassy for guidance. The embassy had held a town-hall meeting for NGOs in late July to review safety protocols, to reassure nervous ex-pats that contracting Ebola wasn’t likely if those safety protocols were observed, and to send the clear message that embassy personnel were not leaving.
On July 30, the Peace Corps said it would pull its combined 340 volunteers out of Guinea, Liberia, and Sierra Leone. After half a century in existence, the Peace Corps had developed a reputation as one of the last organizations to leave a dangerous situation; their exit now spooked the NGO community, which had already been shaken when Brantly and Writebol fell ill. Many organizations made their way to the airports as fast as they could. Others were forced to leave when their insurance providers hiked premiums through the roof.
As those groups departed, the United States Agency for International Development (USAID) Office of Foreign Disaster Assistance (OFDA) was considering ways to join the fight. But it was not clear that an agency more accustomed to fighting famine or providing relief from a devastating hurricane or earthquake would be able to add anything to a fight against a disease that the Centers for Disease Control and Prevention (CDC), or the WHO, or Médecins Sans Frontières (MSF), were not already doing.
The American in charge of the OFDA was Jeremy Konyndyk, a tall and lanky thirty-six-year-old who had worked in refugee camps in Guinea during the Liberian civil war. In early July, he had dispatched Justin Pendarvis, a USAID public health adviser with years of his own experience in West Africa under his belt, to evaluate the situation on the ground. In the space of just a few weeks, Pendarvis observed Ebola treatment units in Conakry, Guinea; Kenema, Sierra Leone; and Monrovia, meeting with teams from the CDC, MSF, WHO, and the United Nations to see what USAID might add. USAID, after all, was full of disaster response experts, not outbreak response experts; historically, the two communities of specialists had viewed each other with suspicion.
Pendarvis bridged the gap between the two communities, and his years in West Africa gave him more insight into what he was seeing. Yes, he concluded, USAID needed to get on the ground—and fast.
Not every NGO had pulled out, and counterintuitively, the absence of so many groups made coordination among those that remained more efficient. In an ordinary disaster response, representatives from perhaps dozens of NGOs will crowd into a massive conference room or community center in an attempt to coordinate efforts; groups shouting over each other is not uncommon, according to those who have been involved in previous disaster relief efforts. In the three West African countries, in late July and early August, the coordination meetings could happen around a single table at a local café, or in a government minister’s small conference room.
Pendarvis had already identified the few groups that were left. The Liberian Ministry of Health’s main organizational group, the Incident Management System, would be chaired by Tolbert Nyenswah—a lawyer by training with a master’s degree in public health from Johns Hopkins University—who served as the nation’s assistant minister of health. When it was established, Nyenswah’s group was focused on Monrovia, where Ebola had the potential to explode within crowded slums. But to get a better handle on what was happening in the northern counties, where the disease had first crossed the border from Guinea, Pendarvis turned to Global Communities and its in-country director, Piet deVries.
DeVries had spent about a decade traveling back and forth from his home outside Washington, D.C., and Liberia, where Global Communities was running a USAID–funded program called Improved Water, Sanitation and Hygiene, IWASH for short. As part of that program, Global Communities had created a network of emergency health technicians (EHTs)—if there is one group that tends toward confusing acronyms more than the U.S. government, it is the community of nongovernmental organizations—who worked in the rural northern counties.
Those EHTs, always local Liberians, had spent years going to small villages working to create a mental link between the proximity of latrines and a water source and corresponding incidences of cholera. They were technically employees of the Liberian Ministry of Health—U.S. federal law prohibits paying foreign government employees a salary—and now they were beginning to use their connections with local villagers to establish burial teams, which they hoped would cut the chain of transmission by safely laying to rest anyone who had died of Ebola.
