Ebola cases are dropping so rapidly that Liberians are talking about the disease in the past tense. They shouldn’t be.
- By Laurie GarrettLaurie Garrett is senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.
MONROVIA, Liberia — Promised by U.S. President Barack Obama in early September, the Monrovia Medical Unit (MMU), built by the United States Army 101st Airborne division, opened yesterday to the appreciative smiles of Liberian President Ellen Johnson Sirleaf and U.S. Ambassador Deborah Malac. The 25-bed tent facility is the Cadillac of the country’s Ebola Treatment Centers, or Ebola Treatment Units (ETUs): air-conditioned, comfortable, and staffed by highly trained members of the U.S. Public Health Service.
“This is a symbol of the strong partnership the government and people of the United States have with the people of Liberia,” Ambassador Malac said at the opening ceremony. Noting that the MMU is meant to handle Liberian and foreign health care workers infected on the job, President Sirleaf added, “those that have trained to preserve life, went out there knowing what they were dealing with and then paid the ultimate price — now they have a place that they can come to. I want to thank President Obama, the Congress, the government, and the people of the United States who have come to our aid.”
The sophisticated Ebola facility was just one element of a massive chain of commitments made by the United States government, dozens of humanitarian groups, the African Union, and a long list of other governments back in September, when Liberia’s epidemic was raging so out of control that dead bodies could be seen abandoned on the streets of the capital city, Monrovia. One day Alex Gasasira stepped out of his office at the World Health Organization — located just two blocks from the U.S. Embassy — and nearly stumbled over a dead Ebola victim.
“You had bodies lying in the streets exposed to dogs, in the absence of war, of natural disaster — that has never happened in modern times, not due to disease,” Swedish infectious disease expert Hans Rosling told me. In early July, Rosling wrote and advised the World Health Organization (WHO) that this Ebola epidemic was easily controllable, and that dedicating excessive resources to it would result in a net increase in deaths due to other ailments such as malaria, chronic diseases, and auto accidents. “You must blame me — I missed it,” Rosling told me, clearly bearing a weight of guilt. When he realized his mistake in September, Rosling took a leave from his professorial job at the Karolinska Institute in Sweden and volunteered to work inside Liberia’s Ministry of Health, where he has toiled since, crunching case and death toll numbers.* Today Rosling accepts the U.S. CDC’s dire predictions — worst-case scenarios that assume no international response was mustered.
The U.S. Centers for Disease Control and Prevention then predicted that unless the world mobilized on a scale unprecedented in the history of disease outbreaks, the countries of Liberia and Sierra Leone could by Feb. 1, 2015 have a combined 1.4 million cases, including 980,000 deaths.
Just six weeks later, the picture is so markedly different that some Liberians talk about the epidemic using the past tense. And that worries Gasasira, the acting director of the WHO in Liberia, deeply.
“Over the last six weeks efforts by everybody have resulted in a scaled-up response. So now we are slightly ahead of the virus,” Gasasira told me in his no-frills concrete WHO office. “But we are nowhere where we need to be. We are still in a very dangerous situation.”
On Nov. 1, a celebratory mood was creeping into conversations among Ebola fighters, as the Halloween case count was less than 30 for the entire nation. But the numbers have more than doubled since, and are on a clear upward trajectory. What worries people like Rosling is that Ebola is “still in half the country. That’s scary. And we have hidden cases in especially remote areas.”
One of the lead scientists for the CDC working here in Liberia is Joel Montgomery, who tells me that “super hot, hot spots” for Ebola are located in areas so remote that people are having to hike four to five hours to reach a mud road, and then as much as a half day more to get to the nearest ETU for Ebola diagnosis and care. CDC colleague Frank Mahoney, who has been fighting Ebola in Nigeria and now Liberia for months, lists one example after another of outbreaks that seem to be starting in tiny villages all over the country, and notes that isolated cases of the viral disease can be found in every neighborhood of Monrovia.
Tracing all the contacts of these remote cases to find and isolate the entire chain of transmission is a Herculean effort that has CDC and Ministry of Health teams forging rivers, hiking over mud slopes, and cutting through bush to reach unmapped villages. Montgomery, who usually works out of Nairobi, says the key to ultimately stopping this scourge is in coupling isolation and care with very rapid diagnosis, even in places so remote that phones and cars are never seen. Some of the chains of transmission of Ebola can be traced back to an isolated individual who took ill and was carried on the backs of neighbors for a day, ultimately reaching an ETU. By then the team of good Samaritans was infected, all too often not developing the disease until they returned to their village and passed the virus onto others.
The downturn in Liberia has been dramatic enough that there is real concern the population will slacken in their vigilance, stop washing in bleach, and start hugging and slapping hands, once again putting themselves at risk. Luke Bawo runs the Liberian Ministry of Health’s disease and general health tracking office, where he has toiled since June, working 16 or more hours a day logging Ebola’s horrible toll on his society. He shared new data analysis that shows Ebola peaked here on Sept. 28, when 69 new cases were found in a single day. And it bottomed out on Halloween, with just 26 cases reported from Liberia’s 15 counties. At its worst, during the week of Sept. 28, nearly 450 cases were identified.
