TOM FRIEDEN FELT THE sweat dripping down his face in the oppressive humidity of equatorial Africa. Dressed in head-to-toe protective gear, peering through the plastic face mask, he struggled to come to terms with the scene of desperation as he walked through a hospital ward in the slums of Monrovia, Liberia’s capital. All around him, he gazed into the faces of the dying, dozens of patients suffering from a terrifying virus that melted their bodies from the inside.
As Frieden walked the aisles, he came to a fourteen-year-old boy sitting on a rickety wooden chair. The young man was barely conscious, a state that so often accompanies the end stages of this particular pathogen. It was clear he had just days, maybe only hours, to live. A bottle of liquid, rehydration solution, sat next to the boy. Frieden begged him to drink as much as he could.
A few beds down the row, Frieden met a young woman who had lived through her ordeal with the virus. She had cared for her husband when he got sick, cared for his body when he died, and she had survived the worst hell on earth after she came down with the virus herself. But the woman had a vacant stare that the lone doctor on the ward, Armand Sprecher, told Frieden had become a common trait among those who survived. It was not clear to doctors and scientists studying this deadly disease whether the stare was from shock, from fluid build-up that caused brain swelling, or from something else entirely. In previous outbreaks, so few people had actually survived that no one had a chance to study the aftereffects. “We see this in survivors and we don’t know what it is,” Sprecher told Frieden.
Amid the heat, the humidity, the moans of human suffering, Frieden saw another woman lying facedown on her cot. He was struck by her hair, woven into beautiful braids that must have taken hours of careful, loving work. Then Frieden noticed the flies on the woman’s legs. He realized she had died during the night, but her body had not yet been moved. A man next to the dead woman complained that the body was a risk to the rest of the patients struggling to survive. Sprecher explained to the man that they needed four staffers to move a body. Patients were dying too fast for the few remaining staffers to cart them off. Throughout the ward, sixty corpses lay among the living and the dying, waiting to be transferred to a crematorium that was working overtime to burn infected bodies. There was no one to remove the bodies, no one to clean the mess of blood and vomit and diarrhea that coated beds and floors. So many were ill that Sprecher and his dwindling team of nurses did not have time to put IVs into the patients’ arms.
Frieden and Sprecher are no strangers to human suffering. Sprecher works with Médecins Sans Frontières, known in the United States as Doctors Without Borders, where he spent a career fighting viruses in Uganda, Angola, and the Democratic Republic of the Congo before being deployed to Liberia. Frieden, the director of the Centers for Disease Control and Prevention in Atlanta, had responded to some of the deadliest disasters in the remotest parts of the world.
“I’ve worked in earthquakes, hurricanes, tornadoes. I’ve seen famine, I’ve worked in war zones,” Frieden said later, recalling his visit to the hospital in Monrovia. “I’ve never seen anything like that. I mean, it was a scene out of Dante.”
When Frieden returned to the United States a few days later, he called the White House, where he was patched through to President Obama. Frieden, agitated after a long transoceanic flight, told Obama what he had seen: the grisly makeshift hospital, three West African nations, already the poorest in the world, decimated by a virus that had claimed the lives of hundreds of health care workers and now left adrift without the help they so desperately needed to fight back. The World Health Organization, ostensibly the agency that was supposed to head the response, was so woefully overmatched for the task, Frieden told Obama, that a global spread of a deadly virus was possible, if not probable. The American government was the only actor with the capacity to stop what could become a global pandemic of an incurable disease.
The virus that raged from remote forest villages to crowded slums of major capitals is one of the most deadly pathogens ever discovered; in previous outbreaks, nine out of every ten people infected had died, often in gruesome ways. It is named for a small subtributary of the mighty Congo River, near the site where four decades ago villagers came down with a hemorrhagic fever that terrified the first Westerners to see it. That small subtributary is called the Ebola River.
By the time Frieden returned to the United States after his eye-opening trip, five months had passed since the World Health Organization had confirmed the presence of the Ebola virus in Guinea. Scientists would later discover it had actually been about eight months since the first victim, known in epidemiological parlance as Patient Zero, fell ill. Just weeks after Patient Zero died, Ebola had spread across the border to Liberia. After a brief moment of cautious optimism that the disease was under control, it appeared in Sierra Leone. Like a horrible feedback loop, the virus was now amplifying itself, and those few epidemiologists brave enough to put themselves in harm’s way were beginning to warn that the situation was spinning out of control.