DeVries told Pendarvis that his EHTs were receiving the equivalent of just US$80 a month, and getting only minimal training from the Liberian Ministry of Health and the WHO, for performing one of the most dangerous jobs around. Lofa County, where the first burial teams were built, had offered an additional $20 per burial for each member of the team, but the county government soon ran out of money. DeVries asked USAID for money to pay the burial team member bonuses. The wire transfer took place in a matter of days. Soon, USAID sent Global Communities more money to pay for new burial teams in Bong and Nimba Counties, two more northern outposts where Ebola was burning fiercely.
DeVries used some of the money to supply his EHTs himself; materials the burial teams needed to do their jobs safely were arriving in Monrovia by the boatload, but they languished in warehouses, waiting for shipments north, which never took place. One hot morning in mid-August, deVries picked up 5,000 body bags at a warehouse in Monrovia and drove them north to Lofa. When deVries arrived, he found the first burial teams wrapping bodies into plastic sheeting, because they had run out of body bags of their own.
In Washington, officials had begun meeting to figure out how they could assist. Gayle Smith, the senior National Security Council (NSC) staffer with a long background in Africa, began convening meetings of what is known as an Interagency Policy Committee, a group of top-ranking representatives from relevant agencies, on July 22. She began holding daily meetings of NSC staff tasked with scaling up international efforts the following week, on July 28. Three days later, on July 31—the day Brantly received his first dose of ZMapp—the White House held its first principals-level meeting, which included national security adviser Susan Rice, Samantha Power, the American ambassador to the United Nations, and health experts like Tom Frieden of the CDC and Anthony Fauci of the National Institute for Allergy and Infectious Diseases (NIAID).
Those early meetings focused on the most basic elements of an outbreak response—how to build an Ebola treatment unit, how to usher a patient from a waiting room to a diagnostics area and, eventually, to an isolation ward. Rajiv Shah, USAID’s administrator, had his staff put together PowerPoint slides that showed the floor plan of a treatment facility. Jimmy Kolker, the assistant secretary of Health and Human Services for Global Affairs, offered to deploy a team of doctors from the U.S. Public Health Service’s Commissioned Corps, an agency that ordinarily sends medical professionals to impoverished communities around the United States. Fauci routinely briefed the president himself, beginning in early August, when Obama asked for an outline of the science of Ebola.
On the sidelines, Frieden and Fauci, who ordinarily chatted several times a week about whatever was happening in the global health world, were talking daily. So too were Shah and Sylvia Matthews Burwell, the secretary of Health and Human Services. Fauci was routinely on the phone with Lisa Monaco, the White House’s top homeland security official, and with Denis McDonough, President Obama’s chief of staff. Shah spent hours on the phone with Sirleaf and her two counterparts, Guinea’s president Alpha Conde and Sierra Leone’s president Ernest Bai Koroma, fielding requests for aid and receiving updates on the extent of the outbreak.
The sense among senior American officials, from the White House to the CDC and National Institutes of Health (NIH), was that the Ebola virus still represented a threat almost exclusively to the three West African nations, and not to the United States. The difference between public health systems in Liberia and America was equivalent to the difference between riding a bicycle and traveling by jumbo jet; few top officials seriously worried that the virus would make its way back to American shores. That gave the White House the sense that they did not need to overcommunicate, in the words of one senior administration official. They didn’t need to sound alarms about a threat they saw as remote—a decision several said in hindsight they would regret.
There were some early signs that the American public saw the threat of an outbreak on American soil as far more likely than the White House did. On August 1, 2014, less than a year before he would kick off his improbable presidential campaign, Donald Trump tweeted to his millions of followers: “The U.S. cannot allow EBOLA infected people back. People that go to far away places to help out are great-but must suffer the consequences!” Nearly 4,300 people retweeted Trump. A subsequent analysis by the White House Office of Digital Strategy found that Trump’s tweet had captured Americans’ worries about the virus. “It was that tweet that created a level of anxiety in the country,” Amy Pope, a senior White House counterterrorism official, said in an interview. “That was a crystallizing moment.”