On Nov. 3 the nation had 63 new cases. And preliminary data for the rest of this week shows a slow upward trend. Bawo is nervous. He recalls what happened after the initial outbreak was reported in the country’s remote Lofa county in March, spreading in April: “There was a lull, 21 days with no cases. Everybody let their guard down.”
But that was just the first wave of Ebola, gently washing over the sands of Lofa. It receded, only to roar back in late May not only in Lofa, but also in neighboring counties and in the capital city. “We didn’t have sufficient beds to put sick people. They would go home and infect others. We didn’t have the ability to pick up sick people, or to remove dead bodies. And a dead body is more infectious than a living case,” Bawo explained.
Lisa Hensley of the National Institute of Allergy and Infectious Diseases leads a tiny team of American Army and Liberian scientists toiling inside a converted HIV chimp research center. Long abandoned, the Liberian Institute of Biomedical Research, located about a 90-minute drive from downtown Monrovia, has grounds covered with rusted cages that once housed chimpanzees used by AIDS researchers. When Hensley and her team got here over the summer, they immediately retrofitted one lab building, creating a poor man’s version of a maximum containment Biosafety Level 4 (BSL-4) laboratory suitable for working with the viruses found in the bodies and on the cadavers of Ebola victims.
Few American scientists would feel safe in Hensley’s jury-rigged lab but it has all the necessities: a bit of negative air pressure, layers of thresholds through which workers pass, donning heavy rubber suits with battery-operated air packs to cool them down and provide virus-free air to breathe. In a jumble of old furniture and nonfunctional sinks the team runs sophisticated genetic analysis of Ebola strains and screens samples for levels of infection. They are doing everything side by side with Liberians Lawrence Fakoli, Yata Walker, and Fahn Taweh, hoping to leave the trio in charge of what would be West Africa’s premiere dangerous virus identification lab. It’s tough work, without Internet access most of the time, toiling in spacesuits inside a building that has a roof so full of bats that the guano drips down the walls during heavy rains.
Hensley’s team has already made important discoveries that help explain these hot spots of Ebola. They have received hundreds of samples swabbed from cadavers, some of them dead more than three days before sampling was done. All of them have enormous amounts of Ebola RNA (genetic material) on them, often far higher than anything found in the blood of living patients. Hensley is cautious in interpreting the significance of this — the presence of genetic material does not mean the viruses were live, capable of causing infection. But loads of viral RNA this high are rarely found in the absence of live virus.
The CDC’s Mahoney thinks that institution of mandatory cremation in Monrovia may have been a key factor in reducing the numbers of new cases. President Sirleaf issued the cremation edict — which goes against cultural burial practices — in early August after a burial crew found a safe site in Monrovia, only to return the following day to find bodies floating and mobs shouting in protest. Monrovia’s water table is so high that it is impossible to dig deeply enough in much of the area to inter a body. WHO’s Gasasira credits much of the Liberian epidemic downturn to “Sirleaf’s courageous cremation policy.”
In most of the rest of the country burials have continued, but are executed by the Red Cross or government officials without family and friends of the deceased having any opportunity to touch the body. Though many have resisted what they consider indignity and defilement of their loved ones, by October it seemed that people came to understand the link between Ebola and traditional practices of washing and dressing loved ones before burial. In the United States these procedures would be executed in a funeral parlor, but in impoverished rural Liberia they are conducted by family members.
Mahoney of the CDC also credits improvements in hospital precautions, especially health workers wearing Personal Protective Equipment (or PPEs), with halting most of the spread of Ebola inside hospitals and clinics. Pioneered by Doctors Without Borders (commonly known by its French acronym, MSF), the Ebola Treatment Unit (ETU) is a fairly safe environment for the doctors, nurses, orderlies, and others working to save lives. Since March MSF has treated more than 6,300 Ebola patients in Liberia, Sierra Leone, and Guinea, and 24 MSF workers have contracted Ebola, killing 17 of them. Mahoney and Gasasira credit the ever-improving standards of health worker protection with playing a big role in reducing the Liberian epidemic. They also argue that the massive expansion of ETUs across Liberia and a network of more modest Community Care Clinics has provided a way to separate the infected, ailing patients from the rest of the population. Seven major ETUs are running now, including the new military-built facility in Monrovia. If all goes according to schedule, the U.S. Agency for International Development (USAID) and some 3,000 U.S. military personnel will construct about two dozen more ETUs by Christmas, for a total of 3,130 new treatment beds, according to documents provided to me by USAID officials.