In the forty years since scientists first identified the virus, Ebola had never reached a city of significant size. Now, Frieden and his counterparts in the global health community watched as Ebola reached three major cities at the same time—Conakry, Monrovia, and Freetown, capitals with populations reaching a million people packed tightly into poor and crowded slums. Those slums were ideal incubators for the highly contagious virus. More worrisome, that meant the virus had, for the first time in recorded history, reached cities served by daily direct flights to Europe and the Middle East. All the epidemic needed to become a pandemic was for the right person to buy a plane ticket.
Two realizations hit Frieden and his counterparts, Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, and Rajiv Shah, the director of the U.S. Agency for International Development. The first was that a combination of factors—dense populations and crushing poverty in massive slums, and the cultural funerary traditions that put family members in close contact with their deceased relatives—meant this outbreak, already the worst in recorded history, was unlike any they had ever seen. The second was that the global health community was woefully unprepared to respond and incapable of marshaling the resources necessary to stop it.
In West Africa alone, thousands, if not hundreds of thousands, of lives were at stake. Globally, millions could be at risk.
The days of an isolated outbreak of a contagious disease are over. Every city of any size, in the modern globalized world, is one connection away from Washington or New York or Beijing or Jakarta. Today’s outbreak in West Africa, if left unchecked, is tomorrow’s global pandemic. Someone had to fight Ebola in West Africa, to prevent a global outbreak that could threaten millions of lives.
Every fire starts with a spark. Every spark, under the right circumstances, can become a conflagration burning out of control, consuming everything within its path—a house, a forest, a people, a country.
The spark that landed in the unique tinderbox of West Africa was made of a few strands of ribonucleic acid, a set of genetic code that, when it comes into contact with human cells, begins rapidly multiplying, searching voraciously for anything that can fuel its growth. The impacts on the human body can be horrifying to witness: bleeding, vomiting, diarrhea, a slow, painful, and violent death. All the while, the small flame is searching for its next host, and the fire spreads.
The Ebola outbreak that killed 11,325 people in West Africa over more than a year and a half was unlike any other epidemic the global health community had seen. Many of the dozens of people interviewed for this book use the same phrase to describe the conditions that contributed to its appearance and spread: the perfect storm.
The circumstances were seemingly tailor-made for a humanitarian disaster of epic proportions: the disease showed up in an area where it had never before appeared, where conditions for its rapid spread were aided by a combination of ancient traditions and modern transportation, all colliding in three desperately poor countries where the medical infrastructure was already teetering on the brink of collapse.
At the same time, the outbreak exposed a woefully inadequate global response network that was ostensibly supposed to find and fight deadly pathogens. After decades of bloat, international organizations had become so overburdened by bureaucracy and corruption that they could not possibly handle a disease of Ebola’s magnitude.
The story of the Ebola outbreak in West Africa is one of incredible lows and incredible highs, of terrible luck and unbelievably good fortunes. It is a story of countries consumed by terror, of politicians taking advantage of fear, and of heroes who ran toward the unfolding disaster, many of whom lost their own lives. It is a story of the past, with deep roots in colonial history, and of the future, with ramifications for the next time the world faces a deadly pathogen. And it is a story of dramatic innovation across the globe—ingenuity and creativity that saved tens of thousands, maybe hundreds of thousands of lives.
“When this is a movie,” said Gayle Smith, who oversaw the American response at the National Security Council, “people will say you overdid it.”
Most of all, it is a story of determination and hope—determination by thousands of West Africans and their friends around the world to save their countries, and hope that the combination of new approaches that helped stop this disaster in its tracks can do the same next time, before thousands of lives are lost.
And that next time is coming. The global population is expanding, moving closer and closer to previously untouched wilderness where viruses like Ebola lurk, at the same time the world is becoming ever more connected. The question is not whether another virus will attack humanity, it is whether someone infected will be able to get on a transcontinental flight when that attack happens—and whether the countries affected will respond quickly enough.
The next sparks are out there, looking for fuel. This is the story of one of the greatest threats the medical world has ever faced, and the lessons it learned that could prevent the next threat from becoming an uncontrollable global inferno.
Our story begins in the remote hills of West Africa, where peace had finally taken hold after more than a decade of war. The next war began with a two-year-old child.