Unbeknownst to Trump, he had tweeted at exactly the moment when some officials at the National Security Council and the State Department were worried for the first time that Ebola could hop a plane across the Atlantic. The occasion was the African Leaders Summit, which brought heads of state from fifty African nations to the Mandarin Oriental Hotel, the State Department headquarters, and the White House. The summit would focus on trade and investment between the United States and Africa; commerce secretary Penny Pritzker announced nearly a billion dollars in new international deals during the three days when motorcades shuttled senior officials across a gridlocked capital. Guinea’s president Alpha Conde, Liberia’s vice president Joseph Boakai, and Sierra Leone’s foreign minister Samura Kamara, all attended with their retinues. Johnson Sirleaf and Ernest Bai Koroma, Sierra Leone’s president, stayed home.
Pope worried that the summit, which included dozens of staff, hangers-on and members of the African media attached to each delegation, might inadvertently serve as the opportunity for Ebola to spread, either between delegations or to civilians in the Washington area. Homeland Security officials and the CDC trained the Secret Service, who would be deployed to protect and watch visiting African dignitaries, to spot signs of Ebola. High-level meetings were held to decide whether someone who exhibited a cough should be let in to official events. Pope breathed a sigh of relief as the African leaders left on August 6, after none had shown obvious signs of being sick.
Meanwhile, the National Security Council sped up its plans to dispatch aid back across the Atlantic. At a meeting of top NSC deputies on August 3, the White House agreed to Shah’s recommendation that they send a formal USAID team—known as a Disaster Assistance Response Team, or DART—to Liberia. The following day, Deborah Malac, the American ambassador in Monrovia, formally declared a disaster, paving the way for a DART deployment.
The first DART team on the ground in West Africa arrived in Monrovia on August 7. Shah and Konyndyk at USAID, Smith at the White House, Fauci at the NIH, and Frieden at the CDC had already concluded that the WHO was in over its head, with central leadership in Geneva badly disconnected from the grim reality on the ground. They were shocked, nonetheless, that it took WHO until August 8 to declare the outbreak a “public health emergency of international concern,” its highest threat level. The declaration came almost four and a half months after the first Ebola case was announced, four months after MSF had declared an emergency, four days after the U.S. ambassador had issued her own formal warning, and a day after the first significant U.S. presence had already landed.
Sending in DART represented a major escalation of American involvement. The team included representatives from the Department of Defense, the Department of Health and Human Services, USAID, and CDC. It consisted of logisticians who would help deliver crucial supplies to Ebola treatment units, burial teams, aid workers, and anyone else who needed help; disaster response experts who embedded within Liberia’s Ministry of Health to support Tolbert Nyenswah, heading the emergency response at the Incident Management System; communications specialists, who fought with Liberia’s unreliable telecommunications systems to make sure the team had a reliable line to Washington and Atlanta; a safety and security officer, who did everything from protecting team members on their travels to and from work to speaking with staff at the team’s hotel, to ensure that proper hygiene techniques were being followed; and even a medical officer, who would constantly check on team members themselves, to make sure no one was coming down with anything—whether malaria or Ebola.
The team, ordinarily sent to the site of a disaster response rather than a viral outbreak, was meant to pave the way for future American investment and to ease the strain on an embassy in an affected country. One embassy is not equipped to handle or coordinate a full-on disaster response; DART parachutes in for the ultimate in crisis management.
USAID, rather than sending thousands of its own responders, instead typically identifies and funds other groups, like Global Communities and Samaritan’s Purse, that execute relief efforts on the ground itself. Still, the dearth of NGOs meant that these DART members had to act quickly, on their own. Early on, a group of team members fanned out across Monrovia, scouring markets and shopping centers for every ounce of chlorine they could find, and spray bottles too. They packaged those supplies up by hand and sent them to every Ebola treatment unit they identified around the country.