The largest MSF facility, dubbed ELWA3 (an acronym based on a pre-existing Liberian phrase, “Eternal Love Winning Africa”) spans about five acres and resembles nothing less than a village, buzzing with activity. Outside the first of several layers of hygienic security a parking lot is filled with waiting family and vehicles for MSF workers. From one a radio blasts a reggae tune, “Hey, Ebola is in Liberia! Liberia will rise against Ebola!” the Bob Marley sound-alike sings. The sprawling 250-bed facility is organized in a series of orange net fences that separate staff from colleagues who are in their PPEs, suspected Ebola cases from confirmed ones, and visitors from all points of potential viral contact. American Dr. Darin Portnoy from Montefiore Medical Center in New York showed me around, explaining every precaution and activity in detail. It is hard to avoid the most obvious challenge, however: the heat. The only shade provided is created by plastic tent sheets, and the sun is blistering.
As Portnoy guided me into the admissions and triage area a man arrived by ambulance, suspected of having Ebola. With tender care, a team of heavily PPE-clad MSF workers (all Liberian) led the ailing man to a chair located in a fenced-off zone. Standing six feet away, in street clothes, the intake nurse called out questions to the man, noting that his wife had recently died of Ebola. After completing the man’s intake chart she advised that he be taken to the Suspected Cases tent. As he walked with difficulty, PPE-clad health workers holding his arms, the man passed me at a safe distance, looked me in the eyes, and I saw terror. He had seen his wife die of Ebola, and the reality of this march into a zone filled only by yellow PPE-clad personnel must have seemed a finality for him.
Catching my concern, Portnoy murmured, “The key at this point is psychosocial support.”
That’s where Ebola survivors like James Harris come in. His entire family of eight contracted Ebola in August and September, killing four of them. Declared disease-free on Sept. 12, 29-year-old Harris tries to offer solace and hope to the patients. He is one of a handful of people who can safely walk about the entire compound, free of PPE encumbrance. He prefers his time inside the compound, despite the pain he felt here during his struggle with Ebola, because the stigma against survivors on the outside is unbearable. “They think we are carrying the virus,” Harris told me. “Stigma is everywhere!”
MSF epidemiologist Bernadette Gergonne believes the construction of ELWA3 and the other ETUs erected in August and September was critical to bringing down Liberia’s infection rate. But even more critical, she argues, were actions taken in local communities, independent of government intervention. “They organized and focused on who was coming from Monrovia,” forcing them to remain separated from the rest of the village or town. In a sense villagers imposed quarantines, and it worked. The Ministry of Health realized the wisdom of the rural people, Gergonne said, and institutionalized the idea in the form of Community Care Clinics — tiny isolation spaces for suspected Ebola cases. Eventually normal health care services will be restored in Liberia, and CCC-type structures alongside hospitals may be the key to preventing Ebola outbreaks in medical settings.
On the other side of Monrovia the Liberian Defense Forces and USAID constructed a new ETU duplex, Ministry of Defense 1 and 2 (or MOD1 and MOD2). In design they draw from the MSF experience, but in a scaled-down form. And like ELWA3 the MOD facilities are almost unbearably hot. Staffed by Liberian and Cuban doctors in MOD1 and physicians from a variety of organizations in MOD2, the total 300-bed complex opened this week, but has yet to take in patients. The problem? No PPEs.
There is a global shortage of PPEs, fostered by real needs in the Ebola epidemic and fears elsewhere in the world. Though manufacturers are revving up production, it is reasonable to ask whether the health care systems of West Africa will have adequate supplies of PPEs for the year, or perhaps several years, during which the risk of exposure to all patients — with or without known Ebola infection — is unacceptably high.
Nothing seems in short supply at the U.S. military-built MMU — except patients. And that, says Chief Medical Officer Capt. Paul Reed of U.S. Public Health Service Home (USPHS), is “a really good thing.” Unlike ELWA3 and MOD, the spacious Ebola hospital is fully air-conditioned, and powered by a powerful generator that will operate even when the nation’s electrical grid goes down, as happens on occasion. Any health care workers who contract Ebola in this country — including Liberians and Cubans — will get close to state-of-the-art treatment here, including IV-drip hydration, blood-clotting factors to stop hemorrhaging, painkillers, and constant bedside monitoring. The facility was based on an Air Force “platform intended for full range combat support,” Reed explained as he gave me a tour. “We carved out the original to create a configuration that’s an Ebola unit. This is the first time one has been massaged into an Ebola unit. It took a long time, and a huge partnership. And here it is.”
Whether the MMU will ever receive a patient depends on the future course of Liberia’s epidemic. And that, in turn, pivots on the hot spots epidemiologists are finding and fretting about. The largest one borders on Sierra Leone, where an epidemic is raging out of control.
Laurie Garrett is in West Africa covering the Ebola epidemic and will be reporting regularly from the ground over the next week.
*Correction, Jan. 9, 2015: Hans Rosling is a professor with the Karolinska Institute. An earlier version of this article mistakenly said he was with Uppsala University. (Return to reading.)