The remaining NGOs started seeing money from American coffers in short order. USAID had already started funneling money to some organizations; in March, it had sent $600,000 to the United Nations Children’s Fund (UNICEF), which was working on rapid response. By the time of DART’s arrival, the spigots of American dollars were opening, from a trickle to a gusher. Within two days of showing up, the team had approved $14.6 million in USAID funding, on top of $2 million already sent to WHO. Three days later, USAID said it would send another $7.5 million to Liberia, which would pay for 105,000 sets of personal protection equipment. Another three days later, a second team was deployed, this time to Sierra Leone.
At the same time that the DART members arrived, and while burial teams began operating in northern rural counties, the Liberian government was having trouble finding space to bury bodies in Monrovia. About 70 percent of all Ebola transmissions came from contact with dead bodies, which became festering cesspools of virus; finding a safe way to remove those bodies was essential, outbreak specialists knew, to ending the chains of transmission.
But early efforts to create a safe burial space ran into local roadblocks. When the Ministry of Health tried to bury thirty bodies at a site near Monrovia, they had to call in security officers to fend off nearby communities that did not want a cemetery in their backyards. Once the residents were gone, an excavator plowed a mass grave. But the ministry had picked a low-lying area at the peak of the rainy season. As the water table rose, it brought bodies floating back up to the surface. It was a major embarrassment for Sirleaf’s government, which was already straining to prove it could handle the crisis.
The Ministry of Health hit upon a new solution, one Sirleaf brought up to Coons in that early August phone call: they needed to burn the bodies to kill the virus.
But cremation is a foreign concept to most Liberians, for whom the ritual of preparing a body for the afterlife was an important cultural touchstone. The thought of burning bodies was unpopular with many Christian Liberians, and even more so with the significant Muslim population.
“The idea of burning bodies is unpalatable in Liberia,” deVries explained. “It doesn’t happen.”
It was so unusual that Liberia did not even have a crematorium capable of handling the bodies. Instead, they borrowed a facility owned by the Indian Embassy; for Hindus, cremation is a cultural tradition. On August 5, the Liberian government ordered every corpse in Monrovia to be burned.
Even then, the government proved to be unprepared, thanks in large part to woefully inadequate record-keeping. A major part of Liberian funerary tradition revolves around having a place to mourn the dead. At government-run Ebola treatment units in the city, however, ashes were put in barrels, with no record of whose remains were lumped together. Families that had worried about relatives going into an Ebola treatment unit and emerging as corpses now worried that they wouldn’t even have a corpse to bury and mourn. Patients who died at facilities run by Médecins Sans Frontières could count on excellent record-keeping, but it was cold comfort for those whose relatives died lonely, painful, frightening deaths.
The cremations also fed a growing sense that some victims of the Ebola virus were being treated differently than others, exacerbating tensions that had lingered since the nation’s devastating civil war between the governing elites—the descendants of freed American slaves—and the tribes that had lived in Liberia for millennia. Many governing elites continued to bury their dead, even though government policy explicitly called for cremations.
At one meeting of a committee dedicated to dead body management, held in a Ministry of Health conference room and attended by senior officials from MSF, Global Communities, the CDC, and the WHO, the woman who chaired the meeting told the shocked crowd of humanitarian responders she had just come from a funeral herself. The Liberian official in charge of enforcing cremations was violating the rule she was meant to enforce.
Zanzan Kawa, head of the Traditional Council of Chiefs and the highest-ranking tribal leader in Liberia, had tacitly accepted the need for cremations, but he sent a powerful message when he saw the different ways his people and governing elites were being treated: They’re not burning the elites, he said. They’re burning us.
The NGO community was unanimous in warning the Liberian government about the danger it was courting: You’re creating a disconnect between the elites and the poor, they told the government. That disconnect threatened to undermine the careful relationship that NGOs were building with the very poor, those who stood the highest risk of catching Ebola because of their close-quartered living conditions and lack of available hygiene. Without that foundation of trust, the NGOs warned, more people would go into hiding rather than seeking treatment, exacerbating the spread of the deadly disease.
On August 17, about two and a half weeks after the ELWA 2 hospital had collapsed under the weight of the two sick Americans, MSF once again stepped in to fill the breach. It opened a massive new clinic in Monrovia called ELWA 3—at 120 beds the largest Ebola management center ever built. Still, the facility was not big enough, and MSF doctors had to turn away clearly sick Liberians simply because there were no beds to hold them. Those who were sent away were given home protection kits to reduce the risk of infecting their families at home.
“The numbers of patients we are seeing is unlike anything we’ve seen in previous outbreaks,” an overwhelmed Lindis Hurum, MSF’s emergency coordinator in Monrovia, said just a few days later. “Our guidelines were written for an Ebola center with 20 beds, and now we are expanding beyond 120 beds.”7
Like its predecessors, the ELWA 3 facility did not resemble a Western hospital. Instead of brick and mortar, patients rested under a series of tents, donated by various government and nongovernment agencies. Fences made of rebar and door flaps separated red zones, where Ebola patients were quarantined, from safe zones, presumably free of the virus. Patients waiting to be admitted lounged under two tall trees outside the hospital; responders called them the Ebola trees.
Barry Fields arrived at the hospital a few days before it opened. Fields, a microbiologist by training, had been based at CDC’s Kenya office for three years. A few days after Kevin De Cock, head of CDC’s Kenya office, left to head up the agency’s response in Liberia, he called Fields and told him to pack his things. Liberia needed more diagnostic capability, and Fields had the equipment necessary to rapidly build up a laboratory for testing blood samples of potentially infected patients.
Initially, Fields and his colleague Heinz Feldmann, chief of an NIH virology lab at the Rocky Mountain Laboratories in tiny Hamilton, Montana, planned to set up their operation in Lofa County, in the rural north. But when they arrived in Monrovia in August, another senior CDC official, Joel Montgomery, told them the plans had changed. The virus was erupting in the slums of Monrovia, and they were needed in the capital.
“We need to control this thing here,” Montgomery told Fields. “It’s going to explode in the city.”
The lab equipment Fields packed up included seven hundred pounds of gear, including generators to keep the delicate and highly technical machines whirring. With it, he could build a level-3 biosafety lab in the field, capable of protecting scientists and technicians from the worst bugs on Earth. But the contractor they had recruited to ferry the gear to Liberia had trouble with the customs paperwork, holding up their mission for three long days.
In the interim, Fields met with staff from Médecins Sans Frontières, to plan where exactly they would set up the lab. The MSF staff had been laboring to get more than a few blood samples tested each day. When Fields told them how many samples his machines could process—about 150 a day—their jaws hit the floor. On the spot, they volunteered to give Fields and his team as many construction workers as they needed. Once construction began, the rudimentary laboratory was completed within twenty-four hours.
Still, the lab was primitive at best. Like the ELWA hospital itself, Fields’s team operated in an open-air tent, stocked with plastic patio furniture they had purchased at a local hardware store. The August monsoons beat down on the roof constantly, and they had to hire a Liberian man to sweep out the rain. They worried constantly about being electrocuted, or that the water would short out their pricey gear. They bought fans, too, in a perpetually losing battle against the tropical heat.
Once the customs paperwork had been fixed and the tent erected, the complicated system of testing blood samples took on a regular order: Fields or one of his colleagues would collect samples from a refrigerator just outside the red zone, walk past patients waiting to be admitted under the Ebola trees, and place the blood in an acrylic box. The blood would be treated with a buffer solution that extracted RNA, which would prove whether Ebola was present in the blood, while killing 99.9 percent of the virus. They added an ethanol solution to kill what virions remained, turning the blood a rust brown color.
The treated samples would then be moved to two extraction machines, which would amplify a few pieces of RNA so that the computers could tell whether a sample had Ebola present. The two machines were able to diagnose a sample with near-perfect accuracy; to be certain, they ran each sample through both machines. Results were entered into a computer, which would then be sent to the appropriate hospitals.
The tent was situated along the main walking path between the road and the ELWA hospital. As patients walked down the path, they frequently stopped by the lab tent in search of treatment. Fields and his colleagues had to direct them to the hospital itself, though they could tell how sick many were.
“You just knew they were dead,” Fields said later, mist coming to his eyes.
In its first week of operation, the CDC team scanned three hundred samples, a huge improvement over the seemingly interminable waits doctors and patients had to endure before. But the results were as depressingly monotonous as the rain that beat on the roof: Positive. Positive. Positive.
The results were so grim that they had to find solace in any way they could. When the first survivor walked out of ELWA under his own power, having beaten Ebola, Fields, Feldmann, and their colleagues snapped photos with the healed man.
But more patients arrived seemingly by the hour. Taxis carrying the sick would pull up to the ELWA hospital, where a team would help the patient inside while another team sprayed the vehicles down with a chlorine solution to kill whatever virus particles remained behind.
Each day was a brutal slog. A Liberian driver would pick them up at their beachside resort, the same hotel where Randy Schoepp and his team were staying, at 8:00 a.m. They spent most of the day testing samples from patients at ELWA, subsisting on Pringles and cookies for lunch. As the sun set, invariably new samples would arrive from John F. Kennedy Hospital on the other side of town. Well after nightfall, they drove back to the hotel. They took what little pleasure they could in a friendly competition with the U.S. Army Medical Research Institute for Infectious Diseases team, comparing how many samples they had each tested that day. They rarely mentioned how many had come back positive.
Exhaustion set in, and nerves increased. When Fields scraped his arm on some rebar, where patients regularly rested, his colleagues tried to reassure him that he wasn’t at risk, that almost certainly any virus particles that remained had died after being exposed to the air and sun. Fields seethed. “It isn’t your damn arm,” he thought.
A few days after a Western doctor stopped by to see their facility, a sample with the doctor’s name on it came through their lab—and tested positive. The team spent days replaying their meeting in their heads: had they shaken his hand? Every few minutes, it seemed, one of them sneaked off to take his or her own temperature to check for symptoms. (The doctor, whose name was never disclosed, was evacuated to the University of Nebraska, where he was nursed back to health.)
Bleach was everywhere. The person who collected samples from the hospital fridge would bleach his or her hands and boots on the way in, and on the way out. Fields wears a sterling silver wedding band; by the time he returned home, the band was black from constant bleaching.
The ever-present fear of the Ebola virus played out at home, too. A photograph of Fields appeared on the front page of USA Today, above a story about another Western health-care provider who had been exposed. The implication that Fields was the one exposed sent his family into a frenzy, before he could assure them he was okay.
The ELWA hospital struggled to accommodate the demand from patients infected with Ebola. Within ten days of the facility’s opening, MSF technicians were already working to build three new tents, each capable of housing another 40 beds. Ultimately, the facility grew to a capacity of 250 beds; during the course of the outbreak, it treated 1,909 patients, 1,241 of whom tested positive for Ebola. Of those cases, just 541 survived.
The flood of American aid continued through August: On the twenty-fourth, USAID airlifted more than 16 tons of medical and emergency equipment to Monrovia from a forward-staging warehouse in Dubai. The shipment included another 10,000 sets of personal protection equipment, two water treatment systems, two portable water tankers, and 100 rolls of plastic sheeting to construct new Ebola wards. Three days later, Shah authorized another $5 million from USAID’s coffers.
The next day, August 28, 2014, a new WHO count showed a total of 3,052 confirmed Ebola cases in the three West African countries. Liberia had reported a jump of almost 300 cases in just a week. Already, half—1,546 souls—had died.
Sirleaf’s call for help, along with increasingly urgent on-the-ground reports from Pendarvis and others, had spurred a flood of relief from an increasingly attentive American government. But there was little evidence that the early efforts were working; the case count was spiking upward at a faster rate than even the most pessimistic projections. It was fast becoming clear that a more aggressive response was essential to bending that curve downward. What was less clear was just how anyone—the American government or the global health community—could provide that more aggressive response.